The place of digital triage in a complex healthcare system: an interview study with key stakeholders in Australia's national provider

Background Digital triage tools such as telephone advice and online symptom checkers are now commonplace in health systems internationally. Research has focused on consumers’ adherence to advice, health outcomes, satisfaction, and the degree to which these services manage demand for general practice or emergency departments. Such studies have had mixed findings, leaving equivocal the role of these services in healthcare. Objective We examined stakeholders’ perspectives on Healthdirect, Australia's national digital triage provider, focusing on its role in the health system, and barriers to operation, in the context of the COVID-19 pandemic. Methods Key stakeholders took part in semi-structured interviews conducted online in the third quarter of 2021. Transcripts were coded and thematically analysed. Results Participants (n  =  41) were Healthdirect staff (n  =  13), employees of Primary Health Networks (PHNs; n  =  12), clinicians (n  =  9), shareholder representatives (n  =  4), consumer representatives (n  =  2) and other policymakers (n  =  1). Eight themes emerged from the analysis: (1) information and guidance in navigating the system, (2) efficiency through appropriate care, (3) value for consumers? (4) the difficulties in triage at a distance, (5) competition and the unfulfilled promise of integration, (6) challenges in promoting Healthdirect, (7) monitoring and evaluating digital triage services and (8) rapid change, challenge and opportunity from COVID-19. Conclusion Stakeholders varied in their views of the purpose of Healthdirect's digital triage services. They identified challenges in lack of integration, competition, and the limited public profile of the services, issues largely reflective of the complexity of the policy and health system landscape. There was acknowledgement of the value of the services during the COVID-19 pandemic, and an expectation of them realising greater potential in the wake of the rapid uptake of telehealth

The Reality of Uncertainty in Mental Health Care Settings Seeking Professional Integration: A Mixed-Methods Approach

Introduction: Uncertainty is a common experience in the complex adaptive health system, particularly amongst mental health professionals structured for the delivery of integrated care. Increased understanding of uncertainty will not necessarily make things more certain, but can act to sensitize professionals to the challenges they face. The aim of this study is to examine the types and situations of uncertainty experienced by professionals working in a mental health setting based on an integrated care model. The research assesses the impact of experience and professional group on reported uncertainties. Methods: First, semi-structured interviews were undertaken with clinical and non-clinical staff to examine uncertainties experienced by professionals working in 'headspace' centres in Australia. Second, an online survey was conducted to quantify the experiences of uncertainty and explore associations. Results: Findings revealed three overarching and largely interrelated aspects of uncertainty, namely: decision-making; professional role; and external factors. Most commonly, staff reported experiences of uncertainty pertaining to deciding to accept a client into the service and then deciding how to treat them. This is often due to arbitrary, or overly-restrictive criteria in integrated care. Findings also suggested that uncertainty does not necessarily decline with experience and there were no significant differences in levels of uncertainty between clinical and non-clinical staff. Conclusions: This study highlights the importance of acknowledging uncertainties and actively clarifying role ambiguities when working alongside diverse professionals in mental health care

Systems resilience in the implementation of a large-scale suicide prevention intervention: a qualitative study using a multilevel theoretical approach

Background Resilience, the capacity to adapt and respond to challenges and disturbances, is now considered fundamental to understanding how healthcare systems maintain required levels of performance across varying conditions. Limited research has examined healthcare resilience in the context of implementing healthcare improvement programs across multiple system levels, particularly within community-based mental health settings or systems. In this study, we explored resilient characteristics across varying system levels (individual, team, management) during the implementation of a large-scale community-based suicide prevention intervention. Methods Semi-structured interviews (n=53) were conducted with coordinating teams from the four intervention regions and the central implementation management team. Data were audio-recorded, transcribed, and imported into NVivo for analysis. A thematic analysis of eight transcripts involving thirteen key personnel was conducted using a deductive approach to identify characteristics of resilience across multiple system levels and an inductive approach to uncover both impediments to, and strategies that supported, resilient performance during the implementation of the suicide prevention intervention. Results Numerous impediments to resilient performance were identified (e.g., complexity of the intervention, and incompatible goals and priorities between system levels). Consistent with the adopted theoretical framework, indicators of resilient performance relating to anticipation, sensemaking, adaptation and tradeoffs were identified at multiple system levels. At each of the system levels, distinctive strategies were identified that promoted resilience. At the individual and team levels, several key strategies were used by the project coordinators to promote resilience, such as building relationships and networks and carefully prioritising available resources. At the management level, strategies included teambuilding, collaborative learning, building relationships with external stakeholders, monitoring progress and providing feedback. The results also suggested that resilience at one level can shape resilience at other levels in complex ways; most notably we identified that there can be a downside to resilience, with negative consequences including stress and burnout, among individuals enacting resilience. Conclusions The importance of considering resilience from a multilevel systems perspective, as well as implications for theory and future research, are discussed.publishedVersio

