Jane Currie

Health professional can hold stigmatising attitudes toward people who use alcohol and other drugs (AOD), affecting therapeutic engagement and health outcomes. Evidence suggests that education can challenge health professionals' bias. However, education is only one strategy, and its impact depends on broader system and organisational factors. Yet AOD education remains limited and rarely incorporates lived‐experience perspectives. Co‐designed and co‐delivered AOD education offers a way to support clinicians to reflect on stigma and strengthen collaborative, person‐centred care. This study aimed to assess whether a co‐designed AOD education program, delivered by lived experience educators, influenced clinicians' attitudes toward people who use AOD. Using a quantitative, non‐randomised pre–post quasi‐experimental design, this paper reports quantitative findings from a pre‐post survey that captured clinician demographics and attitudes using a modified version of the Australian National Centre for Education and Training on Addiction (NCETA) AOD Attitudinal Brief Scale. Post‐education survey results indicated that the education was associated with significant improvements in attitudes, including greater recognition of social and structural influences on substance use and reduced endorsement of personal blame, anger, disappointment, and punitive views (all p < 0.01). Overall, the program contributed to a reduction in stigma and more positive clinician attitudes toward collaborative decision‐making with people who use AOD, underscoring the value of embedding lived experience in clinician education.

Objectives: Few studies have quantified the vulnerability of people experiencing homelessness and its association with emergency department (ED) reattendances. The study objectives were to identify the health and social-related vulnerability, comorbidities and reattendance to an ED within 28 days, of people experiencing homelessness and people living in stable housing. Design: Prospective cohort study, 28 September 2023 to 12 October 2023. Setting: Metropolitan ED in an inner-city public hospital. Participants: Eligible participants were those who attended the ED between 8am and 5pm during the 2 week study period (2023), those aged 18 years and over and able to provide informed consent, and those deemed well enough to participate. Intervention: The homeless health access to care tool (HHACT) assesses a person’s unmet needs and quantifies their level of health and social-related vulnerability (low, moderate, high). The HHACT was applied to each participant. Routinely collected administrative data was used to identify participant demographics and ED usage on the day of study enrolment and any ED reattendance within 28 days. Main outcomes and measures: Outcome measures were the identification of participants’ level of health and social-related vulnerability and its relationship to ED reattendance. Results: Of the 300 ED participants, 38 (12.6%) were experiencing homelessness. There was a greater than twofold increase in odds of 28-day ED reattendance for participants experiencing homelessness (OR=2.93, CI 1.29 to 6.36; p=0.008) or had moderate to high vulnerability scores (participants living in stable housing and participants homeless) (OR=2.67, CI 1.29 to 5.36; p=0.007). Compared with participants in stable housing, prevalence of comorbidities among participants experiencing homelessness was greater regarding mental health challenges (65.8% vs 21.8%); three or more physical health conditions (36.8% vs 13%) and greater alcohol and other drug use (36.8% vs 17.2%). Conclusion and relevance: The high ED reattendance suggests that people experiencing homelessness are not being adequately screened for unmet needs on their first presentation. Comprehensive screening using the HHACT may enhance the identification of the risk of reattendance and provide opportunities to intervene through targeted responses, such as integrated care pathways. While EDs are not designed to address the multifaceted needs of people experiencing homelessness, there is an urgent need to consider how to optimise this population’s access to appropriate care.

