Medicine & Health

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Now showing 1 - 10 of 15
  • (2017) Falster, Michael
    Thesis
    Preventable 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.

  • (2014) Prgomet, Mirela
    Thesis
    The 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.

  • (2014) Debono, Deborah
    Thesis
    Background: 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’.

  • (2012) Low, Lena
    Thesis
    This 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.

  • (2012) Milne, Jacqueline
    Thesis
    This 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.

  • (2013) Hogden, Anne
    Thesis
    Motor 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.

  • (2013) Pereira, David Joseph
    Thesis
    How 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.

  • (2013) Watson, Eilean Genevieve Sinclair
    Thesis
    This research investigates the use of an online curriculum mapping system developed to support the design, delivery and review of undergraduate medical education. This is an advanced, web-enabled and database-driven system known as eMed Map that has been in use by educational staff since late 2003 and by students since early 2004. eMed Map forms part of an integrated curriculum management system which sits at the interface of education, technology and practice. This mixed-method research project uses a case-study approach and a triangulation of methods. It consists of a qualitative component based on observations and textual documentation, a quantitative component appraised via web log reports linked to staff data, and an attitude assessment through a predominantly quantitative self-reported survey questionnaire. The thesis addresses a deficit in the current knowledge base about curriculum map use and impacts. Using systems theory and systems thinking paradigms to synthesise and discuss the findings, the research uncovered a number of interrelated factors affecting map use pertaining to the individual user, the technology and the organisation. Map awareness and use varied considerably, chiefly by staff type and by school location, and distinct groups of users were identified. Knowledge about the Map varied substantially, while utilisation of its help sites was minimal. The system was generally being used for content management while its more advanced educational and organisational uses were not being realised. The need for further information and training for staff was evident, as was the need to review certain educational and organisational procedures and information technology features and functions. Hence, while the system was widely available, its diffusion amongst staff was not what was hoped by planners and advocates of the curriculum map. The thesis considers practical implications for improving the diffusion of eMed Map by reviewing the whole curriculum mapping system and its leverage points from a systems thinking and system dynamics perspective. The lessons learnt from this case-study and the suggestions and key recommendations derived from it can be applied not only to medical education but also to other higher education programs that use or plan to use advanced online curriculum mapping systems.

  • (2013) Plumb, Jennifer
    Thesis
    The patients implied by the term patient safety are most commonly lying on an operating table or in a hospital bed. They are cast as potential victims of harm resulting from their encounters with a health service, harm which is often attributed to malfunctioning systems or toxic cultures of care. Mental health patients and professionals, and the particularities of the illnesses and interventions which structure their encounters, have often been ignored in this discourse. This study is about what patient safety means from the perspective of professionals in a mental health context, where: risk type and severity are contested and unpredictable; patients are often viewed as a threat to their own safety; and the professional role in keeping patients safe extends to interest in their social and economic circumstances. Emphasis in patient safety research is often given to the causes and consequences of error and harm, but this research brings the day-to-day unfolding of professional work to the fore. This shift in perspective allows for a detailed examination of the strategies staff members use to enact safety, and a concomitant exploration of the degree to which policies and rules penetrate practice. This has been accomplished through the ethnographically-informed design of an inquiry into understandings and enactments of safe care among a multidisciplinary range of staff in a community mental health team and an acute inpatient psychiatric unit in New South Wales, Australia. In the course of daily work, these professionals are found to negotiate a tension between two versions of patient safety. In the fluidity of everyday practice, the safe patient is only ever a transient, fragile phenomenon anchored to a particular time, place, and relationship between clinician and patient. However, the expectation of policymakers, Coroners, and members of the public is that the mental health service should act as guarantor of safety. Theoretical frameworks of socio-material ontology are used to tease out the implications of these sometimes contradictory demands, and to explore the possibility of a patient safety which prioritises therapeutic impact on the patient rather than only the management of their risk.

  • (2014) Wiley, Janice
    Thesis
    The health system appears to be in the midst of a paradigm shift. The transition is from provider-centred to patient-centred care (PCC). This emerging ideology has particular relevance in chronic disease management where the need for integrated and accessible care aligns with patient self-management. As the quintessential self-managed chronic disease, Type 1 diabetes (T1D) is at the cutting edge of this evolution. Of particular interest are young adults with T1D. They are known to have high attrition rates from diabetes health services and suffer worse health outcomes. Are these high attrition rates and health outcomes related, at least in part, to a failure to provide PCC? Patientsâ perspectives as the driver for improvement in health service quality and safety standards is both underdeveloped and under researched. This thesis used a combination of qualitative and quantitative methods to explore the perspectives of young adults with T1D in relation to their experience of PCC in diabetes health services. The thesis asked the following questions: Do young Australian adults with T1D access recommended multi-disciplinary health services? Do they perceive the delivery of those heath services as being patient-centred? Do the clinicians they consult engage with shared decision-making? Are diabetes education services patient-centred? In response to these research questions an Australia wide web-based survey provided data from 150 respondents in 2011. To expand on the survey results 33 respondents participated in focus groups health held in cities around Australia. Thesis empirical contributions include findings that show that the majority of young adults with T1D do not access recommended health services for reasons including: time constraints, service accessibility barriers, provision of inconsistent advice by clinicians, cost constraints, variable standards of services and failure of clinicians to refer to other clinicians. Respondents preferred clinicians who engage with shared decision-making and may fail to take-up health services when shared decision-making is not practiced. Reported experiences of diabetes education indicate pedagogical shortcomings and a failure by clinicians to develop patient autonomy in learning skills. The thesis provides evidence for the potential value of patient engagement in quality improvement and health service re-design.