Disagreement among experts about public health decision making: is it polarisation and does it matter?

It is common for aspects of the COVID-19 response-and other public health initiatives before it-to be described as polarised. Public health decisions emerge from an interplay of facts, norms and preferred courses of action. What counts as 'evidence' is diverse and contestable, and disagreements over how it should be interpreted are often the product of differing choices between competing values. We propose a definition of polarisation for the context of public health expertise that acknowledges and accounts for epistemic and social values as part of evidence generation and its application to public health practice. The 'polarised' label should be used judiciously because the descriptor risks generating or exacerbating the problem by oversimplifying complex issues and positions and creating groups that seem dichotomous. 'Independence' as a one-size-fits-all answer to expert polarisation is insufficient; this solution is premised on a scientistic account of the role of evidence in decision making and does not make room for the value difference that is at the heart of both polarisation and evidence-based decision making.

Exploring healthcare workers' perspectives of video feedback for training in the use of powered air purifying respirators (PAPR) at the onset of the COVID-19 pandemic

BACKGROUND

With the advent of COVID-19, many healthcare workers (HWs) in Australia requested access to powered air purifying respirators (PAPR) for improved respiratory protection, comfort and visibility. The urgency of the response at our hospital required rapid deployment of innovative training to ensure the safe use of PAPRs, in particular, a video-feedback training option to prepare HWs for PAPR competency.

AIM

To explore the feasibility, acceptability, and utility of video-feedback in PAPR training and competency assessment.

METHODS

Semi-structured interviews were conducted with 12 HWs, including clinicians from Intensive Care, Anaesthetics and Respiratory Medicine, at a large teaching hospital in Australia.

FINDINGS

Participants believed that the use of video-feedback in PAPR training was feasible, acceptable and useful. They described a variety of benefits to learning and retention, from a variety of ways in which they engaged with the personal video-feedback. Participants also described the impact of reviewing personalised practice footage, compared to generic footage of an ideal performance.

CONCLUSION

By conceptualising video-feedback using a pedagogical approach, this study contributes to knowledge around optimising methods for training HWs in PPE use, particularly when introducing a new and complex PPE device during an infectious disease outbreak.

"One minute it's an airborne virus, then it's a droplet virus, and then it's like nobody really knows…": Experiences of pandemic PPE amongst Australian healthcare workers

BACKGROUND

The SARS-CoV-2 pandemic has challenged health systems globally. A key controversy has been how to protect healthcare workers (HCWs) using personal protective equipment (PPE).

METHODS

Interviews were performed with 63 HCWs across two states in Australia to explore their experiences of PPE during the SARS-CoV-2 pandemic. Thematic analysis was performed.

RESULTS

Four themes were identified with respect to HCWs' experience of pandemic PPE: 1. Risk, fear and uncertainty: HCWs experienced considerable fear and heightened personal and professional risk, reporting anxiety about the adequacy of PPE and the resultant risk to themselves and their families. 2. Evidence and the ambiguities of evolving guidelines: forms of evidence, its interpretation, and the perception of rapidly changing guidelines heightened distress amongst HCWs. 3. Trust and care: Access to PPE signified organisational support and care, and restrictions on PPE use were considered a breach of trust. 4. Non-compliant practice in the context of social upheaval: despite communication of evidence-based guidelines, an environment of mistrust, personal risk, and organisational uncertainty resulted in variable compliance.

CONCLUSION

PPE preferences and usage offer a material signifier of the broader, evolving pandemic context, reflecting HCWs' fear, mistrust, sense of inequity and social solidarity (or breakdown). PPE therefore represents the affective (emotional) demands of professional care, as well as a technical challenge of infection prevention and control. If rationing of PPE is necessary, policymakers need to take account of how HCWs will perceive restrictions or conflicting recommendations and build trust through effective communication (including of uncertainty).

