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(2021)ThesisDementia is a leading cause of disability affecting approximately 50 million people worldwide. Currently, in Australia, there is no optimum way of monitoring the incidence or prevalence of dementia at the population level. There are also many unanswered questions regarding crucial aspects of dementia care, such as whether the provision of home-based services can reduce the time spent in residential care. Routinely collected administrative data have the potential to fill these gaps. This thesis explores the use of linked administrative data for detecting and monitoring dementia in Australia, uses these data to understand the care pathways followed by people with dementia, and addresses policy-focused questions aimed at improving dementia care. It does so by presenting the results of four research studies using the 45 and Up Study, a cohort of 267,153, recruited in 2006-2009 in New South Wales, Australia. The 45 and Up baseline survey was linked to a range of administrative datasets including records of hospitalisations, emergency department visits, aged care assessments, and claims for pharmaceuticals, medical services, aged care services and deaths for the period 2006-2016. Key findings include: (i) measuring dementia incidence with multiple linked administrative datasets identifies almost 80% of expected dementia cases (92% for those aged 80-84 years) and produces age-specific incidence rates that mirror those based on clinical diagnosis; (ii) entering residential care is the norm among people with dementia, and home-based care may not be meeting their needs at end of life; (iii) high-level home care for people with dementia may reduce the subsequent time spent in residential care; and (iv) changing to a new general practitioner (GP) when entering residential care is related to increased polypharmacy and initiation of psychotropic medicines among people with dementia. These findings will inform on-going efforts to monitor dementia incidence and care in Australia. They also have major policy implications, including emphasising the pressing need in Australia for more high-level home care packages, and highlighting end-of-life dementia care as a priority for policy development and innovation in service delivery. The link between GP continuity and psychotropic prescribing highlights a new intervention point that could assist in the efforts to reduce psychotropic prescribing in residential aged care.
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(2017)ThesisPreventable hospitalisations are used in Australia as a high-level indicator of health system performance, specifically the accessibility and quality of primary care. However, there are key gaps in understanding of how preventable hospitalisations relate to characteristics of patients and features of the health system, and surprisingly little evidence validating their use in Australia. In this thesis, new approaches to analysing longitudinal health data were applied to gain insights into the properties of this health performance indicator. This thesis used linked questionnaire and longitudinal health data for a cohort of over 267,000 participants in the 45 and Up Study, Australia, containing detailed information on participants and their use of health services. Temporal patterns in use of primary care and other health services around preventable hospitalisation were explored using a visualisation of unit record health data. Predictors of preventable hospitalisation were identified using multilevel Poisson regression models, with variation partitioned between person- and geographic-levels. Through development of novel weighted-hospital service area networks , variation was further partitioned to the hospital-level. Many patients admitted for preventable hospitalisation were found to have high levels of engagement with the health care system, both around the time of admission and compared to similar non-admitted patients. The supply of general practitioners explained only a small amount of geographic variation in preventable hospitalisation, while over one-third of variation was contributed by the sociodemographic and health characteristics of the population. Hospitals differed in their propensity to admit patients, with the greatest variability in smaller community hospitals, which account for a small proportion of admissions but contribute greatly to regional variation. These findings show the preventable hospitalisation indicator in Australia should not be interpreted simply as a measure of the accessibility and quality of primary care. They suggest the most appropriate policy responses are long-term strategies to promote healthy living and targeted local interventions to efficiently manage the current burden of chronically ill patients. The findings demonstrate why caution should be used when adopting international health performance indicators, but also the benefits of using novel approaches to derive new information from linked and longitudinal data.
