Leadership and community healthcare reform: a study using the Competing Values Framework (CVF).

PURPOSE: The Health Service Executive in Ireland seeks to further develop healthcare in the community. It has identified that this reform requires developing leadership amongst the staff. This study aims to identify what kind of leadership staff in community healthcare observe in practice and their leadership preferences. The core objective has been to identify the readiness of the organisation to implement the adopted national policy of integrated community care reform in terms of leadership development. DESIGN/METHODOLOGY/APPROACH: An online cross-sectional survey was conducted using the Organisational Cultural Assessment Instrument, based on the Competing Values Framework. This tool identifies four overarching leadership types: Clan (Collaborative), Adhocracy (Creative), Market (Competitive) and Hierarchy (Controlling). Participants (n = 445) were a representative sample of regional community health care employees. They were asked to identify presently observed leadership and preferred leadership in practice. The statistical analysis emphasised a comparison of observed and preferred leadership types. FINDINGS: Participants reported the current prevailing leadership type as Market (M = 34.38, SD = 6.22) and Hierarchical (M = 34.38, SD = 22.62), whilst the preferred or future style was overwhelmingly Clan (M = 40.38, SD = 18.08). Differences were significant (all p's < 0.001). The overall outcome indicates a predominance of controlling and competitive leadership and a lack of collaborative leadership to implement the planned reform. ORIGINALITY/VALUE: During reform in healthcare, leadership in practice must be aligned to the reform strategy, demonstrating collaboration, flexibility and support for innovation. This unique study demonstrates the importance of examining leadership type and competencies to indicate readiness to deliver national community health care reform.

First back-calculation and infection fatality multiplier estimate of the hidden prevalence of COVID-19 in Ireland.

BACKGROUND: To date computer models with multiple assumptions have focussed on predicting the incidence of symptomatic cases of COVID-19. Given emerging vaccines, the aim of this study was to provide simple methods for estimating the hidden prevalence of asymptomatic cases and levels of herd immunity to aid future immunization policy and planning. We applied the method in Ireland. METHODS: For large scale epidemics, indirect models for estimating prevalence have been developed. One such method is the benchmark multiplier method. A further method is back-calculation, which has been used successfully to produce estimates of the scale of a HIV infected population. The methods were applied from March to October 2020 and are applicable globally. RESULTS: Results demonstrated that the number of infected individuals was at least twice and possibly six times the number identified through testing. Our estimates ranged from ∼100 000 to 375 000 cases giving a ratio of 1-6 hidden cases for every known case within the study time frame. While both methods are subject to assumptions and limitations, it was interesting to observe that estimates corroborated government statements noting that 80% of people testing positive were asymptomatic. CONCLUSIONS: As Europe has now endured several epidemic waves with the emergence globally of new variants, it essential that both policy makers and the public are aware of the scale of the hidden epidemic that may surround them. The need for social distancing is as important as ever as we await global immunization rollout.

Hidden Harms and the Number of Children Whose Parents Misuse Substances: A Stepwise Methodological Framework for Estimating Prevalence.

Background: Globally, the problem of hidden harms to children of parents who use drugs and alcohol has been recognized. However, it is at a community level that resources must be allocated. Objective: The aim of this research was to provide a methodological framework for estimating the prevalence of children with potential hidden harms, in a community setting. Methodology: Benchmark-multiplier methods were used. Alcohol dependency was measured using the Rapid Alcohol Problem Screen tool. A retrospective audit of records combined with a multisource enumeration to remove duplicates was used to derive a minimum benchmark and a multiplier for the number of children to known adults. Further benchmarks were derived from the localized data of a general population survey. Community services were consulted for estimate validation, needs, and recommendations. The setting was an Irish urban disadvantaged region in 2016. Results: From the audit and multisource enumeration, a ratio of 0.88 children to every one client known to local treatment services was estimated. This provided a minimum estimate of 3.7% of children at risk of being impacted by illicit drug use where parents were known to services. From the general population survey and the local multiplier, an estimate of 15-24% of children potentially impacted by illicit drug use was derived. Finally, from the alcohol dependency data, an estimate of 14-37% of children possibly impacted by parental alcohol dependency was derived. Conclusions: Estimates were accepted as realistic by service providers who highlighted the need to improve interagency and interdisciplinary communication between drug and family services.

The BREATHE Project, a mobile application, video-monitoring system in family homes as an aid to the caring role: Needs, acceptability and concerns of informal carers.