Entanglements of affect, space, and evidence in pandemic healthcare: An analysis of Australian healthcare workers' experiences of COVID-19

The COVID-19 pandemic continues to highlight both global interconnectedness and schisms across place, context and peoples. While countries such as Australia have securitised their borders in response to the global spread of disease, flows of information and collective affect continue to permeate these boundaries. Drawing on interviews with Australian healthcare workers, we examine how their experiences of the pandemic are shaped by affect and evidence ‘traveling’ across time and space. Our analysis points to the limitations of global health crisis responses that focus solely on material risk and spatial separation. Institutional responses must, we suggest, also consider the affective and discursive dimensions of health-related risk environments.

Medical interns' reflections on their training in use of personal protective equipment

BACKGROUND

The current COVID-19 pandemic has demonstrated that personal protective equipment (PPE) is essential, to prevent the acquisition and transmission of infectious diseases, yet its use is often sub-optimal in the clinical setting. Training and education are important to ensure and sustain the safe and effective use of PPE by medical interns, but current methods are often inadequate in providing the relevant knowledge and skills. The purpose of this study was to explore medical graduates' experiences of the use of PPE and identify opportunities for improvement in education and training programmes, to improve occupational and patient safety.

METHODS

This study was undertaken in 2018 in a large tertiary-care teaching hospital in Sydney, Australia, to explore medical interns' self-reported experiences of PPE use, at the beginning of their internship. Reflexive groups were conducted immediately after theoretical and practical PPE training, during hospital orientation. Transcripts of recorded discussions were analysed, using a thematic approach that drew on the COM-B (capability, opportunity, motivation - behaviour) framework for behaviour.

RESULTS

80% of 90 eligible graduates participated. Many interns had not previously received formal training in the specific skills required for optimal PPE use and had developed potentially unsafe habits. Their experiences as medical students in clinical areas contrasted sharply with recommended practice taught at hospital orientation and impacted on their ability to cultivate correct PPE use.

CONCLUSIONS

Undergraduate teaching should be consistent with best practice PPE use, and include practical training that embeds correct and safe practices.

Sustained fall in inpatient MRSA prevalence after a video-reflexive ethnography project; an observational study

BACKGROUND

Maintaining optimal infection prevention and control (IPC) in a busy, clinical environment is challenging. Video-reflexive ethnography (VRE) is a collaborative, interventionist approach to practice improvement. We hypothesised that giving clinicians opportunities to view and reflect on video footage of everyday ward activities would raise awareness of, and suggest strategies to reduce, pathogen transmission risks. We undertook a VRE project, between March and September 2013, in two tertiary hospital surgical wards, with persistently high methicillin resistant Staphylococcus aureus (MRSA) endemicity, despite previous IPC interventions.

METHODS

This study was a retrospective/prospective observational study, using interrupted time-series analyses, to assess the effects of the VRE project on hand hygiene compliance, inpatient MRSA infections (newly infected patients, per 1000 occupied bed days) and inpatient MRSA colonisation prevalence, measured by serial point prevalence surveys. Follow-up continued until June 2016.

RESULTS

The VRE project was associated with changes in IPC behaviour and outcomes. Hand hygiene compliance increased (from 62% to 75%; p < 0.0001) and MRSA colonisation prevalence decreased significantly, in both wards (baseline 42%; average post-VRE 12%; p=<0.0001), MRSA infection rate decreased in one ward. Interpretation of results was complicated by a potential confounding effect of unplanned environmental hydrogen peroxide decontamination (HPD). Improved hand hygiene compliance was a predicted outcome of VRE, but also a potential contributor to reduced MRSA transmission.

CONCLUSION

Separate contributions of VRE (the intervention), HPD and hand hygiene compliance were uncertain, but their combined effect was significantly reduced MRSA endemicity, which previously had been resistant to attempted IPC interventions.

