Medicine, Dentistry & Health Sciences Collected Works - Theses
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ItemGetting the support they need : enhancing education and job prospects for young people receiving Centrelink homeless income(University of Melbourne, 2008)
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ItemHIV in Victoria's African communities: reducing risks and improving care( 2013)The acquired immunodeficiency syndrome caused by the human immunodeficiency virus is an important issue for Australia’s African communities. As in other industrialised countries, African immigrants are over-represented in Australia’s HIV epidemic, diagnosed late and endure social isolation after diagnosis, but focused responses, applied without understanding local HIV epidemiology and social context, risk intensifying stigma against African communities and African Australian people living with HIV in Australia. This study explored the social epidemiology and clinical features of HIV in Victoria’s African communities, collecting data from national and Victorian HIV surveillance databases, a clinical case series of African-born HIV patients and a qualitative inquiry with several African communities. Diverse geographical, biological, psychosocial and structural factors influenced exposure, diagnosis, clinical features and experience of living with HIV. Most exposure occurred in Africa, prior to migration, through heterosexual sex. Some occurred after migration, in Australia and abroad, through heterosexual sex and sex between men. Low self-perceived risk and lack of awareness of HIV in Australia contributed to exposure and delayed diagnosis. HIV was understood as a deadly, highly contagious “African” disease, posing little threat in Australia, being one of several intersecting challenges to the wellbeing and cohesion of African communities during resettlement. Understanding of HIV was based largely on experience in Africa and the process of HIV screening during immigration. HIV-related stigma, based on risk stereotypes of sexual immorality and fear of contagion and death, was the major barrier to social support and information. Key clinical issues for African-born PLHIV included high prevalence of TB and viral hepatitis. HIV treatment uptake was high and response was good. HIV exposure via sex between men led to HIV-1 subtype B infection; those with heterosexual or other exposure carried various non-B subtypes. African communities actively participated in the study leading to greater engagement in Victorian and national HIV responses. Study results provided insights into HIV epidemiology and clinical features in Victoria’s African communities and informed a conceptual framework that should further the understanding of HIV epidemiology in mobile and marginalised populations.
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ItemReframing clinical governance: policy and practice in aged persons mental health( 2011)This study examines the translation of Clinical Governance (CG) policy into risk practices into Aged Persons Mental Health (APMH). CG is the system in which clinicians and governing bodies share responsibility and are held accountable for the delivery of safe quality health care. Policy indicates that it is the health care organisation's responsibility to embed CG as 'everyday business', ensuring that this is not just an optional 'add-on' for care provision. However, since its inception, CG has received mixed reviews both in Australia, and internationally. It is emphasised that CG must be driven through all levels of an organisation, not just emerge as a whole new bureaucracy of its own. The relationship between effective CG and positive consumer outcomes make this especially pertinent in Aged Persons Mental Health. In Australia, Aged care services collectively assist over one million older adults. Although there have been improvements in the range and quality of aged care services over time, several key weaknesses remain. For example, workforce shortages (including the higher than average age of the workforce), uncompetitive wages and over-regulation, and the variable quality in terms of service provision, all hinder improvement initiatives in some way. Additionally, APMH (as in other areas of health) also experience the need for a larger workforce in the context of an ever shrinking pool of recruits. The retirement of the 'Baby Boomers', with their higher expectations of health care, will also place additional pressure on aged care services in the future. More importantly for CG however, is that the system will be challenged by a substantial population increase overall; one that is expected to bring with it increasing diagnostic complexity for the older adult. Consequently, the broad aim of this research is to understand if, and how, clinical governance policies influence risk management practices in APMH. More specifically, this thesis explores the: degree of understanding of CG between the various participant groups; range of facilitators and inhibitors to CG implementation; and possible improvement strategies for embedding CG into practice. A qualitative design was considered appropriate in order to fulfil these aims, which resulted in the development of a three-staged approach. This ensured that data was triangulated from multiple perspectives, with the study strengthened further by using a variety of data collection techniques (including individual and group interviews, and document analysis). Information from three distinct participant groups was obtained across the three stages. Specifically, interviews were carried out with Policy-makers and Organisational Implementers. In addition, the views of clinicians in APMH residential care facilities were sought via case studies. A comprehensive document review of Australian CG policy was also conducted. Collectively, the qualitative approaches of Miles and Huberman, Scott, and Kurland, then provide a framework from which to understand and present the findings. As a result, perceived deficits in knowledge, communication and leadership were identified as barriers to the effective translation of CG policy into practice. Furthermore, the heavy managerial reliance on the risk component of the model (including documentation and reporting) to the perceived detriment of other aspects, was also considered to be problematic. In summary, these findings suggest that the true value of CG may be lost if restricted to mandated ‘tick-box’ reporting, rather than being strengthened by an approach that conceptualises and promotes CG in a way that clinicians understand. Ultimately, if change fails to occur, attention may be diverted away from the quality of care that CG was originally intended to support. Finally, this research provides a new perspective from which to consider the facilitators, limitations, and strategies for improving the translation of CG into risk practices in APMH. A new model for reframing the existing CG approach, and addressing these issues in APMH, is put forward.
