AIMS:To understand the benefits and challenges of shift work, and the coping strategies used by nurses, midwives and paramedics to manage the impact of shift work on sleep and fatigue from shift work. DESIGN:A single case study with embedded units. METHODS:Twenty-seven participants were interviewed exploring their shift work experiences, coping strategies used to improve sleep, and what their recommendations are for improving shift work management. Interviews were completed between November and December 2022. RESULTS:Participants enjoyed the lifestyle, flexibility and financial rewards offered by working shift work. However, fatigue and sleep deprivation undermined these benefits, as it impacted their ability to enjoy social and family events. There were also concerns of long-term health consequences of shift work and delivery of care. Changes to rostering practices and sleep and shift work education were common recommendations. CONCLUSION:This study provides insights on how healthcare professionals manage sleep and fatigue due to shift work and the inadequate support. There is absence of adequate policies, processes and training at an organizational, academic and personal level on how to best manage sleep and fatigue when working shift work. Future research is needed to explore how to equip healthcare shift workers with the skills to successfully manage their schedules to mitigate the negative impact that poor sleep and fatigue has on the health and safety of themselves and their patients. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:Understanding the specific challenges of shift work and how workers manage their shift work schedules is critical for improving the health and safety of themselves and their patients. This study identified that there is insufficient training regarding sleep and shift work management strategies, potentially leading to occupational health and safety concerns. Further education and training to equip staff with the necessary information, training and guidance to staff on how to reduce fatigue risk is required. PATIENT OR PUBLIC CONTRIBUTION:This study involved healthcare shift workers in semi-structured interviews. Data gathered from a previous survey that participants were involved in helped shape the interview topics and the study design.

OBJECTIVE:To explore the preparedness and training needs of a regional public mental health workforce to support people with intellectual disability and mental ill health.SETTING AND PARTICIPANTS:Staff from a regional public mental health service in Victoria, Australia.DESIGN:A mixed-methods design comprised a survey, interviews and a focus group to collect data about staff attitudes, confidence, education and professional development regarding supporting people with intellectual disability and mental ill health. Descriptive and thematic analyses were used.RESULTS:Data from 31 survey respondents, seven interviews and one focus group were analysed. Survey descriptive analyses showed participants believed treating people with intellectual disability was part of their role but reported areas of low confidence along with insufficient education and training in intellectual disability mental health. Thematic analyses from interviews showed that underpinning confidence, education and training were the themes (1) need for flexibility, such as having more time and (2) solutions but with challenges, such as limited opportunity to upskill and availability of experts. A need for collaborative problem-solving where staff share skills and information to work towards person-centred solutions was a key theme from the focus group analysis.CONCLUSION:Professional development in intellectual disability mental health is required for the regional public mental health workforce but needs to account for the challenges experienced and reflect how teams function. Exploration of described preparedness offered a possible learning approach informed by workforce members. Collaborative learning approaches to supporting people with intellectual disability and mental ill health are suggested.

Background Implementing appropriate shift work schedules can help mitigate the risk of sleep impairment and reduce fatigue of healthcare workers, reducing occupational health and safety risks. In Australia, the organisation has a responsibility to make sure all reasonable measures are taken to reduce fatigue of staff. Therefore, it is important to assess what the current rostering processes is for staff responsible for creating the rosters for nurses.Aim The aims of the project were to understand (1) who creates the rosters and what the process is, (2) what training and knowledge these staff have in establishing rostering schedules that optimise the sleep and wellbeing of staff, and (3) what the benefits and limitations are of current rostering practices.Methods Findings were generated through semi-structured interviews, using cluster coding to form categories. Twenty four nurses responsible for rostering staff were interviewed from three different sites in Victoria (one metropolitan and two regional/rural hospitals). Data was analysed using selected grounded theory methods with thematic analysis.Results The common themes that came out of the interviews were that rostering staff were under prepared, unaware of fatigue and safety guidelines and polices from governing bodies and had not received any education or training before taking on the role. The most common rostering style was self-rostering, where staff could submit preferences. However, there were concerns about staff fatigue but were divided as to who should be responsible, with many saying it was up to staff to preference shifts that they could cope with. The final theme was cultural barriers to change.Conclusion While self-rostering resulted in staff having more freedom and flexibility, shift preferences may be influenced more so by a need to fit with lifestyle rather than to minimise fatigue and increase safety in the workplace. Greater consideration of the impact of shift work schedules on fatigue is required to ensure that the layers of clinical governance in health care organisations minimise the risk of occupation health and safety issues for employees delivering direct patient care.

