Approaches for improving sexuality and sexual health care in mental health settings: A qualitative study exploring clinicians' own perspectives.

There is an acknowledged professional practice gap regarding sexuality and sexual health related needs within mental health settings in Australia and internationally. Yet little is known about how clinicians can be best supported or enabled to improve sexuality-related practice, from their own perspective. This is important, given the sensitive and complex nature of sexuality and sexual health within the context of mental distress and service provision. This article reports a follow-up study, where mental health clinicians who participated in an initial study were invited to reflect on and discuss the (finalized) results and recommendations generated. The aim was to generate insights into the tools, strategies, and approaches participants felt would best equip and support clinicians to better incorporate sexuality and sexual health into their work. Six clinicians from three disciplines (mental health nursing, psychology, and psychiatry) participated in in-depth interviews to reflect on a plain language summary of the initial study. Three interconnected themes were generated via reflexive thematic analysis: (1) access to knowledge and information; (2) support from peers, senior colleagues, and workplaces; and (3) enacting a focus on sexuality-related care. These findings provide valuable insights into how clinicians may want to be supported in relation to (improving) their sexuality-related practice. The analysis also demonstrates the importance of a multifaceted approach to improving sexuality-related care in mental health and other health settings. This knowledge will contribute to directing future research and development of interventions, tools, strategies, or other approaches to this end.

'I wasn't made to feel like a nut case after all': A qualitative story completion study exploring healthcare recipient and carer perceptions of good professional caregiving relationships.

BACKGROUND: Professional caregiving relationships are central to quality healthcare but are not always developed to a consistently high standard in clinical practice. Existing literature on what constitutes high-quality relationships and how they should be developed is plagued by dyadic conceptualisations; discipline, context and condition-specific research; and the absence of healthcare recipient and informal carer voices. This study aimed to address these issues by exploring how healthcare recipients and carers conceptualise good professional caregiving relationships regardless of discipline, care setting and clinical condition. DESIGN: A qualitative story completion approach was used. Participants completed a story in response to a hypothetical stem that described a healthcare recipient (and, in some instances, carer) developing a good relationship with a new healthcare provider. Stories were analysed using reflexive thematic analysis. PARTICIPANTS: Participants were 35 healthcare recipients and 37 carers (n = 72 total). RESULTS: Participants' stories were shaped by an overarching discourse that seeking help from new providers can elicit a range of unwanted emotions for both recipients and carers (e.g., anxiety, fear, dread). These unwanted emotions were experienced in relation to recipients' presenting health problems as well as their anticipated interactions with providers. Specifically, recipient and carer characters were fearful that providers would dismiss their concerns and judge them for deciding to seek help. Good relationships were seen to develop when healthcare providers worked to relieve or minimise these unwanted emotions, ensuring healthcare recipients and carers felt comfortable and at ease with the provider and the encounter. Participants positioned healthcare providers as primarily responsible for relieving recipients' and carers' unwanted emotions, which was achieved via four approaches: (1) easing into the encounter, (2) demonstrating interest in and understanding of recipients' presenting problems, (3) validating recipients' presenting problems and (4) enabling and respecting recipient choice. Participants' stories also routinely oriented to temporality, positioning relationships within recipients' and carers' wider care networks and biographical and temporal contexts. CONCLUSION: The findings expand our understanding of professional caregiving relationships beyond dyadic, static conceptualisations. Specifically, the findings suggest that high-quality relationships might be achieved via a set of core healthcare provider behaviours that can be employed across disciplinary, context and condition-specific boundaries. In turn, this provides a basis to support interprofessional education and multidisciplinary healthcare delivery, enabling different healthcare disciplines, specialties, and teams to work from the same understanding of what is required to develop high-quality relationships. PATIENT OR PUBLIC CONTRIBUTION: The findings are based on stories from 72 healthcare recipient and carer participants, providing rich insight into their conceptualisations of high-quality professional caregiving relationships.

Qualitative Story Completion: Opportunities and Considerations for Health Research.

Qualitative story completion (QSC) is an innovative research method that offers researchers a range of unique opportunities for generating and analysing data. Participants are asked to write a 'story' in response to a hypothetical 'story stem', often in the third-person and involving fictional characters, rather than reporting on their direct experiences. QSC is being developed and increasingly taken up by researchers working across a range of fields; but it has been little used in health research, especially in the fields of nursing, health services research, medicine, and allied health. This means that health researchers have few examples to draw on when considering what QSC can offer them and how to rigorously design, conduct, and report a QSC study within health-related fields. We aim to address this gap and contribute to existing QSC literature by promoting increased use of QSC by health researchers and supporting them to produce rigorous QSC research. We outline three case examples illustrating how we have used QSC to conduct multidisciplinary health research relevant to nursing, medicine and nutrition. Drawing on these case examples, we reflect on challenges that we encountered, describe decision-making processes, and offer recommendations for conducting rigorous health research using QSC.

