Reducing hospital readmissions amongst people experiencing homelessness: a mixed-methods evaluation of a multi-disciplinary hospital in-reach programme.

INTRODUCTION: People experiencing homelessness are at increased risk of experiencing ill-health. They are often readmitted to hospital after discharge, usually for the same or similar reasons for initial hospitalisation. One way of addressing this issue is through hospital in-reach initiatives, which have been established to enhance the treatment and discharge pathways that patients identified as homeless receive after hospital admission. Since 2020, the Hospital In-reach programme (which involves targeted clinical interventions and structured discharge support) has been piloted in two large National Health Service (NHS) hospitals in Edinburgh, United Kingdom (UK). This study describes an evaluation of the programme. METHODS: This evaluation used a mixed method, pre-post design. To assess the effect of the programme on hospital readmission rates from baseline (12 months pre-intervention) and follow-up (12 months post-intervention), aggregate data describing the proportions of homeless-affected individuals admitted to hospital during the evaluation period were analysed using Wilcoxon signed rank test, with level of significance set at p = 0.05. Qualitative interviews were conducted with fifteen programme and hospital staff (nurses, general practitioners, homeless link workers) to assess the processes of the programme. RESULTS: A total of 768 referrals, including readmissions, were made to the In-reach programme during the study period, of which eighty-eight individuals were followed up as part of the study. In comparison to admissions in the previous 12 months, readmissions were significantly reduced at 12 months follow-up by 68.7% (P = 0.001) for those who received an in-reach intervention of any kind. Qualitative findings showed that the programme was valued by hospital staff and homeless community workers. Housing services and clinical staff attributed improvements in services to their ability to collaborate more effectively in secondary care settings. This ensured treatment regimens were completed and housing was retained during hospital admission, which facilitated earlier discharge planning. CONCLUSIONS: A multidisciplinary approach to reducing readmissions in people experiencing homelessness was effective at reducing readmissions over a 12-month period. The programme appears to have enhanced the ability for multiple agencies to work more closely and ensure the appropriate care is provided for those at risk of readmission to hospital among people affected by homelessness.

Outreach-based clinical pharmacist prescribing input into the healthcare of people experiencing homelessness: a qualitative investigation.

BACKGROUND: Severely and multiply disadvantaged members of the homeless population are disproportionately vulnerable to exceptionally high levels of multi-morbidity and premature death. Given widespread calls for the development of interventions that might improve the uptake and effectiveness of healthcare for this population, this study investigated patient and other stakeholder perspectives regarding an outreach service, delivered by prescribing pharmacists in collaboration with a local voluntary sector provider, within homelessness services and on the street in Glasgow (UK). METHODS: The qualitative study involved semi-structured face-to-face interviews with 40 purposively sampled individuals with current or recent experience of homelessness (32 of whom had direct experience of the service and 8 of whom did not), all (n = 4) staff involved in frontline delivery of the service, and 10 representatives of stakeholder agencies working in partnership with the service and/or with the same client group. Pseudonymised verbatim interview transcriptions were analysed systematically via thematic and framework analysis. RESULTS: The service was effective at case finding and engaging with patients who were reluctant to utilise or physically unable to access existing (mainstream or specialist 'homeless') healthcare provision. It helped patients overcome many of the barriers that homeless people commonly face when attempting to access healthcare, enabled immediate diagnosis and prescription of medication, and catalysed and capitalised on windows of opportunity when patients were motivated to address healthcare needs. A number of improvements in health outcomes, including but not limited to medication adherence, were also reported. CONCLUSIONS: A proactive, informal, flexible, holistic and person-centred outreach service delivered within homelessness service settings and on the street can act as a valuable bridge to both primary and secondary healthcare for people experiencing homelessness who would otherwise 'fall through the gaps' of provision. Prescribing pharmacist input coupled with third sector involvement into healthcare for this vulnerable population allows for the prompt treatment of and/or prescription for a range of conditions, and offers substantial potential for improving health-related outcomes.