INTRODUCTION: Family carers provide 80% of care to older people in Europe. Our aim was to explore the needs and acceptability among informal carers, of a live video home monitoring system. METHODS: A descriptive qualitative design was implemented with nine interviewees and a focus group of five informal carers in Ireland in 2014. A thematic analysis of the data was conducted. RESULTS: Ten hours of data were recorded. Three themes emerged: routine, risk, and acceptance. Although all assisted persons had a routine, carers not living in the home stated that cameras would assist with less tangible concerns such as nutrition and loneliness. Carers were interested in monitoring risks in specific situations rather than general monitoring. The majority of carers, while expressing concerns about privacy, accepted camera technology for monitoring emergencies and, in-spite of concerns, favoured a real video view. Acceptance in non-emergencies was mixed and concerns about the privacy of the assisted person were expressed. DISCUSSION: While video monitoring is contentious, informal carers did express a willingness for real video-footage monitoring under strict conditions that addressed specific needs. CONCLUSION: The challenge for technology is to address these needs while maintaining personal dignity.

Victimisation in urban primary schools of high-poverty areas: associations with health-related quality of life, depression and social support.

BACKGROUND: Although a widespread issue, research on victimisation among primary school children in high-poverty regions is limited. The aim of this research was to explore victimisation incidence and associated mental health correlates from first-wave data of the 'Healthy Schools' programme in a high-poverty urban region. METHOD: The study explored victimisation incidences among 458 Irish primary school children and associations with depression, health-related quality of life (HRQoL) and social support. RESULTS: Victimisation (33.8%) was consistent with recent literature. On the stand-alone victimisation question, victims scored lower on all HRQoL subscales compared with nonvictims. Further categorisation revealed that frequent victims scored lower on four of these subscales, compared with nonvictims. Furthermore, over half of children felt that their school was not doing enough to combat school aggression. CONCLUSIONS: Although from a high-poverty area, rates were consistent with data from more affluent areas. Results stress an importance on specific school aggression behaviours when measuring victimisation rates, along with corresponding health consequences. Future research should continue to adopt the behaviour-based assessment of victimisation to provide an overall picture of the problem.

Relating annual migration from high tuberculosis burden country of origin to changes in foreign-born tuberculosis notification rates in low-medium incidence European countries.

The level of immigration from high tuberculosis (TB) burden countries (HBCs) which impacts on the foreign-born TB notification rate is largely unknown. In this work, we performed a cross-sectional analysis of epidemiological data from 2000 to 2013 from nine European countries: Austria, Denmark, Finland, Hungary, Netherlands, Norway, Spain, Sweden, and the United Kingdom. Crude notification rates were calculated for foreign- and native-born populations and a multiple-linear regression model predicting notification rates with HBC population data was generated. From 2000 to 2013, the population percentage with a foreign birthplace increased on average each year in all nine countries, ranging from +0.11%/year in the Netherlands to +0.66%/year in Spain. An annual increase in HBC migrants above +0.43% per year (95% Confidence Interval: 0.24%-0.63%) corresponded with higher TB notification rates in the foreign-born population of the countries analyzed. This indicates that migration from HBCs can exert a measurable effect on the foreign-born TB notification rate. However, an increase in the foreign-born TB notification rate coincided with an average annual rise in national TB notification rates only in countries, Norway (+3.85%/year) and Sweden (+2.64%/year), which have a high proportion (>80%) of TB cases that are foreign-born.

Parenthood, Child Care, and Heroin Use: Outcomes After Three Years.

BACKGROUND: Internationally there is a lack of measurement on the impact of childcare on people who use drugs. OBJECTIVES: The aim of this article was to longitudinally measure drug use, familial and social status and criminal involvement between parents and nonparents who use heroin and have children in their care. METHODS: From 2003 to 2006, 404 participants were recruited to the Research Outcome Study in Ireland Evaluating Drug Treatment Effectiveness (ROSIE) as part of a longitudinal cohort study design. Participants completed the Maudsley Addiction Profile and 88% (n = 356) completed interviews at the 3-year period. One way between groups ANOVA with post hoc tests and backward, stepwise multiple regression were employed for analysis. RESULTS: At follow-up, parents who had children in their care used heroin (p = .004), illicit methadone (p ≤ .001) and cocaine (p = .024) on fewer days than those who had no children, or those who had children but did not have children in their care. These differences were not observed at intake. Living with someone at intake who used drugs was found to be significantly associated with increased heroin (p ≤ .001), benzodiazepine (p = .039), and tobacco (p = .030) use at 3 years. Furthermore, a change in childcare status to caring for a child was associated with increased cannabis use (p = .025). Conclusion/Importance: While caring for children was associated with reduced heroin use at 3 years, living with a person who used at intake removed this effect, thus indicating that while individual based addiction theories reflected observed outcomes, social network connectedness was more influential.