Objectives To determine the feasibility of conducting a multisite randomised controlled trial of the Healthy and HomED model of care to determine its capacity to reduce emergency department (ED) representations among people experiencing homelessness. Design Feasibility randomised controlled trial with process evaluation. Setting Single site public metropolitan ED. Participants Our goal was to recruit 204 adults experiencing homelessness attending ED. In total, 190 participants were enrolled. The final sample comprised n=101 control and n=86 intervention. Interventions The Healthy and HomED model of care comprises screening for homelessness, assessing unmet needs via the Homeless Health Access to Care Tool and a Decision Assistance Guide that informs care planning. The intervention was applied by the Assessment Liaison Early Referral Team (ALERT), an ED-based multidisciplinary team specialised in supporting underserved populations. Main outcome measures Clinician acceptability of the implementation of the model of care, improved identification of homelessness and a reduction in ED representations within 28 days among people experiencing homelessness. Results Implementation of the Healthy and HomED model of care was feasible to the ALERT clinicians and the research team. While the Healthy and HomED did not significantly reduce representations to the ED, it improved the identification of homelessness by a third (35.3%). Qualitative findings suggest that the Homeless Health Access to Care Tool provided helpful standardisation to assessments. The Decision Assistance Guide was seldom added to the plan of care for senior clinicians but was reportedly helpful to junior clinicians with less experience in homeless healthcare. Conclusions The study provided assurance that running a multicentre hybrid trial to test the effectiveness and implementation of the Healthy and HomED is feasible. Process evaluation found that intervention adherence could be improved with greater contextualisation to local resources and increased engagement from ED medical and nursing teams. These factors could be addressed through the codesign of a future multisite trial. Trial registration number ANZCTR 12622001085763.

Domestic violence is a public health concern of epidemic proportions in Australia. Women experiencing domestic violence struggle to access the healthcare they need, when they need it. This qualitative longitudinal study explored service users’ perspectives on the impact of a nurse-led domestic violence service on their access to healthcare. Study design was guided by the five pillars of best practice from the Research Integrity Framework on Violence and Abuse and informed by social constructionism. Semi-structured interviews were conducted with women at two time points: within two months of using the service and six to 12 months later. Thematic analysis explored how women’s interactions with the clinical nurse impacted their access to healthcare and their engagement with mainstream health services. Fifteen women participated in first round interviews and ten in the second round. All were housed in emergency accommodation following domestic violence incidents. The clinical nurse provided a safe and flexible way for women to access immediate healthcare in a place of safety, that enabled empathy, validation and practical support to address broader health needs. Three identified themes encompassed the ways the nurse-led service impacted women’s healthcare access: living in between, partnership-based nursing care and empowering choice and staying connected. The nurse-led service was profoundly successful in enabling women’s access to healthcare through outreach and tailored follow up care. Critical to its success was the flexibility of the nurse-led service to meet women in their place of safety and provide an immediate healthcare response. The constellation of the nurse’s specialist knowledge and skills, along with person-centred and trauma informed interpersonal skills and attributes, collectively empowered women to transition towards a state of stability in their wellbeing. Not applicable.

Aim: To explore the key knowledge, skills, attributes and organisational support that nurses require to optimise their scope of practice when providing care to people experiencing homelessness. Design: A qualitative descriptive study exploring nurses' scope of practice for addressing health needs of people experiencing homelessness. Methods: Interviews and focus groups were conducted from 2022 to 2024 with 42 people with lived experience of homelessness across two Australian cities. Thematic analysis identified essential skills, attributes and approaches to improve access to care and eliminate stigma. Findings were then presented in focus groups with 11 registered nurses in specialist homeless health services to elicit views on optimising scope of practice. The study follows COREQ reporting guidelines for qualitative research. Results: Lived‐experience participants—ranging from 18 to 84 years, a third living in cars or tents—identified key nursing attributes and practices, including approachability, compassion, non‐judgement, flexibility, community embeddedness, trauma‐informed and culturally safe practice, plus skills in physical and mental health assessment, medication management and service navigation. Nurse participants agreed with lived‐experience participants, and highlighted organisational support needs, including information sharing, clinical supervision, assertive outreach, nurse prescribing and long‐term funding for nurse‐led programs. Conclusion: With rising housing instability, preparing nurses to optimise access to care for people experiencing homelessness is critical. Optimal scope of practice includes personal attributes to build rapport and reduce stigma alongside clinical skills. Co‐developing educational programs in partnership with people with lived experience of homelessness and homeless health nurses offers a promising approach. Impact: This research informs the scope of practice definitions and the future development of a co‐developed nursing education pathway and organisational framework to improve access to care for people experiencing homelessness in Australia. Patient or Public Contribution: Limited patient and public involvement was incorporated and focused on providing feedback on interview guides.

