In-Home Respite Care Services Available to Families With Palliative Care Needs in Quebec: Novel Digital Environmental Scan.

BACKGROUND: Caregiving dyads in palliative care are confronted with complex care needs. Respite care services can be highly beneficial in alleviating the caregiving burden, supporting survivorship and dying at home. Yet, respite care services are difficult to locate and access in the province of Quebec, Canada, particularly when navigating ubiquitous sources of online health information of varying quality. OBJECTIVE: This project aimed to (1) compile a list of at-home palliative respite care services in Quebec, Canada; (2) describe key accessibility features for each respite care service; (3) identify accessibility gaps and opportunities; and (4) describe a novel method for conducting environmental scans using internet search engines, internet-based community health databases, and member checking. METHODS: A novel environmental scan methodology using 2 internet-based targeted databases and 1 internet search engine was conducted. Results were screened and data were extracted, descriptively analyzed, and geographically schematized. RESULTS: A total of 401 services were screened, and 52 at-home respite care services specific to palliative populations were identified, compiled, and analyzed. These respite care services were characterized by various types of assistance, providers, fees, and serviced geographical regions. Accessibility was explored through the lens of service amenability, availability, eligibility, and compatibility. The data revealed important barriers to accessing respite care services, such as a lack of readily available information on service characteristics, limited availability, and a time-consuming, technical search process for potential respite care users and clinicians to identify appropriate services. CONCLUSIONS: Both methodological and contextual knowledge have been gained through this environmental scan. Few methodologies for conducting internet-based environmental scans have been clearly articulated, so we applied several learnings from other scans and devised a methodology for conducting an environmental scan using the mixed methods of internet search engines, internet-based community health databases, and member checking. We have carefully reported our methods, so that others conducting community health environmental scans may replicate our process. Furthermore, through this scan, we identified assorted respite care services and pinpointed needs in the provision of these services. The findings highlighted that more easily accessible and centralized information about respite care services is needed in Quebec. The data will enable the creation of a user-friendly tool to share with community support services across Quebec and ultimately help alleviate the added burden caregivers and clinicians face when looking for respite care services in fragmented and complex digital spaces.

Acceptance of the Apple Watch Series 6 for Telemonitoring of Older Adults With Chronic Obstructive Pulmonary Disease: Qualitative Descriptive Study Part 1.

BACKGROUND: The Apple Watch is not a medical device per se; it is a smart wearable device that is increasingly being used for health monitoring. Evidence exists that the Apple Watch Series 6 can reliably measure blood oxygen saturation (SpO2) in patients with chronic obstructive pulmonary disease under controlled circumstances. OBJECTIVE: This study aimed to better understand older adults' acceptance of the Watch as a part of telemonitoring, even with these advancements. METHODS: This study conducted content analysis on data collected from 10 older adults with chronic obstructive pulmonary disease who consented to wear the Watch. RESULTS: Using the Extended Unified Theory of Acceptance and Use of Technology model, results showed that participants experienced potential health benefits; however, the inability of the Watch to reliably measure SpO2 when in respiratory distress was concerning. Participants' level of tech savviness varied, which caused some fear and frustration at the start, yet all felt supported by family and would have explored more features if they owned the Watch. All agreed that the Watch is mainly a medical tool and not a gadget. CONCLUSIONS: To conclude, although the Watch may enhance their physical health and well-being, results indicated that participants are more likely to accept the Watch if it ultimately proves to be useful when experiencing respiratory distress.

Experiences of Patients With Chronic Obstructive Pulmonary Disease Using the Apple Watch Series 6 Versus the Traditional Finger Pulse Oximeter for Home SpO2 Self-Monitoring: Qualitative Study Part 2.