School inclusion of students with disabilities relies on reasonable adjustments to curriculum and class activities. The Reasonable Adjustments for Inclusive Education (RAIE) was designed to elicit reasonable adjustments from stakeholders in mainstream school inclusion for three contrived students with varied learning needs. We evaluated a scale for rating the quality of elicited reasonable adjustments across five dimensions: Agency, Authenticity, Real Learning, Strengths Based, and Inclusion. A trial (n = 5 participants) led to refinement of the scale, which was tested for inter-rater reliability with data from a randomized controlled trial (RCT) of an intervention to improve the quality of reasonable adjustments. RCT participants (10 parents, 10 educators, nine allied health professionals) provided 596 reasonable adjustments, rated for each dimension by two independent raters (n = 2980 ratings). Overall agreement was 75.3%; intraclass correlation (ICC) was .778. ICCs were moderate-good (.612-.816). Further refinement and testing with multiple raters are recommended.

Training key stakeholders in the design of reasonable adjustments for students with disabilities could promote collaboration and inclusion. We tested the feasibility of a randomized controlled trial to evaluate the effectiveness of online education (intervention) in designing reasonable adjustments by Victorian (Australian) parents and professionals (n = 31). Participants suggested reasonable adjustments for contrived students with varied needs to support their participation in described classroom activities. Data collected pre- and post-intervention, and, at follow-up, were rated across five dimensions: Authenticity, Agency, Real Learning, Strengths Based, and Inclusion. Analyses from 15 intervention and 14 control participants (10 parents, 10 teaching staff, and 9 allied health professionals) showed higher scores for Inclusion post-intervention for the intervention group. This difference was maintained at follow-up, generalized to a new contrived student scenario, and mostly attributable to parents. Online education may improve parents’ contribution in the design of reasonable adjustments that promote inclusion. A larger study is warranted.

The study aim was to scope research into student outcomes of co-teaching models to promote inclusive school education for students with disability. A systematized search was conducted of studies addressing models of co-teaching involving two teachers and student outcomes published from January 2008 to June 2019. Each study was appraised for quality. Most of 21 studies that met inclusion criteria were conducted in the United States (n = 17). Fourteen studies followed quantitative approaches, six followed qualitative and one included both. Although the benefits of co-teaching for students were demonstrated, it was difficult to determine comparative effectiveness across models, with only one study providing a systematic comparison. There was some evidence of differential effects across factors such as disability type, grade level, and outcome types, but heterogeneity across study aims, participants characteristics, extent to which co-teaching models were described or implemented, and outcomes targeted precluded meaningful comparisons. Limitations were found in study designs, with appraisal scores ranging from 0.6% to 89%. Hence, the research into student outcomes for various models of co-teaching was found to be limited both in number and quality. Findings point to the need for greater attention to what occurs in classrooms to support positive student outcomes of inclusive education through co-teaching.

Background and Objective: There is a question as to whether melatonin levels in breast milk are impacted by the cooling rate postpasteurization. Past research that has used in the Australian donor bank's breast milk Holder Pasteurization technique has reported varying findings regarding melatonin levels postpasteurization. Where breast milk was cooled slowly, a significant reduction in breast milk melatonin levels was observed. Conversely, where a rapid cooling method was used, there was no significant reduction in melatonin levels. The aim of this study was to investigate whether the cooling process between the different pasteurization techniques impact on melatonin levels in breast milk postpasteurization.Materials and Methods: Twenty-seven nighttime breast milk samples were collected, with each sample divided into three; one remained unpasteurized, one was pasteurized and rapidly cooled to 4(degrees)C, and the other was pasteurized and cooled slowly to 4(degrees)C.Results: Melatonin levels were significantly reduced in both the rapidly cooled and slow cooled breast milk samples when compared to their unpasteurized counterpart (p < 0.001). There was no significant difference in melatonin levels between the two cooling methods (p = 0.91).Conclusion: This study showed that both the rapid and cooling pasteurization processes had a similar reduction in melatonin levels in breast milk. However, even after pasteurization melatonin was still present. Therefore, it is recommended that donor banks still take into consideration circadian timing hormones such as melatonin and the time of day breast milk is expressed.