"I just can't sit around and do nothing!": A qualitative study of Indonesian women's experiences diagnosed with heart disease.

Research into cardiovascular disease and its management in Indonesia, where it currently accounts for 67% of all deaths, has heavily emphasized the biomedical aspects; little is known about the individual's experience of the disease, especially for Indonesian women. This study aimed to understand how gender shapes Indonesian women's experiences of living with heart disease in their daily lives. Twenty-six women aged 30-67 years were interviewed, and the transcriptions analyzed using a qualitative framework informed by intersectional approaches to gender and culture. Three major themes emerged: (i) the effect of cardiovascular disease on women's day-to-day activities, (ii) its effects on women's family relationships, and (iii) the women's coping strategies. The inability to fulfill their required social roles as mother or wife undermined the women's sense of self, a problem particularly acute in a cultural context where responsibility for maintaining harmony in the home and society is ascribed to women. Healthcare professionals should be aware of the ethnic and cultural backgrounds of women with cardiovascular disease, in order to deliver services that meet female patients' social, spiritual, and cultural needs.

Home level bureaucracy: moving beyond the 'street' to uncover the ways that place shapes the ways that community public health nurses implement domestic abuse policy.

Street-level bureaucracy is an increasingly useful way to understand how strategic policy is implemented in day-to-day practice. This approach has uncovered the ways that individual health and social care practitioners work within institutional constraints to influence policy implementation at the micro-level. Nonetheless, despite the diversity of settings where these street-level bureaucrats (SLBs) work, little attention has been focused on the impact of place on policy delivery. This paper draws on empirical research to examine the ways that delivering government domestic abuse policy in the intimate space of the family home shapes the delivery of strategic policy in the everyday. Drawing on qualitative research with Health Visitors (HVs) in the UK in 2016, the study findings illuminate the ways that the material, socio-spatial and idealised boundaries of the family home shape the implementation of policy. Key themes in the HV's narratives emerged as they described themselves as both a danger and in danger in the family home. In challenging the ontological security of the home (Giddens 1990) - privacy, security and control are key concepts here - HVs described how they shape their actions to achieve policy outcomes while simultaneously managing threats to the home, to professional identity and to self.

Political representation for social justice in nursing: lessons learned from participant research with destitute asylum seekers in the UK.

The concept of social justice is making a revival in nursing scholarship, in part in response to widening health inequalities and inequities in high-income countries. In particular, critical nurse scholars have sought to develop participatory research methods using peer researchers to represent the 'voice' of people who are living in marginalized spaces in society. The aim of this paper is to report on the experiences of nurse and peer researchers as part of a project to explore the experiences of people who find themselves destitute following the asylum process in the UK. In seeking to explore social injustice, three challenges are identified: lack of a robust political theory, institutional/professional constraints and an absence of skills to engage with the politics of social (in)justice. Each challenge is presented, opposing voices outlined and some possible solutions are suggested. The work of political theorist Nancy Fraser is used as a conceptual framework, in particular her focus on mis/framing and political representation for social justice. In addition, it is suggested that social justice needs to be further embedded in nursing policy and curriculum. Finally, nurses are encouraged to develop practical political skills to engage with both politics and the media in a neoliberal globalizing world.

Fluctuating power: an exploration of refugee health nursing within the resettlement context in Victoria, Australia.