The bulimic self : constructions of bulimia and women's embodied experiences of bulimic practices

Bulimia nervosa disproportionately affects young women and is associated with considerable distress and debilitation. Much of the research on this phenomenon focuses upon the complex and biopsychosocial causes of disordered eating behaviour. On the other hand, rather than examining causes, constructionist approaches to eating disorders find evidence of how these practices reflect broader cultural values and discourses, and thereby challenge the assumption that bulimia is only an individual abnormality or pathology. More specifically, research taking a feminist poststructural approach has explored a multitude of gendered meanings of thinness and disordered eating that might make sense of “extreme” body management behaviours. However, this body of work has typically focused on the meanings of women’s bodies, and of anorexia; consequently, there has been little focus on the actual embodied experiences and meaning of bulimic behaviours. The purpose of this research has been to explore the construction and experience of bulimia, and has used the methods of Q methodology and interviews to do so. Through a feminist poststructural theoretical approach it has examined a range of personal, embodied and cultural meanings of these practices, as well as other important objects, such as food, bodies, and femininity. The Q methodological study used a sample of participants with varying experience and knowledge of eating disorders, and identified different cultural construction of bulimia through factor analysis and qualitative interpretation. These constructions included bulimia as uncontrolled behaviour, as self-medicating with food, and as being the best at being thin. Construction and experiences of bulimia were further elaborated through a thematic decomposition of the interview accounts of women who engage in bulimic behaviours. Three major themes were identified. The first involved the way participants often purposively deployed two alternative constructions of bulimia, one in which bulimia was something they had (a mental illness), and another in which bulimia was something they did (a cycle of behaviours). As such, this thesis explores the reasons for which women might take up, or move between, a position of having or doing bulimia. Second, women constructed their bulimia as a relational problem, as caused by, maintained and even relieved through relationships with others. Drawing upon relational-cultural theory, this thesis examine how this construction might work in conjunction with women’s gendered subjectivity, as well as being rendered problematic through broader cultural values of masculinity and individualism. Third, a range of cultural and embodied constructions of food, including consumption as a means to moral virtue, health, spirituality, love and comfort, were used by these participants to make sense of bulimic behaviours. The contradictions and gendered nature of these constructions are then explored. Finally, drawing together findings from the Q methodological and interview studies, the thesis concludes with the argument that bulimia can be made sense of as both a problem and a solution by women who engage in these behaviours. The implications these findings have for research and practice, including informing treatment, prevention and help seeking are explored, as well as future directions for research into bulimia

Exploring coronial determination of intent for poisoning-related deaths in Australia, 2001–2013

Abstract Background In countries like the United States and the United Kingdom, systematic variation in the classification of intent in pharmaceutical poisoning deaths have been identified between jurisdictions. This study aimed to explore whether the coronial determination of intent (unintentional, intentional, undetermined) for pharmaceutical-related poisoning deaths may have affected death rates over time and by jurisdiction in Australia. Methods A retrospective examination of mortality records in the National Coronial Information System (NCIS) during 1 January 2001 to 31 December 2013 was conducted. The NCIS is a national internet-based data storage and retrieval system for deaths that were notified to a coroner. Pharmaceutical deaths due to unintentional, intentional or undetermined intent were identified using the NCIS classification. Proportions of the different intent classifications and the mortality rates by intent over time were compared between jurisdictions. Results There were 17,895 pharmaceutical-related poisoning deaths in Australia between 2001 and 2013 that had closed cases in the NCIS. Proportions of deaths classified as unintentional (48.3–66.3%), intentional (24.7–35.9%) and undetermined (6.7–24.7%) varied significantly among Australian jurisdictions. There were significant increases in the rate of classification of unintentional poisoning for some states, and significant increases in intentional poisoning classification in Western Australia, and decreases in New South Wales and Victoria. There was no significant change in classification of undetermined intent. Conclusions Significant variation in classifications of intent, both between state jurisdictions and over time, may be the result of regional differences in demographics and increases in prescription drug misuse. However, the inconsistent use of ‘undetermined’ intent between state jurisdictions suggests coroners may experience varying difficulty in retrospectively ruling on intent in the equivocal circumstances of pharmaceutical poisoning. The widespread use of psychological autopsy may assist coroners to classify intent, while the implementation of new classifications for pharmaceutical poisoning death may overcome some of the inherent difficulty in intent classification and improve the potential for injury surveillance irrespective of intent