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ItemMalaysian nurses' experiences of an Australian degree( 2002)The purpose of this study was to explore Malaysian graduate nurses' perceptions of their educational experiences of an overseas post-registration degree programme conducted as a twinning venture by Victoria University, Australia and Assunta Hospital, Malaysia. The aim was to provide an understanding of how that learning experience had contributed to the Malaysian registered nurses' personal professional growth and professional learning. The scarcity of nursing degrees in Malaysia has resulted in twinning ventures between international universities and local educational institutions to offer post-registration nursing conversion degree programmes in Malaysia. Moreover, internationalising education implies that it is possible to actually take a curriculum from one part of the world to another, expecting it can be implemented in a different cultural context. The literature review indicated that no study has been undertaken to investigate the impact of such educational programmes on the Malaysian registered nurses' personal professional growth and professional leaming. Therefore, this study was warranted. It also emerged from a personal interest due to my own commitment to the development of such a programme. The conceptualisation of professionalisation through professional learning was taken from the three notions: professionalisation of nursing; professional development; and formal professional learning such as, the post-registration nursing conversion degree programme. A qualitative case study methodology was used. A purposive sample of twelve participants was voluntarily recruited from the first cohort of graduates five years after their completion of the degree. The data were collected in three phases: in-depth semi-structured individual interviews, journals and a focus group interview. Transcripts were coded and thematically analysed. The findings highlight that there are Malaysian nurses who are prepared to gain a better image and status for the profession. From their perceptions, the degree programme has impacted on their personal professional growth and professional learning by providing them with broad knowledge, increased self-image and self-confidence, critical and creative thinking ability, interpersonal skills, and research awareness and knowledge, and a readiness for professional participation. This has indirectly influenced their professional practice and delivery of quality nursing care. Although concern was raised about the recognition of the degree because of differences in accreditation criteria by the Malaysian governing body, some participants have gained promotion to senior positions. Additionally, there is enhanced interest in lifelong learning with two participants having achieved their master's degree, and others undertaking continuing educational programmes subsequent to the degree. The curriculum content with some suggested minor changes was perceived to be adequate to provide the Malaysian registered nurses with a foundational knowledge for professional practice. By and large, the findings indicate that a curriculum designed in the West can be taught and practised in another culture, provided there is a conscious blending of the culture into the curriculum. This study was confined only to one cohort of students from one particular University degree and from graduates' own perspectives, however it is a positive beginning.
