Indigenous lands and health access: The influence of a sense of place on disparities in post-stroke recovery in Taiwan.

Despite many countries having policies and systems for universal healthcare coverage, health disparity persists, with significant variations in disease prevalence and life expectancy between different groups of people. This focused ethnography explored the post-stroke recovery of Indigenous and non-Indigenous populations in three geographical areas in Taiwan. Forty-eight observations and 24 interviews were carried out with 12 dyads of stroke survivors and family caregivers, revealing their varied experiences of healthcare. Findings indicate that repeatedly engaging in social activities in the same place increases stroke survivors' attachment to the environment, facilitating their reintegration into the community and improving wellbeing following stroke. The significance of 'place' in post-stroke life and healthcare access is particularly salient for Indigenous people's recovery. Indigenous people tend to employ cultural symbols, such as Indigenous languages and kinship ties, to define and interpret their surrounding environment and identity. Indigenous people residing within or close to their own native communities make better recoveries than those based in urban settings, who are attached to and yet located away from their native lands. A sense of place contributes to identity, while loss of it leads to invisibility and healthcare inaccessibility. To promote equitable healthcare access, future policymaking and care practices should address the environmental and cultural geography and structural barriers that impede the connection between minority groups and the mainstream community healthcare system. The study findings suggest extending welfare resources beyond Indigenous administrative regions and establishing partnerships between Indigenous organisations and the mainstream healthcare system. Leveraging Indigenous people's attachment to cultural symbols and increasing healthcare facilities staffed with Indigenous healthcare workers could help ease structural barriers, maintain identifiable Indigenous beneficiaries and increase entry points into the mainstream healthcare system.

Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Unit Discharge: The RECOVER Randomized Clinical Trial.

IMPORTANCE: Critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. OBJECTIVE: To evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post-intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. DESIGN, SETTING, AND PARTICIPANTS: A parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. INTERVENTIONS: During the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. MAIN OUTCOMES AND MEASURES: The Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). RESULTS: Median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, -0.2 [95% CI, -1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, -0.1 [95% CI, -3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, -3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. CONCLUSIONS AND RELEVANCE: Post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery. TRIAL REGISTRATION: isrctn.com Identifier: ISRCTN09412438.

Shifting the balance of care? A qualitative study of policy implementation in community nursing.

AIM: This qualitative study examined the interaction between policy implementation and service organisation and delivery for community nursing services. BACKGROUND: Leadership in nursing is at the fore front of the policy agenda for shifting the balance of care from hospitals to the community setting and for improving the quality of healthcare services. Yet, little is known about the implementation of policy within the community setting. METHOD: A qualitative, interpretive analysis including semi-structured interviews with nurse leaders (n = 12) and community nurses (n = 27) and three focus groups (n = 13) with community nurses (Total N = 39) in three Health Boards in Scotland. RESULTS: Policy implementation is not adequately integrated between primary and secondary care service at the point of care delivery. The 'top down approach' to policy implementation for shifting the balance of care is currently at odds with the grass roots service organisation and delivery in the community setting. CONCLUSIONS: The aspirations of integrated, collaborative health and social care require more clinicians working at the frontline in both primary and secondary care to value more the work of colleagues in the different sectors. IMPLICATION FOR NURSING MANAGEMENT: The current 'top down approach' to policy implementation encourages resistance in the frontline community nurses rather than commitment. A more 'bottom up' integrated approach to policy implementation is therefore required.

Understanding leadership in community nursing in Scotland.

There is limited evidence concerning leadership in community nursing. NHS policy also fails to clarify and define what leadership is, though regarding it as key to developing safe and high quality care. This paper reports the findings of a research study that aimed to identify how leadership is perceived and experienced by community nurses, and to examine the interaction between recent policy and leadership development in community nursing. Mixed qualitative methods were used involving 31 individual interviews and three focus groups with community nurses and nurse leaders (n-39) in three health boards in Scotland. Findings indicate the leadership qualities valued by participants, including the importance of leaders' visibility. Team leaders in particular were recognised for their visibility and clinical leadership. Strategic and professional leadership was less evident, so acting as a barrier to the development of the profession. The strategic vision was often not clear to community nurses, and they engaged in differing ways with the strategies and action plans of senior nurse leaders. New leadership roles, like change, need time to evolve and new leaders need space and the education to develop leadership. Future leaders in community nursing need to focus beyond clinical leadership, ensuring that good leadership is a process requiring interdependence between leaders and followers.