Why reducing avoidable hospital readmissions is a 'wicked' problem for leaders: A qualitative exploration of nursing and allied health perceptions.

AIMS: To investigate nursing and allied health professional perceptions of the interrelationship between avoidable hospital readmissions and fundamental care delivery. DESIGN: A qualitative, exploratory study using a critical realist approach. METHOD: One-to-one semi-structured interviews with 14 nursing and allied health professionals conducted between May and September 2019. RESULTS: Several tensions and contradictions were identified in the data, which demonstrated clinicians' perceptions about the priority of both fundamental care and two avoidable readmission conditions (aspiration pneumonia and constipation). These tensions are illustrated in two major themes: Avoidable versus inevitable; and everyone versus no one. The first theme demonstrates clinicians' perceptions that readmissions for aspiration pneumonia and constipation are not common, despite acknowledging that they generally lacked knowledge on readmission rates; and that these conditions may not be preventable in acute settings. The second theme demonstrates clinicians' perception that preventing readmissions is everyone's responsibility, however, this was coupled with a lack of articulation around how this multidisciplinary approach could be achieved, leading to a distinct lack of agency for care delivery. CONCLUSION: Articulating the tensions described in the results provides vital knowledge for understanding how clinicians may respond to initiatives designed to reduce avoidable readmissions. Avoidable hospital readmissions may be usefully understood as a wicked problem: one that is complex and requires adaptive, not linear, solutions. Wicked problems pose a challenge for leaders and managers in healthcare because top-down, hierarchical strategies are unlikely to be successful. Effective prevention of avoidable readmissions requires leaders to enable facilitator-led change through relational leadership strategies. IMPACT: Avoidable hospital readmissions are a global problem increasingly addressed via funding changes and the introduction of penalties to hospitals. This study provides insights on clinicians' perspectives of avoidable hospital readmissions and their prevention, demonstrating the complexity of this challenge and the need for healthcare leaders to enable individual and organizational readiness for change.

'It's Not Really a Part of Standard Practice': Institutional Silencing of Sexuality Within Australian Mental Health Settings.

Research seeking to understand and improve sexuality-related practice in mental health settings has paid little attention to the institutional context in which clinicians' practice is embedded. Through a social constructionist lens, we used thematic analysis to examine how 22 Australian mental health clinicians implicated the wider institutional context when discussing and making sense of sexuality-related silence within their work. Interviews were part of a study exploring participants' perceptions of sexuality and sexual health in their work more generally. Broader silences that shaped and reinforced participants' perceptions and practice choices were situated in professional education; workplace cultures; and the tools, procedures and policies that directed clinical practice. We argue that sexuality-related silence in mental health settings is located in the institutional context in which clinicians learn and work, and discuss how orienting to this broader context will benefit research and interventions to improve sexuality-related practice across health settings.

Who decides when people can have sex? Australian mental health clinicians' perceptions of sexuality and autonomy.

Sexuality is a central aspect of human experience but there is evidence that this is largely constrained, pathologised or ignored in mental health settings. We conducted in-depth interviews with 22 psychologists, psychiatrists and mental health nurses working across a variety of settings in four Australian cities. Sexuality was most often perceived as relevant in the mental health setting when it was simultaneously constructed as dangerous. Participants located this danger in sexual expression itself or within individuals who, because of mental illness, lacked the autonomy required to successfully engage in 'safe' sex. We discuss these findings and their implications for research and professional practice.

'It's just a peripheral issue': A qualitative analysis of mental health clinicians' accounts of (not) addressing sexuality in their work.

Sexuality, relationships, and intimacy are integral parts of many peoples' lives, not negated by mental distress and illness. Yet typically, these needs are not addressed adequately in mental health settings. In-depth interviews were conducted with mental health clinicians with an aim of exploring their perceptions and understandings of sexuality and sexual concerns within mental health settings. Participants were 22 mental health nurses, psychologists, and psychiatrists working with people across a range of settings in four Australian cities. Sexuality or aspects of this were often not addressed in clinical practice, and this was common across participants' accounts. A critical thematic analysis was conducted to explore how participants made sense of or explained this silence in relation to sexuality. Two key themes were 'Sexuality is hard to talk about' and 'Sexuality is a "peripheral issue"'. In positioning sexuality as a peripheral issue, participants drew on three key explanations (sub-themes): that sexuality rarely 'comes up', that it is not pragmatic to address sexuality, and that addressing sexuality is not part of participants' roles or skill sets. A third theme captured the contrasting perception that 'Sexuality could be better addressed' in mental health settings. This analysis indicates that, beyond anticipated embarrassment, mental health clinicians from three disciplines account for omissions of sexuality from clinical practice in similar ways. Moreover, these accounts serve to peripheralize sexuality in mental health settings. We consider these results within the context of espoused holistic and recovery-oriented principles in mental health settings.