An exploration of clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners, in Ireland.

BACKGROUND: Clinical specialist (CS) and advanced practitioner (AP) roles have increased in nursing and midwifery internationally. This study explored clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners in Ireland. METHODS: Using a case study design, interview, observational and documentary data from postholding sites (CSs or APs employed) were compared with data from non-postholding sites (no CSs or APs employed). Interviews and observations were conducted with postholders (n = 23), and compared with data from healthcare professionals (nurses or midwives, doctors) (n = 23) in matched services. Interviews were held with Directors of Nursing and Midwifery (n = 23), healthcare professionals (n = 41), service users (n = 41) with experience of receiving care or working with postholders, and non-postholders in matched services. The data were analysed using Nvivo (Version 8). RESULTS: The findings suggest that postholders' practice appeared to differ from non-postholders' in relation to case management and service provision. Postholders were seen as having an impact on readmission rates, waiting lists/times, collaborative decision-making, continuity of care and workload management. Postholders' autonomy to manage caseloads was perceived to lead to smoother transition of patients/clients through the healthcare system. Service-users' self-reports appeared to appreciate the individualised holistic care provided by postholders. Postholders' role in facilitating person-centred care and promoting interprofessional team working, are essential elements in quality care provision and in global healthcare workforce planning. CONCLUSIONS: To meet changing healthcare demands, promote person-centred care, and improve service delivery, more specialist and advanced practice posts in nursing and midwifery should be developed and supported within healthcare.

Using Client's Routine Urinalysis Records From Multiple Treatment Systems to Model Five-Year Opioid Substitution Treatment Outcomes.

BACKGROUND: At global, national, and local level, the need for ongoing, timely and cost efficient, comprehensive drug treatment monitoring, and evaluation systems have clearly been well recognized. OBJECTIVES: To test the feasibility of linking laboratory data and client intake data and its usefulness for modeling retrospectively, for the first time, 5-year longitudinal drug treatment outcomes in an Irish opiate treatment setting. METHODS: A multisite, retrospective, longitudinal cohort study was implemented to evaluate outcomes for opiate users based on 1.7 million routine urinalysis results collected from 4,518 individuals presenting for opioid substitution treatment in Ireland from January 2006 to December 2010. RESULTS: Analysis of opiates, cocaine, benzodiazepine, and cannabis use at treatment intake, 6 months and at 1-5 year follow-ups revealed differences in urinalysis protocols; significant differences in age of first drug use between those using and not using opiates at 5 years; significant decreases in opiate use; increases in benzodiazepine use and significant increasing effects of concurrent cocaine and benzodiazepine use on the odds of using opiates. Time series analysis of weekly proportions opiate positive predicted 16% (95% confidence interval: 7%-25%) of clients would be opiate positive 5 years postinitial intake. CONCLUSIONS IMPORTANCE: Underutilized urinalysis data can be used to address the need for cost effective, efficient evidence of drug-treatment outcomes across time, place, and systems. Linking and matching the cross-sectional data across sites and times also revealed where improvements in electronic records could be made.

Scaling up nurse education: An evaluation of a national PhD capacity development programme in South Africa, in the context of the global shortage of nursing graduates.

BACKGROUND: The global shortage of nursing professionals educated at baccalaureate level and beyond has been highlighted. Within America, services are preparing to treat an additional 32 million individuals under the Health Reform Bill. Within South Africa nursing education outputs do not meet demands. Countries are addressing these shortages by developing advanced nurse roles which require research degrees. OBJECTIVE: To evaluate a national PhD programme within the context of a nurse education strategy and a national health insurance plan. DESIGN: A comparative effectiveness research design was employed. SETTING: The setting was in South Africa between 2011 and 2013, a county with 51.7 million inhabitants. PARTICIPANTS: Participants included PhD candidates, programme facilitators, supervisors and key stakeholders. METHODS: Data from a one day workshop was analysed using an inductive thematic analysis. Three years of evaluation reports were analysed. A mapping of the alignment of the PhD topics with healthcare priorities, and a comparison of the development of nurse education, of the national and international funder were conducted. RESULTS: The evaluation reports rated the programme highly. Three themes were identified from the workshop. These were, "support" with the sub-themes of burden, leveraging and a physical supportive place; "planning" with the sub-themes of the national context and practice, and "quality" with the sub-themes of processes and monitoring and evaluation. The mapping of PhD topics revealed that research was in line with development priorities. However, further investment and infrastructural changes were necessary to sustain the programme and its impact. CONCLUSIONS: To address sustainability and capacity in nations scaling up nurse education and healthcare insurance, it was recommended that top-up degrees for diploma educated nurses be developed along with, the implementation of a national nursing strategy for PhD and post-doctoral training encompassing clinical practice implementation and collaboration.