Abstract Introduction Infants are not born with a circadian rhythm. Research shows that breast milk clearly exhibits a 24-hour pattern, with melatonin concentrations high during the evening and night but barely detectable in daytime milk. The presence and timing of melatonin in breast milk suggests that this hormone may help provide sleep timing information to infants, thereby supporting the development of their own circadian cycle. Currently, it is not known if disturbances of maternal circadian rhythm, such as shift work, impact the circadian rhythmicity of breastmilk. The aim of this study was to investigate whether maternal circadian disruption, from working night shift has an impact on melatonin timing in breastmilk. Methods A prospective repeated measures study design was undertaken to compare melatonin levels in breastmilk across shift types (day shift/non-workdays and night shifts). Four 10ml breastmilk samples were collected by participants the same time of the day, across five consecutive days. Results. A total of 11 mothers completed the study. Analysis is still ongoing but preliminary results show a potential difference in breastmilk melatonin between pre-night shift, night shift and post night shift, indicating a change in the circadian timing of the breastmilk. Discussion The findings from this study suggest that there is a potential effect from maternal circadian disruption from shift work on breast milk melatonin. This is an important first step in exploring the impact of maternal circadian misalignment disorders on breastmilk hormones and provides preliminary evidence that future research is needed in this area.

OBJECTIVES:To explore if there are differences in shift patterns and work-related factors between metropolitan and regional/rural healthcare shift workers and their risk of poor sleep and mental health. Furthermore, explore whether these factors impact on medical errors, workplace and car/near car accidents.DESIGN:A cross-sectional study.SETTING:An anonymous online survey of healthcare shift workers in Australia.PARTICIPANTS:A total of 403 nurses, midwives and paramedics completed the survey.MAIN OUTCOME MEASURES:Sample characteristics, employment location, shift work-related features, sleep and mental health measurements, workplace accidents, medical errors and car/near car accident post shift.RESULTS:Regional/rural healthcare shift workers were significantly older, had more years' experience, worked more nights, on-call and hours per week. Those in metropolitan areas took significantly longer (minutes) to travel to work, had higher levels of anxiety, increased risk of shift work disorder, reported significantly more workplace accidents and were more likely to have a car/near car accident when commuting home post shift. Both groups reported ~25% having a medical error in the past year. Workplace accidents were related to more on-call shifts and poor sleep quality. Medical errors were associated with fewer years' experience, more evening shifts and increased stress. Car accidents were associated with metropolitan location and increased depression.CONCLUSION:Differences in work-related factors between metropolitan and regional/rural healthcare shift workers were observed. Some of these factors contributed to occupational health and safety risks. Further exploration is needed to understand how to reduce occupational health and safety risks, and improve employee and patient safety both in both regional/rural and metropolitan areas.

Background and Objective: Melatonin in breast milk exhibits a 24-hour circadian rhythm, present in nighttime breast milk but nearly undetectable in daytime breast milk. Shift work can disrupt the circadian timing of individuals, evident in changes in melatonin in saliva and urine samples. However, it is unknown whether these changes are also reflected in breast milk from a shift working mother. The aim of this study was to investigate whether maternal circadian rhythm disturbance from shift work impacts the melatonin concentration in breast milk. Materials and Methods: Breast milk and saliva samples were collected from 11 shift working mothers at four timepoints across five consecutive days. This included during their day shift or nonworkdays to act as a control, night shift, subsequent night shifts and postnight shift. Where possible, pre- and postfeed collections were also undertaken. Samples were grouped into four-time intervals: 12-6:30 am, 7-11:30 am, 12-6:30 pm, 7-11:30 pm, and melatonin levels (picogram per milliliter) in the breast milk and saliva samples were analyzed. Results: There was a significant decrease in breast milk melatonin (p = 0.026) at the 12-6:30 am time interval on subsequent night shifts, compared with control days. However, there was no overall time and shift type interaction effect (p = 0.70). In addition, no observed difference in melatonin levels was found in saliva samples, or when comparing pre- and postfeed breast milk. Breast milk melatonin however was found to be significantly higher compared with saliva (p > 0.001), at all but one time interval. Conclusion: The findings suggest that there is a potential effect of maternal circadian rhythm disruption from shift work on breast milk melatonin levels. This is an important step in exploring the role of maternal circadian timing and the effect on breast milk composition. Expansion of this research and exploration of other circadian rhythm misalignment sleep disorders on breast milk is highly recommended.