BACKGROUND: Amid the rise in mobile health, the Apple Watch now has the capability to measure peripheral blood oxygen saturation (SpO2). Although the company indicated that the Watch is not a medical device, evidence suggests that SpO2 measurements among patients with chronic obstructive pulmonary disease (COPD) are accurate in controlled settings. Yet, to our knowledge, the SpO2 function has not been validated for patients with COPD in naturalistic settings. OBJECTIVE: This qualitative study explored the experiences of patients with COPD using the Apple Watch Series 6 versus a traditional finger pulse oximeter for home SpO2 self-monitoring. METHODS: We conducted individual semistructured interviews with 8 female and 2 male participants with moderate to severe COPD, and transcripts were qualitatively analyzed. All received a watch to monitor their SpO2 for 5 months. RESULTS: Due to respiratory distress, the watch was unable to collect reliable SpO2 measurements, as it requires the patient to remain in a stable position. However, despite the physical limitations and lack of reliable SpO2 values, participants expressed a preference toward the watch. Moreover, participants' health needs and their unique accessibility experiences influenced which device was more appropriate for self-monitoring purposes. Overall, all shared the perceived importance of prioritizing their physical COPD symptoms over device selection to manage their disease. CONCLUSIONS: Differing results between participant preferences and smartwatch limitations warrant further investigation into the reliability and accuracy of the SpO2 function of the watch and the balance among self-management, medical judgment, and dependence on self-monitoring technology.

Information and Communication Technologies to Support the Provision of Respite Care Services: Scoping Review.

BACKGROUND: Respite care is one of the most frequently requested support services by family caregivers. Yet, too often, respite care services are inaccessible, due in part to families' lack of knowledge regarding available services and a lack of service flexibility. Information and communication technologies (ICTs) may help to improve the flexibility of services available and families' knowledge of such services. However, an understanding of the use of ICTs and research in this area is lacking. OBJECTIVE: The objective of this study was to provide a comprehensive overview of the academic literature on ICTs for supporting the provision of respite care services. METHODS: A scoping review study was conducted. Six library databases were systematically searched for relevant literature. Key data were extracted into a summary chart. Text and quantitative data were coded using descriptive qualitative content analysis techniques, and the results were collated and summarized into a comprehensive narrative. RESULTS: A total of 23 papers describing 15 unique ICT programs exploring the potential of ICTs to support respite care services met the inclusion criteria. ICTs supported the provision of respite care by facilitating information-sharing with families and providers, recruiting and training respite care providers, and coordinating services. Key design considerations for developing respite care ICTs were trustworthiness and participatory design methods. Implementation considerations included designing for complementarity with existing services, assessing the appropriate timing for introducing the ICT-based services, and ensuring adequate promotion strategies to raise awareness about the services. CONCLUSIONS: There is limited but promising research on the potential of ICTs to support the provision of respite care services. Further research should be conducted to advance the results of this review, ultimately aiming to build ICTs that can improve the quality of, and access to, respite care services.

Digital health education and training for undergraduate and graduate nursing students: a scoping review protocol.

OBJECTIVE: The objective of this review is to collate and analyze literature reporting on digital health education and training courses, or other pedagogical interventions, for nursing students at the undergraduate and graduate level to identify gaps and inform the development of future educational interventions. INTRODUCTION: In this era of technology-driven health care, upskilling and/or reskilling the nursing workforce is urgently needed for nurses to lead the digital health future and improve patient care. While informatics competency frameworks serve to inform nursing education and practice, they do not address the entire digital health spectrum. INCLUSION CRITERIA: This review will include research studies, theoretical/discussion papers, and reports, as well as gray literature from relevant sources published in the last 10 years. Opinion pieces, editorials, conference proceedings, and papers published in languages other than English will be excluded. METHODS: The JBI methodology for scoping reviews will be followed. Searches will be conducted in Embase, CINAHL, ERIC, MEDLINE, Scopus, and Education Research Complete to retrieve potentially relevant studies. Hand searches of reference lists of included studies will be conducted. Two reviewers will independently screen records against predefined eligibility criteria and consult a third reviewer if conflicts arise. Decisions will be documented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Quantitative data will be analyzed using descriptive statistics. Content analysis will be applied to qualitative data to identify categories and themes. Findings will be synthesized and reported in tables and narrative format. REVIEW REGISTRATION NUMBER: Open Science Framework osf.io/42eug.

"Informal Caregiver" in Nursing: An Evolutionary Concept Analysis.

The informal caregiver experience has surged as a research topic in health care, including in nursing. However, the "informal" language is controversial, lacking conceptual clarity. Without a common understanding of who an "informal caregiver" may be, nurses may fail to consistently identify informal caregivers requiring support. Therefore, a concept analysis of "informal caregiver" was conducted on the basis of a sample of 20% of relevant nursing literature. The analysis of the attributes, antecedents, consequences, and contexts associated with "informal caregiver" offers a foundational guide for the ongoing development of nurses' understanding of the informal caregiver role.