Background: The Refugee Health Program (RHP) is a nurse-led community initiative, introduced in 2005 with the aim of responding to complex health issues of refugees arriving in Victoria, Australia. Little is known about refugee health nursing in the resettlement context and the impact of dedicated refugee healthcare. Aim: To explore the experiences and perspectives of Refugee Health Nurses (RHNs), Refugee Health Managers (managers) and refugees, gaining insight into professional relationships and the complexities of offering a specialised refugee health service. Method: A focused ethnographic approach incorporated semi-structured interviews with five RHNs, two managers and eight refugees, two focus groups with refugees and participant observation within the RHP during April 2017 to December 2017. Data collection was undertaken across two sites and interviews, focus groups and observations were transcribed and thematically analysed. Social constructionism asserts that the focus of enquiry should be on interaction, group processes and social practices. Emphasis is placed upon relationships between RHNs, managers and refugees, with knowledge viewed as relational and interactional. Results: Professional relationships between RHNs and refugees are complex, with power oscillating between them. Contrary to discourses of 'vulnerability' of refugees, both RHNs and refugees demonstrated power in their relationships with each other. Nurses also suggested that these relationships were stressful and could lead to burnout. Key themes were developed: (1) nursing autonomy and gatekeeping; (2) vicarious trauma and burnout; and (3) refugee negotiation of care. Conclusions: The balance of power is central to therapeutic relationships. In relationships between RHNs and refugees, power fluctuates as RHNs are exposed to vicarious trauma and symptoms of burnout, while refugees exercise agency by recognising benefits to specialised care. In developing effective therapeutic relationships between RHNs and refugees, attention should be paid to how care is delivered to protect RHNs from burnout while ensuring that refugees receive appropriate care.

Nursing students' knowledge, attitudes, preparedness and practice towards intimate partner violence against women: a scoping review and thematic synthesis.

BACKGROUND: Nursing students regularly work with women who have experienced intimate partner violence in their clinical placements and subsequently as registered nurses. They have a role in early detection, intervention, onward referral and education of women about intimate partner violence. Therefore, it is necessary to gain a comprehensive understanding of their capability to care for abused women and identify learning needs. Nonetheless, the level of preparedness of nursing students to deal with intimate partner violence has not been reviewed. AIM: To search and review the existing evidence on nursing students' knowledge, attitudes, preparedness and practice towards intimate partner violence. METHOD: This scoping review was guided using the PRISMA extension checklist for scoping reviews. Four databases were searched to identify relevant evidence published between 2010 and 2021. The review included eighteen empirical studies (10 quantitative, 4 qualitative and 4 mixed-method studies). Data were extracted and synthesized into seven themes. RESULT: Nursing students were more knowledgeable of and readily recognized physical and sexual abuse than psychological abuse. Nursing students' roles and attitudes varied widely between different countries. Students faced difficulty in identifying and managing intimate partner violence clinically. Students who received education on domestic violence held more positive attitudes and were more knowledgeable and prepared. CONCLUSION: Nurse educators need to enhance students' understanding and perception of intimate partner violence and optimize their capability to manage it in the clinical setting. This study identifies barriers to nursing students' readiness to manage intimate partner violence and suggests four areas of development for nursing curricula.

Benefits of GP care in outreach settings for people experiencing homelessness: a qualitative study.

BACKGROUND: Although people experiencing homelessness (PEH) have the worst health outcomes in society, they have a low uptake of primary care services. GP outreach has developed as a way of increasing their access into primary care but little is known about the experience of patients receiving care in this way. AIM: To explore PEHs' experiences of GP care in community outreach settings in UK; and to seek staff/volunteers' views on the strengths and weaknesses of GP community outreach services. DESIGN AND SETTING: A multi-method qualitative study with PEH and staff/volunteers working in three different community outreach settings in the UK. METHOD: Individual semi-structured interviews were carried out with 22 PEH and two focus groups with key staff/volunteers. Data were analysed thematically using framework analysis. RESULTS: GP outreach services better enabled PEH to access medical care and staff/volunteers valued GP support to promote, and facilitate access to, healthcare services. In particular, the findings illuminate the high value that PEH placed on the organisational environment of the GP outreach service. Valued aspects of GP outreach were identified as comfortable, safe, and engendering a sense of belonging; convenient, opportunistic, and a one-stop shop; and being heard, having more time, and breaking down barriers. CONCLUSION: The organisational environment is important in enabling PEH to engage with GP services. The physical and organisational environment of the outreach settings were the most important factors; they created a space where professional barriers between the GP and patients were flattened, so facilitating a therapeutic relationship.