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(2014)ThesisThe mobile and information intensive nature of clinical work in hospital settings presents a critical challenge: how to provide clinicians with access to information at the time and place of need? This challenge is particularly pertinent to decision-makers responsible for the selection of computing devices. Mobile devices are often promoted as a means to meet this challenge, with existing literature tending to portray the mobility of devices as inherently beneficial. However, evidence to clearly demonstrate how mobile devices support clinical work is limited. This research aimed to generate new knowledge to contribute to answering two significant questions: (i) how do decision-makers select computing devices? and (ii) how do mobile devices support clinical work practices? The research was conducted in two stages. In stage one, interviews were conducted with 28 individuals involved in decisions regarding the selection of computing devices for hospital wards. Decision-makers reported a range of factors that influenced device selection. Role of the user, types of tasks, and location of tasks, for example, were deemed important. In stage two, a mixed methods design comprising structured observations, interviews, and field notes was employed. A sample of 38 clinicians, on two wards of a metropolitan hospital, was observed for 90 hours. In total 4,423 clinical tasks were recorded, capturing key information about tasks doctors and nurses undertake, where, and devices used. The findings provide evidence validating core assumptions about mobile devices: namely, that they support clinicians work by facilitating access to information at patients bedsides. Notably, mobile devices also supported work away from the bedside and whilst clinicians were in transit, allowing continuity in work processes. However, mobile devices did not provide the best fit for all tasks and additional factors, such as the temporal rhythms of the ward and structure of ward round teams, affected how mobile devices supported work. Integration of findings from the two stages resulted in the development of a detailed list of factors that influence the use of mobile devices on hospital wards. This new evidence provides valuable knowledge to guide the selection of computing devices to support, and potentially optimise, clinical work.
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(2014)ThesisBackground: Electronic medication management systems (EMMS) aim to reduce medication errors. Rather than use them as prescribed by policy, nurses commonly employ workarounds. EMMS-related workarounds have been attributed to a mismatch between introduced technology and nurses’ workflow. Comparatively little attention has been focused on examining nurses’ enactment, explanations and experiences of using workarounds. This is a significant lacuna because nurses’ contextual rationalisation is integral, I will argue, to understanding their use of workarounds. Aims: To improve our knowledge and understanding of nurses’ use of workarounds with EMMS in order to inform policy and technology development. Methods: A qualitative study was conducted in four phases: scoping and process mapping; data collection and analysis; explanatory framework generation and member checking; and interpretation of emergent findings using existing sociological theory. The study sampled EMMS implementation stakeholders and nurses across all shifts and days of the week, from six wards in two Australian hospitals, representing two EMMS types and two models of nursing care. Data collection methods included observations, interviews and focus groups. Data analysis used a general inductive approach in which data were coded for emerging themes, framed by the research questions. Results: While sometimes EMMS related problems offered the best explanation for workarounds, nurses used workarounds largely to circumvent perceived barriers to being, or being perceived to be, a ‘good nurse’ in the sense of being time-efficient, safe, patient-centred and/or a team player. Whether nurses used workarounds, and how they felt about doing so, was moderated by a number of contextual factors. The use of workarounds provoked a range of emotions, in particular, feelings of tension. Interpretation: Nurses were motivated to use workarounds, even when doing so made them professionally vulnerable, primarily by the desire to be, or be perceived to be, a ‘good nurse'. Bourdieu’s concepts of habitus, field and capital offered useful constructs to interpret the intensity and complexity of the drivers of workarounds. Conclusion: Technology and policy designers need to be cognisant of creating potential barriers to being a ‘good nurse'. Unless they do so, problematic workarounds will continue unabated, and potentially useful workarounds will remain ‘underground’.