Experiences of patients with chronic obstructive pulmonary disease receiving integrated telehealth nursing services during COVID-19 lockdown.

OBJECTIVE: Even though telemonitoring existed prior to COVID-19, the need was accelerated for patients with COPD due to the limited medical consultations and the anxiety for being infected. To our knowledge, no qualitative study has explored the experiences of COPD patients and the potential benefits of receiving integrated telehealth nursing services during the lockdown. METHODS: Ten participants were interviewed after receiving telehealth nursing services for 3 months; data was analyzed thematically. RESULTS: Irrespective of COPD severity, all participants expressed that the existing fragmented follow-up care was intensified during COVID. The telenursing services provided them with the comfort and reassurance that a clinician is available for support, advice, and care during the times of isolation. Despite diverse opinions regarding the respiratory-related questions for follow-up, all were enthusiastic about the use of the oximeter in their daily lives. None perceived sharing data as an issue, instead they encouraged the exchange across levels of care. CONCLUSION: Despite an appreciation for the service, it is imperative for sustainability reasons that standardized protocols are developed to balance patient preferences in terms of response frequency and the clinical data needed for a telenurse to provide appropriate interventions.

Patients' experiences of telenursing follow-up care after bariatric surgery.

AIM: To explore the postsurgical management experiences of bariatric patients after receiving telenursing follow-up care, using a telemonitoring platform for approximately 1 month. BACKGROUND: Obesity prevalence rates among adult Canadians are increasing, and as such the number of bariatric surgeries. Adapting to life following bariatric surgery is challenging, and patients are often experiencing difficulties to adhere to the postsurgical behavioural recommendations. The use of technology has been introduced in bariatric aftercare programmes, yet patients voiced a desire to communicate with a clinician between routine visits to improve continuity of care. To our knowledge, there is a lack of research on emerging practice of telenursing to provide monitoring, support and aftercare to bariatric patients remotely. DESIGN: A qualitative descriptive design was used. METHODS: A total of 22 semi-structured interviews were thematically analysed. The SRQR checklist was used. RESULTS: Participants embraced the idea of integrating telenursing care in bariatric aftercare programmes, as they viewed this novel approach to care as a way to overcome the current challenges of accessing bariatric services. The most salient benefit reported by participants was the timely advice and care provided by the telenurse. The provision of tailored nursing care and the accessibility to a first-line professional empowered participants to exercise greater control over their recovery process, which promotes self-management and enhances feelings of security and reassurance. Lastly, participants voiced areas of improvement to better the system and to render it most accessible and user-friendly. CONCLUSION: Despite its novelty in bariatric aftercare, our findings indicated that patients are eager to integrate telenursing in mainstream services. Discussions are needed regarding patient adherence to telemonitoring, and the need to develop clinical follow-up protocols. RELEVANCE TO CLINICAL PRACTICE: Results provide new insights into the importance of a telenurse in providing individualised care to bariatric patients.

Developing an mHealth Application to Coordinate Nurse-Provided Respite Care Services for Families Coping With Palliative-Stage Cancer: Protocol for a User-Centered Design Study.

BACKGROUND: Patients living with palliative-stage cancer frequently require intensive care from their family caregivers. Without adequate community support services, patients are at risk of receiving inadequate care, and family caregivers are at risk for depression and poor health. For such families, in-home respite care can be invaluable, particularly when the services are flexible and staffed by trusted care providers, such as nurses. Other industries are using mobile apps to make services more flexible. However, few apps have been developed to coordinate nurse-provided respite care services, and to our knowledge, none have been designed in conjunction with families affected by cancer. OBJECTIVE: The aim of this study is to develop a mobile health (mHealth) app prototype for coordinating flexible and trusted in-home respite care services provided by nurses to families coping with palliative-stage cancer in Québec, Canada. METHODS: This user-centered design research comprises the core component of the iRespite Services iRépit research program. For this study, we are recruiting 20 nurses, 15 adults with palliative-stage cancer, and 20 of their family caregivers, from two palliative oncology hospital departments and one palliative home-care community partner. Overseen by an Expert Council, remote data collection will occur over three research phases guided by the iterative Information Systems Research Framework: Phase 1, brainstorming potential app solutions to challenging respite care scenarios, for better supporting the respite needs of both family caregivers and care recipients; Phase 2, evaluating low-fidelity proofs of concept for potential app designs; and Phase 3, usability testing of a high-fidelity interactive proof of concept that will then be programmed into an app prototype. Qualitative and quantitative data will be descriptively analyzed within each phase and triangulated to refine the app features. RESULTS: We anticipate that preliminary results will be available by Spring 2022. CONCLUSIONS: An app prototype will be developed that has sufficient complimentary evidence to support future pilot testing in the community. Such an app could improve the delivery of community respite care services provided to families with palliative-stage cancer in Québec, supporting death at home, which is where most patients and their families wish to be. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/34652.