Modeling the impact of place on individual methadone treatment outcomes in a national longitudinal cohort study.

BACKGROUND: Little has been published on the effect of geography on methadone treatment outcomes. OBJECTIVE: To measure the effect of place on longitudinal outcomes Methods: From 2003 to 2006, 215 clients were recruited to a cohort study of methadone treatment. Participants had their address and clinic geocoded. Treatment outcomes were measured at intake, at one and three years posttreatment using the Maudsley Addiction Profile instrument. Spider diagrams and buffer rings were used to visually map clinics and clients. Regression models were used to measure the effect of place. RESULTS: Client's accommodation and social and criminal problems in the region had a medium to large effect on heroin use. Analysis of buffer rings revealed that clients located within a 10-km radius of a major clinic demonstrated poorer outcomes in terms of heroin use. Conclusion/Importance: Findings illustrated the relevance of geography on drug treatment outcomes and the planning of services.

Using chi-Squared Automatic Interaction Detection (CHAID) modelling to identify groups of methadone treatment clients experiencing significantly poorer treatment outcomes.

In times of scarce resources it is important for services to make evidence based decisions when identifying clients with poor outcomes. chi-Squared Automatic Interaction Detection (CHAID) modelling was used to identify characteristics of clients experiencing statistically significant poor outcomes. A national, longitudinal study recruited and interviewed, using the Maudsley Addiction Profile (MAP), 215 clients starting methadone treatment and 78% were interviewed one year later. Four CHAID analyses were conducted to model the interactions between the primary outcome variable, used heroin in the last 90 days prior to one year interview and variables on drug use, treatment history, social functioning and demographics. Results revealed that regardless of these other variables, males over 22 years of age consistently demonstrated significantly poorer outcomes than all other clients. CHAID models can be easily applied by service providers to provide ongoing evidence on clients exhibiting poor outcomes and requiring priority within services.

Differences between clinical specialist and advanced practitioner clinical practice, leadership, and research roles, responsibilities, and perceived outcomes (the SCAPE study).

AIM: To report a study designed comparing the roles, responsibilities, and perceived outcomes of Clinical Nurse Specialists, Clinical Midwife Specialists, and Advanced Nurse Practitioners in Ireland. BACKGROUND: A clinical career pathway that encompasses progression from staff nurse or midwife through clinical specialist to advanced practitioner level was introduced in Ireland in 2000. Such roles are common internationally, but little evaluation has been conducted and few comparisons have been made between roles. DESIGN: A mixed-method case-study design was used. METHODS: Following Research Ethics Committee Approval, data were collected in 2009-2010, using non-participant observation (92 hours) of 23 Clinical Specialists and Advanced Practitioners, interviews with 21 clinicians and 13 Directors of Nursing or Midwifery. A survey was completed by 154 service-users. RESULTS: A clear difference was seen between Clinical Specialist and Advanced Practitioners, with advanced practice roles providing improved service delivery, greater clinical and professional leadership, increased research, and a clear governance and accreditation structure. Clinical Midwife Specialists were rated at a similar level to Advanced Nurse Practitioners for certain aspects and rated more highly for 'continuity of care and carer'. CONCLUSION: Advanced Practitioners do give a higher level of care, particularly at a strategic level. Existing Clinical Specialists should therefore be encouraged to develop their skills and education to achieve advanced practice level and more specialist and advanced practice posts should be instituted.

A 3 year national longitudinal study comparing drug treatment outcomes for opioid users with and without children in their custodial care at intake.

The aim of this research was to measure the longitudinal effects of having children in a client's custodial care, on opioid treatment outcomes. A 3 year national, longitudinal study was implemented. Outcomes were measured using the Maudsley Addiction Profile, 404 clients (75% male) were recruited and 97% were located at 3 years. At 1 year significantly fewer of those with children in their care were using heroin, benzodiazepines and cannabis but having children in a client's care at intake was a significant and positive predictor of using other opioids at 1 year. Analysis also revealed that there was a significant reduction in the proportion using alcohol in the last 90 days and in the mean days alcohol was used among those with no children in their care. Results demonstrate that having children in a client's care improves outcomes for heroin use but also suggest the possible use of substitution substances.