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(2021)ThesisChapter 1 - Introduction. This provides an overview of mental and behavioural disorders (MBD) definitions and current knowledge about MBD in pregnancy. Maternal MBD in pregnancy are often overlooked. Most studies of MBD in pregnancy focused on a single class of MBD. This thesis used linked data from NSW Perinatal Data Collection and the NSW Admitted Patient Data Collection to assess diagnosed MBD in NSW maternities between 2002 and 2006. Chapter 2 – Methods. Describes data linkage, MBD definitions and preliminary data processing. Chapter 3 – Admissions for MBD in pregnancy. A study to compare rates of MBD admissions in pregnancy relative to MBD admissions in a baseline period. Overall, admissions for MBD were lower in early pregnancy (RR 0.71) and higher in late pregnancy (RR 1.91). Drug disorder admissions were more than 3-fold higher in late pregnancy. Schizophrenia admissions increased from early pregnancy and alcohol admissions remained lower throughout pregnancy. Baseline MBD admissions rates were higher for multiparous than primiparous maternities. Chapter 4 – Admissions with MBD in pregnancy. MBD prevalence in pregnancy was 2.4% overall, 1.4% for drug/alcohol disorders (DA) and 1.2% mental disorders (MD). Pregnancy DA prevalence was the same, psychotic disorder prevalence was half, affective disorder a third and anxiety a tenth that of comparable disorders in women of reproductive age. Coexisting MBD ranged from 23.6% for anxiety to 91.5% for sedative disorders. Smokers and residents in outer regional or more remote locations were identified as maternity populations at high risk of MBD. Chapter 5 – Neonatal outcomes. Assessed relative risks of individual classes of MBD on perinatal mortality, preterm birth, small size at birth, neonatal morbidity, and admission to neonatal intensive care (NICU). Adverse outcomes were on average 3- 4-fold higher for MBD relative to no MBD. Effects were universally attenuated by adjustment for smoking and co-existing MBD. Independent effects of opiate and cannabis disorders remained for most adverse neonatal outcomes, but not for schizophrenia or bipolar disorder. Chapter 6 – Discussion and conclusions. This thesis demonstrates the value of linked population data; has added to the evidence for pregnancy as risk for MBD; provided the first comprehensive prevalence estimates of MBD in pregnancy for all maternities in NSW, including both high and low prevalence MBD; provided evidence to support findings elsewhere of an independent association of alcohol, cannabis, or opiate disorder with poor neonatal outcomes, but not for schizophrenia or bipolar disorder.
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(2021)ThesisThe application of machine learning models to big data has become ubiquitous, however their successful translation into clinical practice is currently mostly limited to the field of imaging. Despite much interest and promise, there are many complex and interrelated barriers that exist in clinical settings, which must be addressed systematically in advance of wide-spread adoption of these technologies. There is limited evidence of comprehensive efforts to consider not only their raw performance metrics, but also their effective deployment, particularly in terms of the ways in which they are perceived, used and accepted by clinicians. The critical care outreach team at St Vincent’s Public Hospital want to automatically prioritise their workload by predicting in-patient deterioration risk, presented as a watch-list application. This work proposes that the proactive management of in-patients at risk of serious deterioration provides a comprehensive case-study in which to understand clinician readiness to adopt deep-learning technology due to the significant known limitations of existing manual processes. Herein is described the development of a proof of concept application uses as its input the subset of real-time clinical data available in the EMR. This data set has the noteworthy challenge of not including any electronically recorded vital signs data. Despite this, the system meets or exceeds similar benchmark models for predicting in-patient death and unplanned ICU admission, using a recurrent neural network architecture, extended with a novel data-augmentation strategy. This augmentation method has been re-implemented in the public MIMIC-III data set to confirm its generalisability. The method is notable for its applicability to discrete time-series data. Furthermore, it is rooted in knowledge of how data entry is performed within the clinical record and is therefore not restricted in applicability to a single clinical domain, instead having the potential for wide-ranging impact. The system was presented to likely end-users to understand their readiness to adopt it into their workflow, using the Technology Adoption Model. In addition to confirming feasibility of predicting risk from this limited data set, this study investigates clinician readiness to adopt artificial intelligence in the critical care setting. This is done with a two-pronged strategy, addressing technical and clinically-focused research questions in parallel.