Healthcare professional disclosure of mental illness in the workplace: a rapid scoping review.

BACKGROUND: Although mental health difficulties are common among healthcare professionals (HCP), little research exists exploring the decision to disclose these difficulties in the healthcare context. AIMS: This rapid scoping review aims to explore HCP disclosure of mental health difficulties in the workplace. METHODS: The methodological framework was based on rapid and scoping review guidelines. A thematic synthesis approach was used for data analysis. RESULTS: Seventeen articles were included. Disclosure was found to be a process that starts with weighing its pros ("personal benefits", "personal beliefs", and "professional responsibility") and cons ("fears related to professional identity", "fears related to employment", "risk of stigmatization", and "personal experiences with mental health difficulties"). A decision-making process then occurs to help HCPs figure out how to disclose. Situations of nonconsensual disclosure can transpire through "third party disclosure" or "inadvertent disclosure". Disclosure results in outcomes including "positive experiences", "negative personal consequences" and "negative consequences related to others". CONCLUSION: Disclosure in healthcare and other workplaces is a complex process with few benefits and many potential repercussions. However, there is an opportunity to improve. Recognizing the value of and educating the workforce about HCPs with mental health difficulties will help work environments become safer for disclosure.

Experiences of emergency triage nurses in the police handover of mentally ill patients: A qualitative descriptive study.

BACKGROUND: Due to the high prevalence of mental health illnesses, police officers are often the community resource to emergency calls for someone experiencing a mental health crisis. Despite the successful efforts of crisis intervention teams, the police frequently escort and transfer the individual in crisis to the emergency department (ED). To our knowledge, one study has explored the interactions of first responders and ED staff; however, we lack an understanding of ED triage nurse experiences. AIM: To explore the experiences of ED triage nurses regarding the handover of a mental health patient by police in a Quebec University Health Center. METHOD: Semi-structured interviews with seven nurses were thematically analyzed. The COREQ checklist for reporting qualitative research was used. RESULTS: Nurses and police officers are both concern about patient's well-being; yet, their approach, as discussed in the theme "Medical versus Legal Responsibility", varied based on their differing responsibilities and views of caring versus protecting. Despite a need for ED-triage protocols, as described in the theme "Ambiguities of Existing ED-Triage Protocols", all nurses saw police officers as fellow colleagues and expressed that a change had taken place in police culture towards mental health. The latter issues are explained in the themes "Interagency Collaboration and Team-Based Approach", and "Changing Police Culture on Mental Health." CONCLUSION: There is a need for inter-professional collaboration and education to better understand the roles and scope of practice of both professions, and ED triage nurses should receive more training in the domain of mental health.

Experiences of psychiatrists and support staff providing telemental health services to Indigenous peoples of Northern Quebec.

BACKGROUND: Due to regional, professional, and resource limitations, access to mental health care for Canada's Indigenous peoples can be difficult. Telemental health (TMH) offers the opportunity to provide care across vast distances and has been proven to be as effective as face-to-face services. To our knowledge, there has been no qualitative study exploring the experiences of TMH staff serving the Indigenous peoples in Northern Quebec, Canada; which is the purpose of this study. METHODS: Using a qualitative descriptive design, the entire staff of a TMH clinic was recruited, comprising of four psychiatrists and four support staff. Individual semi-structured interviews were conducted through videoconferencing, and results were thematically analyzed. RESULTS: To address the mental health gap in Northern communities, all psychiatrists believe in the necessity of in-person care and note the synergistic effect of combining in-person care and TMH services. This approach to care allows psychiatrists to maintain both an insider and outsider identity. However, if a patient's condition requires hospitalization, then the TMH staff face a new set of information sharing and communication challenges with the inpatient staff. TMH staff believe that the provision of culturally sensitive care to Northern patients at the inpatient unit is progressing; however, more work needs to be done. Despite the strong collegial atmosphere within the clinic and collective efforts to provide quality TMH services, all participants express a sense of frustration with the paper-based and scattered documentation system. CONCLUSION: The TMH team works in cohesion to offer TMH services to Indigenous peoples; yet, automatization is needed to improve the workflow efficiency within the clinic and collaboration with the Northern clinics. More research is needed on the functioning of TMH teams and the separate but important roles of each team member.