Facilitating Whole Person Care Using Video Reflexive Ethnography

Aim: Explore the application and potential of video reflexive ethnography (VRE) to facilitate whole person care (WPC).Objectives: Discuss the ethical issues associated with VRE; explore the foundations of the methodology; and discuss its potential to facilitate WPC.Description: WPC requires a paradigm shift in how we see those we care for, how we see our co-workers and how we see ourselves. VRE involves videoing real-time everyday clinical practice and or patient and family accounts of care, and then involving participants to analyse the visual data that they feature in or have gathered themselves. Uniquely, video footage can challenge the taken for granted and attune people to dimensions of themselves and others that they might not otherwise have considered. This has the potential to open people up to alternative ways of thinking and perceiving, being and acting. It offers “transformative potential” towards WPC.We draw from our diverse disciplinary perspectives to explore the potential of VRE as a tool to facilitate WPC. Using specific examples from five research studies, this workshop will demonstrate the use of VRE in a variety of health care contexts. The contexts of the studies we draw from include: end of life care; autism diagnostics; infection control, and intensive care.The workshop proceeds in four parts. We first invite you, the participant, to engage in a video reflexive event, where you are expected to reflect on the socio-interactive conduct that you produce as a group in response to a specific task.  We then describe the process of VRE, outline its pedagogic and theoretical foundations, and present some examples from our research. We then invite questions about the theoretical basis and practical approach of VRE. Finally, participants will be asked to project a version of reflexive video onto their 'home' area of research, and reason about potential outcomes.1. Carroll, K., Iedema, R.  and  Kerridge, I. 2008, 'Reshaping ICU Ward Round Practices Using Video Reflexive Ethnography', Qualitative Health Research, vol. 18, no. 3, pp. 380-390.2. Collier, A. 2012, 'Safe Healing Environments', in N. Godbold  and  M. Vaccarella (eds), Autonomous Responsible Alone: The Complexities of Patient Empowerment, Interdisciplinary Press, London, pp. 155-170.3. Iedema, R. 2011, 'Creating Safety by Strengthening Clinicians' Capacity for Reflexivity ', British Medical Journal, vol. 20, pp. S83-S86.4. Iedema, R.  and  Carroll, K. 2011, 'The 'clinalyst': Institutionalising reflexive space to realise safety and flexible systematisation in health care', Journal of Organisational Change Management vol. 4, no. 1, pp. 65-86.5. Iedema, R., Long, D., Forsyth, D.  and  Lee, B.B. 2006, 'Visibilising Clinical Work: Video ethnography in the contemporary hospital', Health Sociology Review, vol. 15, pp. 156-168.

Finding the patient in patient safety

In the last decade, the field of patient safety has grappled with the complexity of health-care systems by attending to the activity of frontline clinicians. This article extends the field by highlighting the activity of patients and their carers in determining the safety of these systems. We draw on data from three studies exploring patients' accounts of their health-care experiences in Australia and internationally, to show how patients and carers are currently contributing to the safety of their own care. Furthermore, we emphasise the importance of patient-clinician collaboration in ensuring the success of these activities. We argue that it is no longer sufficient to discuss if patients should be involved with ensuring their own safety. Given that patients are already involved, we propose a new conceptualisation of safety and systems that acknowledges their involvement and supports patient-provider collaboration to achieve safer care.

Out of the frying pan? Streamlining the ethics review process of multisite qualitative research projects

This paper describes the ethics approval processes for two multicentre, nationwide, qualitative health service research projects. The paper explains that the advent of the National Ethics Application Form has brought many improvements, but that attendant processes put in place at local health network and Human Research Ethics Committee levels may have become significantly more complicated, particularly for innovative qualitative research projects. The paper raises several questions based on its analysis of ethics application processes currently in place. What is known about the topic? The complexity of multicentre research ethics applications for research in health services has been addressed by the introduction of the National Ethics Application Form. Uptake of the form across the country’s human research ethics committees has been uneven. What does this paper add? This paper adds detailed insight into the ethics application process as it is currently enacted across the country. The paper details this process with reference to difficulties faced by multisite and qualitative studies in negotiating access to research sites, ethics committees’ relative unfamiliarity with qualitative research, and apparent tensions between harmonisation and local sites’ autonomy in approving research. What are the implications for practitioners? Practitioners aiming to engage in research need to be aware that ethics approval takes place in an uneven procedural landscape, made up of variable levels of ethics approval harmonisation and intricate governance or site-specific assessment processes.