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(2012)ThesisThis thesis examines the role of medical clinician surveyors (MC surveyors) working in the hospital-based health care accreditation arena. The thesis examines their motivations for participating in accreditation, the issues that influence them during the survey process, and the ways in which they deal with the influences to facilitate a reliable and credible survey outcome. The study is an evidence-based examination of MC surveyors working for the Australian Council on Healthcare Standards (ACHS), the dominant accreditation agency for public and private hospitals in Australia. There is limited research and empirical evidence as to the benefits of accreditation and improved service quality, despite the significance of accreditation for hospitals and the resources expended on it. The research consisted of three distinct stages: a questionnaire which examined the motivations for MC surveyors participating in accreditation; interviews which looked at the scale and scope of influences on MC surveyors during the accreditation survey process; and a case study approach which assessed how MCs and other surveyors dealt with the influences. The large amount of data generated was analysed utilising a range of social science methods. The findings corroborate and augment past research into the motivations for MC surveyors participating in accreditation, and extend existing knowledge considerably. These motivations included participants perceptions that accreditation facilitated improvement of quality in the health system and within their own organisation, and provided an external perspective and the opportunity to benchmark and share ideas. Furthermore, participants considered accreditation assisted in their professional development, supported professional networking, augmented their prestige, and increased their influence and respect whilst being an enjoyable experience. The research identified fourteen interrelated factors that influence the survey process and potentially, the accreditation outcome. It found that MC surveyors were acutely aware of the need to be objective in their surveying and furthermore were conscious of the difficulty in attaining objectivity. It also provided evidence supporting MC involvement in the accreditation process and reported a positive view of accreditation. In addition, it highlighted the characteristics of the accreditation process that MC surveyors consider benefits health care as well as leading to a more reliable and credible accreditation outcome.
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(2012)ThesisThis study explored Junior Medical Officers' (JMOs), particularly international medical graduates' (IMGs) understanding of interprofessional practice (IPP) and its links to patient safety. It investigated their willingness to practise interprofessionally and identified factors inhibiting collaborative IPP. The links between IPP and patient safety are established. Evidence supports the benefits of health professionals working collaboratively for enhanced patient outcomes. Hospital environments are complex with proliferating professional and departmental cultures. Patients are managed by a multiplicity of health professionals. We know that to practise interprofessionally challenges the territorial traditions of health professionals. An understanding of IPP and a preparedness to put patient interests before professional self interests are fundamental to realising improved patient safety. There are difficulties associated with transformation to a collaborative approach to patient care. Paradoxically, overcoming cultural boundaries between interdependent health professionals is one prerequisite for practising interprofessionally. This thesis contributes to our knowledge about junior doctors' perceptions of IPP in teaching hospitals and organisational factors challenging their interprofessional functioning. It reveals compromised intraprofessional practice linked to the hierarchical culture of hospital doctors. A triangulated method comprising semi-structured interviews, a survey questionnaire and ethnographic observations was employed for the research. Thirty two international and Australian medical graduates (IMGs and AMGs) from three Australian teaching hospitals participated. Four themes framed the study: culture, communication, collaboration and competency. The findings highlight diversity in the cultures and medical training of JMOs. Participants' experience of shared learning was minimal, limiting their proclivity to IPP in postgraduate training. JMOs' willingness to embrace IPP is overshadowed by the challenges of adapting to different cultures within hospitals, understanding other health professionals' roles, and working with inadequate support and supervision. Mutual respect and communication are lacking, both intraprofessionally and interprofessionally. Excessive demands, bounded professional cultures and uncompromising hospital organisational cultures impede IPP. The findings can be applied to other comparable settings and individual issues such as supervision, explored in further research.