Nurses' experiences of their decision-making process when participating in clinical trials during the 2014-2016 West African Ebola crisis.

OBJECTIVE: Due to the absence of a licenced vaccine or drug for treatment of Ebola patients during the 2014-2016 West Africa outbreak, frontline nurses were at increased risk of exposure. Hence, they were prioritized to participate in clinical trials to receive experimental therapeutics. To our knowledge no study has explored the nurses' experiences of their decision-making process when volunteering in clinical trials using unproven agents, which is the purpose of this qualitative study. METHODS: This study, part of a larger Ebola study, thematically analyzed the interview data of nine nurses recruited from Sierra Leone, Guinea and Liberia; of which four joined a convalescent plasma trial and five a vaccine trial. RESULTS: In their decision-making process to partake in a clinical trial, nurses identified two distinct decision points: the initial commitment followed by the point of no return when they presented themselves to participate. Each of these decisions were influenced by risk versus benefits calculations, and contextual factors. CONCLUSION: Results showed the need for more health education and communication around the unproven agents in order for nurses to make informed decisions.

Experiences of women receiving mhealth-supported antenatal care in the village from community health workers in rural Burkina Faso, Africa.

OBJECTIVE: This qualitative study explored the experiences of women receiving mhealth-supported antenatal care in a village, from community health workers (CHWs) in rural Burkina Faso, Africa. INTERVENTION: CHWs entered patient clinical data manually in their smartphone during their home visits. All wireless transferred data was monitored by the midwives in the community clinic for arising medical complications. METHODS: Semi-structured interviews were conducted with 19 pregnant women, who were housewives, married and their age ranged from 18 to 39 years. None had completed their formal education. Depending on the weeks of gestation during their first antenatal care visit, length of enrollment in the project varied between three and eight months. Transcripts were content-analyzed. RESULTS: Despite the fact that mhealth was a novel service for all participants, they expressed appreciation for these interventions, which they found beneficial on three levels: 1) it allowed for early detection of pregnancy-related complications, 2) it was perceived as promoting collaboration between CHWs and midwives, and 3) it was a source of reassurance during a time when they are concerned about their health. Although not unanimous, certain participants said their husbands were more interested in their antenatal care as a result of these services. CONCLUSION: Findings suggested that mhealth-supported visits of the CHWs have the potential to increase mothers' knowledge about their pregnancy and, as such, motivate them to attend more ANC visits. In response to this increased patient engagement, midwives approached women differently, which led to the mothers' perception of improvement in the patient-provider relationship. Results also indicated that mhealth may increase spousal involvement, as services are offered at home, which is an environment where spouses feel more comfortable.

The educational gaps of nurses in entrepreneurial roles: An integrative review.

Nurse entrepreneurship remains a foreign concept in education, forcing nurses to turn to graduate degrees in business and finance or otherwise, learn 'as they go'. Before addressing the question 'Why does nursing curricula exclude business content and skill development?', one must evaluate the perceived educational gaps of current nurse entrepreneurs; the purpose of this integrative review. An initial total of 2485 articles was generated in September 2016, of which 15 methodologically-diverse studies, published between 1977 and 2015, were appraised using the QATSSD tool. Perceptions of business-related educational gaps were categorized into 4 leadership skillsets: cognitive, interpersonal, business and strategic. Cognitive skills were further subdivided into self-regulation, professional know-how, and grasping the larger context; Interpersonal skills consisted of networking and selling your services, dealing with contextual resistance, and communicating clearly; Business skills were regrouped into mitigating and managing risk, marketing, financial and operations management; and lastly, Strategic skills were all related to knowing how to start a business. Business mindedness is not readily integrated into our collective professional identity resulting in an exclusion of this content from nursing curricula. To address service gaps, nurses should be introduced to entrepreneurial concepts during initial training with an option of further specialization for those considering a business career.