Baseline results of the first healthy schools evaluation among a community of young, Irish, urban disadvantaged children and a comparison of outcomes with international norms.

BACKGROUND: In 2008, the Irish Government initiated a pilot Healthy Schools Programme based on the World Health Organization Health Promoting Schools Model among children attending schools officially designated as urban and disadvantaged. We present here the first results on physical and emotional health and the relationship between childhood depression and demographic and socioeconomic factors. METHODS: The Healthy Schools Programme evaluation was a 3-year longitudinal outcome study among urban disadvantaged children aged 4 to 12 years. Physical and psychological health outcomes were measured using validated, international instruments at baseline. Outcomes at baseline were compared with international norms and where differences were found, results were statistically modeled to determine factors predicting poor outcomes. RESULTS: A total of 552 children responded at baseline, representing over 50% of all eligible children available to participate from 7 schools. Findings at baseline revealed that in general, children did not differ significantly from international norms. However, detailed analysis of the childhood depression scores revealed that in order of importance, psychological well-being, the school environment, social support, and peer relations and age were statistically significant predictors of increased childhood depression in children under 12 years of age. CONCLUSION: Future health and well-being studies in schools among urban disadvantaged children need to broaden their scope to include measures of depression in children under 12 years of age and be cognisant of the impact of the school environment on the mental and emotional health of the very young.

Does concurrent cocaine use compromise 1-year treatment outcomes for opiate users?

The current study aimed to determine whether cocaine use compromises treatment outcomes for opiate users. Data were collected from 404 opiate users at treatment intake and 1-year follow-up as part of a national treatment outcome study. Because of higher intake measures, cocaine users improved in more outcomes than nonusers, but comparisons between groups found that cocaine users had more coexisting problems. Regression analysis revealed that those who used cocaine at intake were more likely to use cocaine at 1-year follow-up, to commit crime, and to be homeless. It is concluded that treatment for opiate use "works" even in the presence of concurrent cocaine use.

Analysis of the impact of treatment setting on outcomes from methadone treatment.

How methadone setting, duration of drug career, and dose impact on treatment are assessed. Two hundred fifteen participants were recruited. Analysis revealed significant reductions in drug use at 1 year within all settings, but the pattern varied. Proportions using heroin reduced in all settings, unprescribed benzodiazepines reduced in community, and general practitioner settings and cocaine use reduced in community and Government health board settings. A logistic model controlling for intake methadone dose, setting, previous treatments, and intake heroin use revealed that setting was a significant factor in predicting heroin use at 1 year but was not significant in predicting changes in health. Findings illustrate that drug outcomes improved across all settings, and health did not improve in any setting. For optimum outcomes to be achieved, opiate users must be directed to settings that best match their needs and that the "one-stop-shop for methadone" is not the most effective solution.

A study of bone mineral density in adults with disability.

OBJECTIVES: To examine prevalence of low bone mineral density (BMD) among adults with disability, using World Health Organization diagnostic categories. DESIGN: Cross-sectional study. SETTING: National Rehabilitation Hospital, Dublin, Ireland. PARTICIPANTS: Patients (N=255; 178 men, 77 women) who were disabled for at least 3 months because of acquired brain injury, spinal cord injury, other neurologic condition, or lower-limb amputation. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Laboratory investigations including intact parathyroid hormone, 25-hydroxyvitamin D (25-OHD), and sex hormones; and BMD of lumbar spine and at least 1 hip, measured by dual-energy x-ray absorptiometry and expressed as T scores and z scores. RESULTS: Mean age +/- SD of participants was 48.7+/-15.6 years. Vitamin D deficiency, 25-OHD level 50 nmol/L or less, occurred in 154 (62.9%); insufficiency, a level between 51 and 72 nmol/L, occurred in 36 (14.7%). Based on T scores, 108 participants (42.4%) had osteopenia, and 60 (23.5%) had osteoporosis. A z score of -1 or less but more than -2 occurred in 76 (29.8%); a further 52 (20.4%) had a z score of -2 or less. On multiple linear regression analysis, ambulatory status and duration of disability were independent predictors of BMD at neck of femur (beta=.152, P=.007; beta=-.191, P=.001, respectively) and total proximal femur (beta=.170, P=.001; beta=-.216, P<.001, respectively). CONCLUSIONS: Osteopenia and osteoporosis are very common in adults with disability participating in rehabilitation, compared with the general young adult population. Duration since onset of disability and mobility status are independent predictors of BMD at the hip. Bone health monitoring should form part of the long-term follow-up in adults with newly acquired disabilities.