Background: Surgery often causes anxiety in adults due to various factors, including fear of anaesthesia and loss of independence. This anxiety can lead to higher anaesthesia requirements and more postoperative complications. Virtual Reality (VR) is increasingly used as a non‐pharmacological intervention to decrease perioperative anxiety. This systematic review and meta‐analysis aim to evaluate the effectiveness of VR to decrease perioperative anxiety in adult patients undergoing elective surgery.Design: A systematic review was conducted according to the Joanna Briggs Institute (JBI) method for systematic reviews of effectiveness. This paper complies with the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) statement.Methods: Four electronic databases were searched from inception to July 2024. Inclusion criteria were experimental and quasi‐experimental studies using VR preoperatively to reduce perioperative anxiety as the primary outcome, with no language or date restrictions. Two independent reviewers screened and critically appraised the studies using the JBI appraisal tool. Randomised controlled trials (RCTs) were synthesised, and data were pooled in a statistical meta‐analysis. A random effects meta‐analysis was used due to heterogeneity. For studies that could not be meta‐analysed, a narrative synthesis was performed.Results: 11 studies met the inclusion criteria, including eight RCTs and three quasi‐experimental studies. Overall, the majority of studies demonstrated that VR effectively reduced anxiety and increased patient satisfaction. The meta‐analysis revealed a small, non‐significant reduction in preoperative anxiety, favouring VR (Standardised Mean Difference − 0.29, 95% Confidence Interval − 0.83 to 0.24), with moderate heterogeneity (I² = 47%). However, findings regarding secondary outcomes including VR side effects, stress levels, preparedness levels, patients' satisfaction and length of hospital stay were inconsistent.Conclusions: The evidence is limited to support the use of VR in reducing perioperative anxiety among adults. Larger sample sizes, high‐quality RCTs and standardised anxiety measures are required to determine the effectiveness of VR on perioperative anxiety.Trial Registration: PROSPERO CRD42020158529 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=158529.Patient or Public Contribution: No patient or public contribution was required to design or undertake this review.

Aim: To explore the perceived impact of a nurse‐led domestic and family violence service on access to care. Background: Delivered from a metropolitan community based not for profit organisation, this nurse‐led service provided a multidisciplinary response to meeting the needs of women, and or women and children experiencing the consequences of domestic and family violence and homelessness. This involved integration of specialist community services to support women's safety planning, housing, and mental health. Design: A mixed methods single‐site study was conducted. Methods: Routine patient attendance data were analysed to identify service use. Semi‐structured interviews with service providers and key stakeholders explored perceived service impact on access to care. Results: Data were collected over 2.5 years from n = 233 women experiencing domestic and family violence, of whom 28% ( n = 64) identified as First Nations, and 26% ( n = 61) had at least one dependent child. The nurse facilitated access through referrals, and care navigation, often driving and accompanying women to their appointments. Person‐centered and trauma sensitive approaches were highly effective in gaining trust. Qualitative data themes were, care environment , macro context , care outcomes and person centeredness. Conclusion and Implications: Stakeholders' perspectives highlight the need to improve health professionals' capability to respond effectively when women disclose domestic and family violence. The success of this nurse‐led service was its capacity for flexibility, which meant it could address women's unmet health needs in most environments and directly facilitate their access to mainstream healthcare and social supports. Impact: Accessing healthcare is extremely challenging for women experiencing domestic violence in Australia. The nurse‐led specialist service provided much needed support to women experiencing domestic and family violence and to health professionals within the broader organisation, to improve access to care. Optimising the nurse's scope of practice in terms of authority to refer for investigations and prescribe medications, would further increase access to care. Reporting Method: This study has been reported using the Consensus Reporting Items for Studies in Primary Care (CRISP) checklist. Patient or Public Contribution: No Patient or Public Contribution.