Determining the cost of implementing and operating a remote patient monitoring programme for the elderly with chronic conditions: A systematic review of economic evaluations.

Introduction Remote patient monitoring (RPM) in conjunction with home nursing visits is becoming increasingly popular for the follow-up of patients with chronic conditions and evidence exists that it improves patients' health outcomes. Current cost data is reported inconsistently and often gathered from studies of poor methodological quality, making it difficult for decision-makers who consider implementing this service in their organizations. This study reviewed the cost of RPM programmes targeting elderly patients with chronic conditions. Methods After evaluation against the inclusion and exclusion criteria and appraisal against two criteria which are important for economic evaluations, data from selected studies were extracted and grouped into meaningful cost categories, then adjusted to reflect November 2015 US dollars. Results In the 13 selected studies, the newly-created cost category 'Combined intervention cost' (reflecting equipment purchasing, servicing and monitoring cost) for the various RPM programmes ranged from US$275-US$7963 per patient per year. The three main findings are: (a) RPM programme costs have decreased since 2004 due to cheaper technology; (b) monitoring a single vital sign is likely to be less costly than monitoring multiple vital signs; and (c) programmes targeting hypertension or congestive heart failure are less costly than those targeting respiratory diseases or multiple conditions. Conclusions This review recommends that future studies present their cost data with more granularity, that grouping of costs should be minimized and that any assumptions, such as amortization, should be made explicit. In addition, studies should compare programmes with similar characteristics in terms of type of conditions, number of vital signs monitored, etc. for more generalizable results.

Nursing students' perceptions of using smartphones in the community practicum: A qualitative study.

BACKGROUND: Smartphones have the potential to revolutionize the way in which nurses practice by facilitating access to evidence-based resources, however their integration in nursing practice remain variable. Millennials tend to be more comfortable with technology, yet find themselves limited in their ability to use smartphones within the context of clinical practice. METHODS/DATA SOURCES: Using a qualitative descriptive design, we explored nursing students' perceptions of using smartphones in the community practicum. Individual semi-structured interviews were conducted and verbatim transcripts were subjected to data analysis. PARTICIPANTS: The sample consisted of 8 undergraduate and graduate nursing students. Participants were recruited using a purposive sampling strategy. RESULTS: Students' narratives describe unclear expectations regarding the use of smartphones that force them to adopt individualized strategies to maintain their professional image and avoid negative consequences. CONCLUSION: A cultural shift will be required at the academic and organizational levels if we are to foster acceptance of smartphones in community practice going forward.

Establishing and maintaining the clinical learning environment for nursing students: a qualitative study.

BACKGROUND: Experience in the clinical setting is viewed as a crucial aspect of nursing education. Evidence suggests that students experience acceptance to alienation on the clinical unit. Little is known about preceptor beliefs underlying their approach with students, and the perspective of unit management is absent. OBJECTIVES: To provide a description of the beliefs and processes that emerge at the unit level regarding the clinical learning environment for nursing students. DESIGN: Multiple case study design. SETTING: Four units from across an urban university health center who have a demonstrated ability to accept students. PARTICIPANTS: A purposive sample of four nurse managers, four assistant nurse managers, three advanced practice nurses, and six staff nurses with recent and recurrent precepting experience were recruited from across four units. METHODS: Semi-structured focus group interviews were conducted with all participants from each unit. Content analysis was used to identify major themes and categories in the interview data. RESULTS: Two overarching themes were revealed: (1) Influencing factors included cultural factors and contextual factors that either inform units' beliefs about the ideal learning environment, or affect their ability to provide it. (2) Willingness refers to a willingness to invest in students and the forms that investment takes. It includes openness, taking them under wing, and structuring to meet goals. The influencing factors provide the foundation upon which the unit's work to accommodate students is built. CONCLUSIONS: The degree to which a unit is able to manage the contextual factors determines how well they can shape the students' environment. The sturdiness of their culture with regard to hosting students determines the pervasiveness of their approach by staff on the unit.