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(2013)ThesisMotor neurone disease (MND), also known as amyotrophic lateral sclerosis, presents many challenges to patient and carer engagement in decision-making. A progressive and terminal multisystem disorder without a cure, MND care focuses on symptom management and quality of life, as patients and families attempt to come to terms with the diagnosis. In addition to physical deterioration, the cognitive, communication and behavioural abilities of many patients are affected. Care is delivered in specialised multidisciplinary clinic settings, creating decision-rich environments in which to test normative models of patient-centric decision-making. As patients continually face care decisions, few options are available to slow disease progression or extend survival time. Family carers are extensively involved in patient care, yet the decision-making relationships between MND health professionals, patients and their carers are undefined. Models of decision-making used in cancer and chronic disease care have limited applicability to MND care. Patients use a cyclic process of adaptation to their rapidly changing needs. The available treatment choices are often ethically and culturally complex, and may be time-constrained. While patient choices are well documented, little is known about the underlying factors influencing their decisions. This study addresses two research questions. The first asks: what are the influences on patient decision-making in MND multidisciplinary care? The second question is: how is patient-centred decision-making is delivered in MND multidisciplinary care? The thesis contributes insight into the underlying aspects of decision-making, and their implications for delivering patient-centred, collaborative and evidence-based care. Qualitative methods were used to examine factors influencing patient-centred decision-making. Fifty-four respondents from two specialised MND multidisciplinary clinics participated in semi-structured interviews. These were 32 health professionals, 14 patients and eight carers. The views of each group were analysed separately, and then combined to provide a comprehensive picture of MND patient-centred decision-making. Thematic analysis revealed broad agreement between the groups on key factors influencing patient-centred decision-making. These were: the decision-making process; patient-centred focus; timing and planning; information sources; engagement with specialised ALS services; and access to non-specialised services. Specialised MND multidisciplinary clinics offered an optimal setting for decision-making. The roles and expectations of stakeholders influenced the decision-making process, while psychosocial factors and continually changing symptoms impacted on patients capacity to participate. Issues of timing of evidence-based care delivery and the role of carers were contentious. Patient-centred decision-making is a complex and cyclical process, with health professionals, patients and carers collaborating to form a decision-making triad. A four-stage triadic model, embedded in the specialised MND multidisciplinary clinic environment, was derived from the data. The first stage, Patient Engagement , identifies the participants and establishes their values, preferences and expectations. In stage two, Option Information , information and guidelines on the available management options are determined, including the optimal timing for implementation of each choice. During the third stage, Deliberation , patients weigh up the risks and benefits, and decide between proceeding with an option, deferring their decision, or choosing to do nothing. The final stage, Implementation , results once an option is chosen. The model captures the complexities of MND patient-centred decision-making and offers a framework for health professionals, researchers and policy makers in this challenging environment.
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(2013)ThesisHow does Human Resource Management (HRM) contribute to organisations and their functioning? What is the relationship between HRM, teamwork and clinical performance? We know that organisations deploy Human Resources (HR) departments and initiate HRM with the express purpose of improving performance, yet little is known about their associations, especially in the healthcare setting. HRM is essentially a black box which needs to be understood, thereby informing organisations on how to maximise the benefits of the HR function. This thesis contributes to this deficit in knowledge, examining team characteristics, job satisfaction and clinical performance and how these relate to HRM policy and practice. Specifically, it investigates the links between aspects of HRM with teamwork and performance. A mixed method cross sectional study was conducted focusing on full service category rehabilitation services from public hospitals in Australia. This setting was selected for investigation because of the strong teamwork orientation and the lack of research comprehensively evaluating the contribution of HRM in this medical field. A total of 163 participants, comprising 152 rehabilitation clinicians and 11 managerial staff from seven hospitals were enrolled. A semi-structured questionnaire was administered to clinicians to determine their individual and team characteristics. Two measures of team performance were employed, namely: self reported job satisfaction, and compliance with clinical indicators defined by the Australian Council of Healthcare Standards. Twenty four focus groups and 18 interviews were conducted with clinicians and HR managers to investigate HRM policy and practice. Quantitative input from survey and clinical indicator data were analysed using descriptive and inferential statistics while qualitative data from focus groups and interviews were thematically analysed. The results show that a holistic approach to HRM is related to teamwork and facets of performance. Influenced by local context, HRM has the potential to either positively or negatively affect teamwork, job satisfaction and clinical performance. HRM s links to teamwork and performance were found to be significantly mediated by elements of efficiency, effectiveness, change, structure, service constraints, leadership, staffing, specialisation and research. The tailoring of HRM approaches to take account of local organisational circumstances could contribute positively to desirable teamwork and performance outcomes.