'A bridge to normal': a qualitative study of Indonesian women's attendance in a phase two cardiac rehabilitation programme.

BACKGROUND: Cardiac rehabilitation is effective in reducing mortality and morbidity, in improving life expectancy and quality of life for people with cardiovascular disease. Despite these recognised benefits, women's attendance rates in cardiac rehabilitation programmes remain suboptimal. AIMS: This paper details the study that explored factors that influence women's attendance of a phase two cardiac rehabilitation programme in Indonesia. METHODS: An exploratory qualitative research design was used in the study. Semi-structured interviews were used as the main method of data collection. Data were collected from June to September 2016. Twenty-three women aged between 30 and 66 years were interviewed. Transcribed interview data were analysed using a qualitative framework analysis. RESULTS: Three major themes were inferred from the analysis: (a) a bridge to normal; (b) connecting with others; and (c) contextual factors. The first theme is illustrated by two subthemes: 'making my heart work again' and 'performing social roles'. The second theme was illustrated by the following subthemes: 'exchanging knowledge and experience' and 'developing a give-and-take relationship'. The third theme was illustrated by three subthemes: 'recommendations from the staff', 'family support' and 'availability of health insurance'. CONCLUSION: Women's attendance in cardiac rehabilitation in Indonesia is mainly influenced by their expectations and desire to be able to resume their previous social roles in the family and society. The findings of this study can assist healthcare professionals to understand better the needs of women and the fit between women's needs and existing cardiac rehabilitation programmes. Such understanding could provide direction for more effective approaches to the cardiac rehabilitation programmes that are currently offered in Indonesia.

Sensitivity and specificity of procedures for the differential diagnosis of epileptic and non-epileptic seizures: a systematic review.

OBJECTIVES: Non-epileptic seizures (NES) present a considerable challenge in clinical practice. This paper reviews published evidence for the reliability of a number of procedures for the differential diagnosis of NES and epilepsy. METHODS: Papers identified from MEDLINE and PsychInfo Databases (1980-2001) and additional hand searches were independently reviewed using methods for evaluating evidence in systematic reviews [Liddle, J., Williamson, M. Irwig, L. Method for evaluating research guideline evidence. New South Wales Department of Health; 1996 [State Health publication no. (CEB) 96-204]; SIGN. An introduction to SIGN methodology for the development of evidence based clinical guidelines. Scottish Intercollegiate Network; 1999]. Included studies had to have an NES group and a control group of people with epilepsy (each n> or =10), allocated using EEG linked video-recording of concurrent behaviour, and sensitivity and specificity values had to be stated or be calculable. RESULTS: Thirty-three papers were identified, of which 13 satisfied criteria. Excluded studies are briefly described. Those retained comprised a range of procedures [seizure induction, MMPI assessment, physiological assessment (prolactin, SPECT), pre-ictal pseudosleep, and ictal/post-ictal characteristics]. No procedure emerged with both high sensitivity and specificity and adequately replicated findings, although high levels of specificity were more commonly reported than high levels of sensitivity. This suggests that procedures were generally better at excluding a possible diagnosis. CONCLUSIONS: No procedure attains reliability equivalent to EEG video-telemetry. Further rigorous evaluation, using standardised and replicable methodologies, is required. The range of symptoms presented in NES suggests that a multi-method approach may be required. This too would require evaluation.

[Educational Inequality in Physical Inactivity in Leisure Time in Spanish Adult Population: differences in Ten Years (2002-2012)]. / Desigualdad en la prevalencia de sedentarismo durante el tiempo libre en población adulta española según su nivel de educación: diferencias entre 2002 y 2012.