Age-related differences in sequence learning: Findings from two visuo-motor sequence learning tasks.

The Serial Reaction Time Task (SRTT) is thought to assess implicit learning, which seems to be preserved with age. However, the reaction time (RT) measures employed on implicit-like tasks might be too unreliable to detect individual differences. We investigated whether RT-based measures mask age effects by comparing the performance of 43 younger and 35 older adults on SRTT and an explicit-like Predictive Sequence Learning Task (PSLT). RT-based measures (difference scores and a ratio) were collected for both tasks, and accuracy was additionally measured for PSLT. We also measured fluid abilities. The RT-difference scores indicated preserved SRTT and PSLT performance with age and did not correlate with fluid abilities, while ratio RT and the accuracy-based measures indicated age-related decline and correlated with fluid abilities. Therefore, RT-difference scores might mask individual differences, which compromises the interpretation of previous studies using SRTT.

Commonly-occurring polymorphisms in the COMT, DRD1 and DRD2 genes influence different aspects of motor sequence learning in humans.

Performing sequences of movements is a ubiquitous skill that involves dopamine transmission. However, it is unclear which components of the dopamine system contribute to which aspects of motor sequence learning. Here we used a genetic approach to investigate the relationship between different components of the dopamine system and specific aspects of sequence learning in humans. In particular, we investigated variations in genes that code for the catechol-O-methyltransferase (COMT) enzyme, the dopamine transporter (DAT) and dopamine D1 and D2 receptors (DRD1 and DRD2). COMT and the DAT regulate dopamine availability in the prefrontal cortex and the striatum, respectively, two key regions recruited during learning, whereas dopamine D1 and D2 receptors are thought to be involved in long-term potentiation and depression, respectively. We show that polymorphisms in the COMT, DRD1 and DRD2 genes differentially affect behavioral performance on a sequence learning task in 161 Caucasian participants. The DRD1 polymorphism predicted the ability to learn new sequences, the DRD2 polymorphism predicted the ability to perform a previously learnt sequence after performing interfering random movements, whereas the COMT polymorphism predicted the ability to switch flexibly between two sequences. We used computer simulations to explore potential mechanisms underlying these effects, which revealed that the DRD1 and DRD2 effects are possibly related to neuroplasticity. Our prediction-error algorithm estimated faster rates of connection strengthening in genotype groups with presumably higher D1 receptor densities, and faster rates of connection weakening in genotype groups with presumably higher D2 receptor densities. Consistent with current dopamine theories, these simulations suggest that D1-mediated neuroplasticity contributes to learning to select appropriate actions, whereas D2-mediated neuroplasticity is involved in learning to inhibit incorrect action plans. However, the learning algorithm did not account for the COMT effect, suggesting that prefrontal dopamine availability might affect sequence switching via other, non-learning, mechanisms. These findings provide insight into the function of the dopamine system, which is relevant to the development of treatments for disorders such as Parkinson's disease. Our results suggest that treatments targeting dopamine D1 receptors may improve learning of novel sequences, whereas those targeting dopamine D2 receptors may improve the ability to initiate previously learned sequences of movements.

Accuracy-based measures provide a better measure of sequence learning than reaction time-based measures.

The Serial Reaction Time Task (SRTT) was designed to measure motor sequence learning and is widely used in many fields in cognitive science and neuroscience. However, the common performance measures derived from SRTT-reaction time (RT) difference scores-may not provide valid measures of sequence learning. This is because RT-difference scores may be subject to floor effects and otherwise not sufficiently reflective of learning. A ratio RT measure might minimize floor effects. Furthermore, measures derived from predictive accuracy may provide a better assessment of sequence learning. Accordingly, we developed a Predictive Sequence Learning Task (PSLT) in which performance can be assessed via both RT and predictive accuracy. We compared performance of N = 99 adults on SRTT and PSLT in a within-subjects design and also measured fluid abilities. The RT-difference scores on both tasks were generally not related to fluid abilities, replicating previous findings. In contrast, a ratio RT measure on SRTT and PSLT and accuracy measures on PSLT were related to fluid abilities. The accuracy measures also indicated an age-related decline in performance on PSLT. The current patterns of results were thus inconsistent across different measures on the same tasks, and we demonstrate that this discrepancy is potentially due to floor effects on the RT difference scores. This may limit the potential of SRTT to measure sequence learning and we argue that PSLT accuracy measures could provide a more accurate reflection of learning ability.