Australia has a worldclass universal health and social care system, yet for many reasons the ~122,000 people experiencing homelessness are unable to access the healthcare they need, when they need it. Subsequently, homelessness leads to chronic disease and premature death often from treatable conditions. We present three ideas for emergency department clinicians to help improve access to care for people experiencing homelessness: 1. Screen - Homelessness isn’t always obvious. 2. Link - Health disparities aren’t insurmountable, and services are available. 3. Design with - Co-design to optimise health outcomes.

Aim: To explore specialist homeless health professionals' perceptions of gaps in homeless health care and understand whether these might be addressed through existing nursing scopes of practice.Design: Qualitative descriptive study.Methods: Semi‐structured interviews and focus groups with a purposive sample of 22 staff in nursing (11) and non‐nursing (11) roles, engaged with a Homeless Health Service. Data were collected via videoconferencing and recordings transcribed verbatim. An exploratory framework guided deductive and inductive thematic analysis.Results: Service gap themes included the need for integration with mainstream health services, more specialised health professionals, and adaptations to the existing models of care. Addressing these gaps involved enhancements to the broad scope of nursing practice, workforce development by establishing homeless health as a nursing specialty and optimising organisational governance to minimise risk.Conclusion: The most pressing homeless health service delivery gap was lack of health service integration, and it was unclear how this could be resolved through nursing scopes of practice. Other service gaps could be addressed through skilling nurses to practice preventative health care, as well as crisis management. Enhancing nurses' capability in physical and mental health assessment skills including alcohol and other drugs and procedural skills would support wraparound care for people experiencing homelessness. We conclude that a homeless health nursing specialty could be established that formalises the scope of practice of nurses in this field to ensure future post‐graduate training aligns with service gaps.Impact: This study identifies opportunities to optimise nursing scopes of practice to address Homeless Health Service gaps through reviewing models of care and nursing practice. For example, enhancing nurses' capability to provide preventative and wraparound care. This research may inform a development pathway to enhance education and training for nurses working with vulnerable populations.Reporting Methods: COREQ 32‐item checklist.No patient or public contribution.

Issue Addressed: In 2021, the Australian government implemented a population wide COVID‐19 vaccination program. People experiencing homelessness faced challenges accessing vaccines and many were not being reached. By reorienting vaccination services to include assertive outreach strategies, a Brisbane‐based non‐profit health care team successfully administered 2065 COVID‐19 vaccinations to homeless and precariously housed people. This study examines insights from stakeholders delivering the service and perspectives of clients who received a vaccine.Methods: Semi‐structured interviews with five stakeholders and a survey of 63 clients involved in the Micah Projects COVID‐19 vaccination program are reported. Client survey questions covered demographic characteristics, and motivations and hesitancies around vaccination. Stakeholder interviews were inductively analysed and quantitative survey data were exported into SPSS (IBM V27) and analysed using descriptive statistics.Results: The Micah Projects team initiated 220 pop‐up vaccination clinics and worked closely with Aboriginal and Torres Strait Islander communities. Downsizing and mobilising the service engaged greater numbers of people sleeping rough and Aboriginal and Torres Strait Islander people. Clients' decisions to vaccinate were often spontaneous, driven by immediate availability and motivated by a desire to stay healthy and protect the community.Conclusions: Tailoring vaccination programs to include assertive outreach strategies effectively reduces barriers for people experiencing homelessness. Community embeddedness, trust, flexibility and cultural safety are critical elements for success.So What?: People experiencing homelessness are motivated to vaccinate. Reorientating health services to remove structural barriers and build the supportive environments needed to work through vaccine hesitancies are critical elements to ensure equitable access and promote health.