Mental health services conceptualised as complex adaptive systems: what can be learned?

Abstract Despite many attempts at promoting systems integration, seamless care, and partnerships among service providers and users, mental health services internationally continue to be fragmented and piecemeal. We exploit recent ideas from complexity science to conceptualise mental health services as complex adaptive systems (CASs). The core features of CASs are described and Australia’s headspace initiative is used as an example of the kinds of problems currently being faced. We argue that adopting a CAS lens can transform services, creating more connected care for service users with mental health conditions

‘Broken hospital windows’: debating the theory of spreading disorder and its application to healthcare organizations

Abstract Background Research in criminology and social-psychology supports the idea that visible signs of disorder, both physical and social, may perpetuate further disorder, leading to neighborhood incivilities, petty violations, and potentially criminal behavior. This theory of ‘broken windows’ has now also been applied to more enclosed environments, such as organizations. Main text This paper debates whether the premise of broken windows theory, and the concept of ‘disorder’, might also have utility in the context of health services. There is already a body of work on system migration, which suggests a role for violations and workarounds in normalizing unwarranted deviations from safe practices in healthcare organizations. Studies of visible disorder may be needed in healthcare, where the risks of norm violations and disorderly environments, and potential for harm to patients, are considerable. Everyday adjustments and flexibility is mostly beneficial, but in this paper, we ask: how might deviations from the norm escalate from necessary workarounds to risky violations in care settings? Does physical or social disorder in healthcare contexts perpetuate further disorder, leading to downstream effects, including increased risk of harm to patients? Conclusions We advance a model of broken windows in healthcare, and a proposal to study this phenomenon

Nursing home leaders’and nurses’experiences of resources,staffing and competence levels and the relation to hospital readmissions –a case study

Background Thirty-day hospital readmissions represent an international challenge leading to increased prevalence of adverse events, reduced quality of care and pressure on healthcare service’s resources and finances. There is a need for a broader understanding of hospital readmissions, how they manifest, and how resources in the primary healthcare service may affect hospital readmissions. The aim of the study was to examine how nurses and nursing home leaders experienced the resource situation, staffing and competence level in municipal healthcare services, and if and how they experienced these factors to influence hospital readmissions. Method The study was conducted as a comparative case study of two municipalities affiliated with the same hospital, chosen for historical differences in readmission rates. Nurses and leaders from four nursing homes participated in focus groups and interviews. Data were analyzed within and across cases. Results The analysis resulted in four common themes, with some variation in each municipality, describing nurses’ and leaders’ experience of the nursing home resource situation, staffing level and competence and their perception of factors affecting hospital readmissions. The nursing home patients were described as becoming increasingly complex with a subsequent need for increased nurse competence. There was variation in competence and staffing between nursing homes, but capacity building was an overall focus. Economic limitations and attempts at saving through cost-cutting were present, but not perceived as affecting patient care and the availability of medical equipment. Several factors such as nurse competence and staffing, physician coverage, and adequate communication and documentation, were recognized as factors affecting hospital readmissions across the municipalities. Conclusion Several factors related to nurses’ and leaders’ experience of the resource situation, staffing and competence level were suggested to affect hospital readmissions and the municipalities were similar in their answers regarding these factors. Patients were perceived as more complex with higher patient mortality forcing long-term nursing homes to shift towards an acute care or palliative function, and short-term nursing homes to function as “small hospitals”, requiring higher nurse competence. Staffing, competence and physician coverage did not seem to have adjusted to the new patient group in some nursing homes.publishedVersio