Multiple accountabilities in incident reporting and management

In this article, we examine the current and increasing emphasis on accountability and patient safety in health care, focusing on practices of incident reporting and management in New South Wales, Australia. We describe the frames of accountability associated with an incident reporting system, and explore how this system manifests in practice. In contrast to literature that situates incident reporting and local practices as oppositional, we used ethnographic methods to observe the incident management practices of clinical staff in a hospital, and found evidence to characterize this relationship differently. We found that accountability has multiple conceptualizations, and we present three findings that demonstrate how the reporting system and incident management policy are interwoven with local enactments of accountability. We suggest that systematic efforts toward improvement cannot be divorced from the local context, and emphasize the importance of local ecologies of practice in facilitating the meaningful utilization of such incident reporting systems.

The National Open Disclosure Pilot: evaluation of a policy implementation initiative

OBJECTIVE

To determine which aspects of open disclosure "work" for patients and health care staff, based on an evaluation of the National Open Disclosure Pilot.

DESIGN, SETTING AND PARTICIPANTS

Qualitative analysis of semi-structured and open-ended interviews conducted between March and October 2007 with 131 clinical staff and 23 patients and family members who had participated in one or more open disclosure meetings. 21 of 40 pilot hospital sites, in New South Wales, South Australia, Victoria and Queensland, were included in the evaluation. Participating health care staff comprised 49 doctors, 20 nurses, and 62 managerial and support staff. In-depth qualitative data analysis involved mapping of discursive themes and subthemes across the interview transcripts.

RESULTS

Interviewees broadly supported open disclosure; they expressed uncertainty about its deployment and consequences, and made detailed suggestions of ways to optimise the experience, including careful pre-planning, participation by senior medical staff, and attentiveness to consumers' experience of the adverse event.

CONCLUSION

Despite some uncertainties, the national evaluation indicates strong support for open disclosure from both health care staff and consumers, as well as a need to resource this new practice.

PXR, CAR and HNF4alpha genotypes and their association with pharmacokinetics and pharmacodynamics of docetaxel and doxorubicin in Asian patients

Previously studied candidate genes have failed to account for inter-individual variability of docetaxel and doxorubicin disposition and effects. We genotyped the transcriptional regulators of CYP3A and ABCB1 in 101 breast cancer patients from 3 Asian ethnic groups, that is, Chinese, Malays and Indians, in correlation with the pharmacokinetics and pharmacodynamics of docetaxel and doxorubicin. While there was no ethnic difference in docetaxel and doxorubicin pharmacokinetics, ethnic difference in docetaxel- (ANOVA, P=0.001) and doxorubicin-induced (ANOVA, P=0.003) leukocyte suppression was observed, with Chinese and Indians experiencing greater degree of docetaxel-induced myelosuppression than Malays (Bonferroni, P=0.002, P=0.042), and Chinese experiencing greater degree of doxorubicin-induced myelosuppression than Malays and Indians (post hoc Bonferroni, P=0.024 and 0.025). Genotyping revealed both PXR and CAR to be well conserved; only a PXR 5'-untranslated region polymorphism (-24381A>C) and a silent CAR variant (Pro180Pro) were found at allele frequencies of 26 and 53%, respectively. Two non-synonymous variants were identified in HNF4alpha (Met49Val and Thr130Ile) at allele frequencies of 55 and 1%, respectively, with the Met49Val variant associated with slower neutrophil recovery in docetaxel-treated patients (ANOVA, P=0.046). Interactions were observed between HNF4alpha Met49Val and CAR Pro180Pro, with patients who were wild type for both variants experiencing least docetaxel-induced neutropenia (ANOVA, P=0.030). No other significant genotypic associations with pharmacokinetics or pharmacodynamics of either drug were found. The PXR-24381A>C variants were significantly more common in Indians compared to Chinese or Malays (32/18/21%, P=0.035) Inter-individual and inter-ethnic variations of docetaxel and doxorubicin pharmacokinetics or pharmacodynamics exist, but genotypic variability of the transcriptional regulators PAR, CAR and HNF4alpha cannot account for this variability.