Background and Objective: Donor human milk banks are used when breast milk directly from mothers is unavailable or insufficient. Breast milk contains melatonin, which exhibits a 24-hour pattern. Melatonin promotes sleep onset and is barely detected in daytime milk but rises in the evening and peaks early in the morning. Melatonin supports the development of an infant's own circadian rhythm and is important for neurodevelopment. Currently, donor banks pasteurize breast milk using a Holder Pasteurization (HoP) technique where breast milk is treated at a high temperature (+62°) for 30 minutes before cooling to eliminate any pathogens before it is given to infants. It is not known how the pasteurization process affects the melatonin levels in breast milk. The aim of this study was to investigate whether the pasteurization process reduces melatonin levels in breast milk. Materials and Methods: Ten night-time breast milk samples were collected and each divided into two groups; one group remained unpasteurized and the other group was pasteurized using the HoP technique. Results: Melatonin levels between the unpasteurized and pasteurized groups were compared. Results showed that there was a significant reduction after pasteurization (mean ± standard deviation = 51.92 pg/mL ± 19.54 versus 39.66 pg/mL ± 13.05, p = 0.01). Conclusions: It is important to understand that pasteurization can reduce melatonin levels in breast milk because this hormone is considered important to support the neurodevelopment of infants, especially those born preterm. Further focus on the effect of pasteurization techniques on melatonin in donor breast milk is warranted.

Abstract Introduction Sleep impairment can decline alertness and performance and increase the risk of occupational injuries such as medical errors, workplace injuries and car accidents. Australia has a shortage of healthcare shift workers, particularly in regional/rural areas. The consequence of this is that rural healthcare shift workers potentially have to work longer hours, be more on-call and/or have to commute longer distances to/from work. These factors could impact the worker's sleep and recovery. The aim was to explore the differences in sleep and shift work patterns in regional/rural and metropolitan healthcare shift workers and the risk of workplace accidents, medical error, and car accidents. Method An anonymous online survey was distributed targeting nurses, midwives and paramedics. Results 403 healthcare shift workers completed the survey. Those in regional/rural locations were significantly older, had more experience, worked significantly more hours per week, more night shifts and on-call shifts in the previous two weeks. However, metropolitan shift workers took significantly longer (in minutes) to travel to work, reported more feelings of sleepiness while driving to/from work, having a car accident or near accident while commuting home, and having a workplace accident in the last 12 months. There was however no differences in sleep quality between the groups but poor sleep quality was the main contributing factor related to workplace incidents, medical errors and car accidents. Conclusion There were differences in shift work patterns between metropolitan and regional/rural healthcare shift workers. More exploration is needed to understand the components that contribute to increased OH&S risks.

BACKGROUND:Collaborative consultation involving educational staff, allied health professionals and parents working towards goals for children with disability is considered best practice in inclusive education. However, challenges can hinder effective collaboration, thereby potentially limiting child outcomes.AIMS:The study aims were to (a) explore the experiences of teachers, teacher assistants, allied health professionals, and parents engaging in collaborative teamwork to support inclusion of children with disability in mainstream primary schools, and (b) identify key factors influencing effective teamwork and the design of support strategies.METHODS AND PROCEDURES:A co-design research method emulated collaborative consultation and authentic stakeholder teamwork. Data were from a series of six co-design workshops (15 h); discussions were audio-recorded and transcribed verbatim. An interpretive descriptive method of thematic analysis resulted in four key themes.OUTCOMES AND RESULTS:Critical factors that influenced collaborative teamwork were access to diagnosis and funding, mechanisms for team communications, practical ways of working together, and shared understandings of inclusion.CONCLUSIONS AND IMPLICATIONS:Stakeholder teams require effective communication mechanisms and practical ways of working together within and outside of classrooms. Shared understandings of inclusion provide a foundation for collaboration, requiring access to professional development to ensure teamwork is informed by best inclusive education practice.