BACKGROUND: Social inequality in health is an increasing phenomenon in the world. The aim was to compare in 2002 and 2012, the magnitude of inequalities in leisure-time physical inactivity by educational level in Spain, but also the trends in health perception, in physically inactive people. METHODS: A cross-sectional study from the National Health Survey in Spain in 2002 (n=21,650) and 2012 (n=21,007). The population aged from 25 to 64 years. At the first stage, physical inactivity in leisure-time was the dependent variable, and educational level was the independent variable. At the second stage, self-perception of health in last 12 months was the dependent variable. Logistic regression was adjusted using other variables: age, marital status, employment status and social class of the head of the family. RESULTS: Prevalence of leisure time physical inactivity was in 2012, up to 53.9% (men) and 67.5% (women), in the group aged between 25-44 with primary education. It declined in all age and sex groups in 2012, compared to 2002 (down to 18.7 percentage points). More than three times inactive women in between those who have primary or less education: OR 3.27 (2.35-4.55) in 2012. Bad health perceived in women with less educational level comparing with those with higher education. It also has declined over time: OR 1.45 in 2002 to OR 1.91, in 2012 (45-64 aged group). CONCLUSIONS: Although the prevalence of physical inactivity has decreased, inequalities in such behavior have increased in 2012 respect 2002.

Understanding the ways in which health visitors manage anxiety in cross-cultural work: a qualitative study.

AIM: This paper is a report of part of a study that explored the ways in which health visitors manage uncertainty and anxiety when working with clients across cultures. BACKGROUND: Internationally health care professionals are required to deliver a high standard of culturally appropriate care to increasingly diverse communities and yet problems persist. Research evidence informing cultural 'competence' is focused largely around student experience and consequently little is known about the day-to-day experiences of health professionals in diverse community settings. Anxiety and uncertainty are increasingly recognised as important emotions experienced by a variety of health care professionals when working across cultures and yet the ways in which anxiety and uncertainty is managed in practice is less well understood. DESIGN: Grounded theory methodology was used and 21 semi-structured interviews were conducted with participating health visitors in the North East of England between May 2008 and September 2009. All participants described themselves as white. FINDINGS: This study identified three different positions adopted by the health visitors to manage uncertainty and anxiety in their work across cultures. Identified as, 'Fixing a culture', 'Reworking the equality agenda' and 'Asserting the professional self', these strategies identify the ways in which health visitors try to manage the uncertainty and anxiety they feel when working in diverse communities. All of these strategies attempt in different ways to negate cultural difference and to render culture as static and known. CONCLUSION: Given that health professionals report anxiety and uncertainty when working across diverse community settings, identification of the strategies used by health visitors to manage that anxiety is important for both policy and practice. New strategies need to be developed to help health professionals to manage uncertainty and anxiety in ways that promote both cultural safe care and health equity.

Development and psychometric properties of the Glasgow Depression Scale for people with a Learning Disability. Individual and carer supplement versions.

BACKGROUND: There is no reliable and valid self-report measure of depressive symptoms for people with learning disabilities. AIMS: To develop a scale for individuals with learning disability, and a supplementary scale for carers. METHOD: Items were generated from a range of assessment scales and through focus groups. A draft scale was piloted and field tested using matched groups of people with or without depression, and their carers. The scale was also administered to a group without learning disabilities for criterion validation. RESULTS: The Glasgow Depression Scale for people with a Learning Disability (GDS-LD) differentiated depression and non-depression groups, correlated with the Beck Depression Inventory - II (r=0.88), had good test-retest reliability (r=0.97) and internal consistency (Cronbach's alpha=0.90), and a cut-off score (13) yielded 96% sensitivity and 90% specificity. The Carer Supplement was also reliable (r=0.98; alpha=0.88), correlating with the GDS-LD (r=0.93). CONCLUSIONS: Both scales appear useful for screening, monitoring progress and contributing to outcome appraisal.