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ItemOutpatient commitment: is it effective?( 1998)Outpatient Commitment (OPC) is a legal procedure that allows for involuntary psychiatric treatment in the community. Legislation for OPC first emerged in the 1970s in the USA in an attempt to provide a legal remedy for the problems posed by ideological reforms to institutional psychiatry and mental health law. OPC in particular attempts to address the difficulties presented by persons with chronic relapsing forms of serious mental illness and poor compliance with outpatient treatment - persons whose disadvantage is now particularly visible in the streets of our large cities. OPC sits awkwardly between the developing and expanding frameworks of community mental health services and mental health law. It potentially overlaps with guardianship laws, enduring medical power of attorney and court orders. Despite the growing provision for OPC and its increasing frequency of use in North America, the Antipodes, and most recently on the boarders of the European continent, there remains little understanding of the conceptual mechanisms involved in its application. Even less is known about the group of patients who might respond best to its implementation. Without taking stock of its potential adverse effects, societies run the risk of enthusiastically embracing this rather crude legal mechanism of persuasion, instead of exploring or supporting the development of potentially more effective and sophisticated clinical interventions to address the problem of non-compliance with outpatient psychiatric treatment. Given the current limitations of clinical interventions for serious mental illness and treatment non-compliance, OPC may provide a very useful role in enhancing the efficacy of these interventions/treatments through its effects on the way a treatment service is provided as well as on the patient's treatment adherence. With this aim in mind, many different forms of OPC have now emerged. However, without adequate research evidence, it is not possible to advocate strongly for the development of one form of OPC legislation over another. Nor is it possible to argue for its use in preference to other legal mechanisms of treatment orders e.g., guardianship orders. The final decision about which form of OPC legislation is chosen appears to have relatively little to do with any empirical evidence of clinical efficacy but more to do with historical and legal concerns. This thesis attempts to go some way to further bridge the gap between evidence based psychiatry and the application of mental health law with respect to Outpatient Commitment. Chapters 1 and 2 describe a brief account of the historical context within which OPC has emerged both internationally and in Australia. Chapter 3 provides a review of clinical outcome studies in the USA and elsewhere, concluding that on simple clinical measures of outcome, OPC appears to be associated with significant benefits. It is of note that all these studies have considerable limitations, and none provide a useful comparison of patients' objective clinical ratings with patients' subjective ratings of the "persuasiveness" or "coerciveness" of OPC. Chapters 4 and 5 of this thesis outline the results of a retrospective controlled study of the clinical outcome of all patients on a form of OPC in a sector of metropolitan Melbourne, Victoria, Australia, between 1987-1992. The characteristics of the patients selected has already been reported in a previous study which describes the sample as being mainly those with chronic relapsing forms of psychotic illness complicated by a history of violence and noncompliance with outpatient treatment. In Chapter 4, the results of an analysis of the clinical outcome of this group of patients suggests that the majority of these patients benefit from the application of OPC. In Chapter 5, the results of the control group comparison also indicate that though these OPC patients have evidence of higher levels of morbidity than other involuntary patients discharged directly into the community, OPC patients improve relatively better while on OPC orders. However, a minority of OPC patients do not seem to benefit or even deteriorate with the application of OPC. The study attempts to identify the characteristics that might predict better or worse clinical outcomes associated with OPC. It is important to note that the study, because of its retrospective design, suffers from limitations similar to those evident in other studies and, in particular, it does not account for influence of patients' subjective experiences of OPC. Finally in Chapters 6 & 7, based on the experience of this study and on a review of the literature, a conceptual model is proposed in order to assist with an understanding of how OPC might work. This model focuses on the nature of the impact of OPC on treatment adherence, through its effect on the patient and on the system within which the patient is being treated. It suggests that a balance needs to be struck between the persuasiveness versus the coerciveness of the Outpatient Commitment procedure. An ineffectual mechanism may discredit the procedure as a persuasive aid to treatment adherence. Conversely, an overly coercive mechanism may actually deter patients from accepting any form of assistance for their illness. This model forms the basis of recommendations for future research to test the effectiveness of OPC and to compare or contrast different forms of OPC with each other and with other less formal mechanisms of coerced community psychiatric treatment. Australia, given its relatively uniform structure and administration of mental health services, is in a good position to compare the benefits or otherwise of the rather disparate forms of OPC being introduced into each of its various states and territories. With a multi-centre randomised controlled trial of OPC in this setting, it may then be possible to make recommendations about which form of OPC most effectively and collaboratively assists in the improvement of poor treatment compliance, and which group of patients with serious mental illness are likely to benefit most from its application. It may also assist with determining OPC's relative clinical merit when compared with other less formal coercive/persuasive clinical interventions for treatment non-compliance. Without attempts to study and confirm the empirical evidence for the 'clinical efficacy' of OPC, this increasingly internationally accepted model of OPC oriented community psychiatric care runs the risk of being prematurely challenged in some future wave of mental health reform. As in the example of de-institutionalisation, the ultimate future of OPC may, however, rest not with the law but with the advent of better and more effective treatments for psychotic disorders.