Background and Objective: The presence and fluctuation of melatonin in breast milk during the night and day may be providing sleep timing information to infants, thereby supporting/enabling the development of their own circadian cycle. If this is the case, then it is important that infants consume breast milk according to the time of day it is produced. However, breast milk is not always consumed at the "right" time. The aim of this study was to investigate whether consuming mistimed expressed breast milk impacts infant sleep compared with other feeding types.Methods: A total of 329 mothers completed an online anonymous survey. Mothers were grouped into one of five groups; direct breastfed only, formula only, express mistimed, express-timed, and combined breastfed/formula fed.Results: Cross-sectional analysis showed mistimed expressed breast milk was significantly associated with delayed sleep onset of the infant (p < 0.001), but direct breastfed infants had significantly more awakenings at night (p < 0.001).Conclusions: The findings from this study suggest a potential effect of mistimed expressed breast milk consumption on an infant's circadian rhythm, affecting some aspects of their sleep. This is an important first step in exploring mistimed feeding on infant sleep outcomes and provides preliminary evidence that warrants future research.

The study aim was to scope research into student outcomes of co-teaching models to promote inclusive school education for students with disability. A systematized search was conducted of studies addressing models of co-teaching involving two teachers and student outcomes published from January 2008 to June 2019. Each study was appraised for quality. Most of 21 studies that met inclusion criteria were conducted in the United States (n = 17). Fourteen studies followed quantitative approaches, six followed qualitative and one included both. Although the benefits of co-teaching for students were demonstrated, it was difficult to determine comparative effectiveness across models, with only one study providing a systematic comparison. There was some evidence of differential effects across factors such as disability type, grade level, and outcome types, but heterogeneity across study aims, participants characteristics, extent to which co-teaching models were described or implemented, and outcomes targeted precluded meaningful comparisons. Limitations were found in study designs, with appraisal scores ranging from 0.6% to 89%. Hence, the research into student outcomes for various models of co-teaching was found to be limited both in number and quality. Findings point to the need for greater attention to what occurs in classrooms to support positive student outcomes of inclusive education through co-teaching.

BACKGROUND:Previous research has shown poor hospital experiences and dire outcomes for people with intellectual disability. The main objective of this study was to prospectively track episodes for adults with intellectual disability (ID) in Australian hospitals, with a focus on indications of the quality of care provided.METHODS:A prospective audit of hospital records over 35 months yielded quantitative data about patient characteristics, frequency and length of hospital episodes, diagnostic assessments and outcomes, post-emergency department (ED) destinations and post-discharge recommendations. Fifty participants were recruited largely by identification on hospital ED entry. An audit of patients' hospital records was conducted towards the end of hospital episodes, using a tool developed for the study.RESULTS:Participants were mostly men (70%), aged 42.9 years on average, living mostly with family (46%) or in supported accommodation (44%). Of 157 recorded episodes, 96% started in ED,  85% required urgent or semi-urgent care and 62% were in the first 3 months of study participation. Average time in ED exceeded the 4-h national benchmark, met in 40% of episodes. One or more diagnostic assessments were conducted in 91% episodes and others in short stay units. Almost half (49%) resulted in a ward stay. With an extreme data point removed, <1-35 days were spent in wards. The most frequent diagnosis in 75% of episodes was for digestive problems, followed by nervous system problems then injuries. Median length of bed stays reflected data available for Australian refined diagnosis-related groups. High hospital re-presentations were found: for 67% of episodes in total, 26% (n = 12) of which were within 72 h and 59% (n = 23) within 30 days.CONCLUSIONS:Adults with ID presented frequently to ED and often had lengthy stays. We found no indication of poor care practices in terms of hospital staff willingness to keep patients in ED and conduct of diagnostic assessments. Frequent re-presentations, however, indicated failed hospital care at some level.

Codesign is increasingly used for health research and service improvement. Codesign combines generative and exploratory methods, enabling collaboration between service end users and researchers as equal partners. The aim of this study was to evaluate a codesign method used to design an online education package about inclusive education for children with disability in mainstream schools. The study design was a multiple methods evaluation informed by participatory and transformative research paradigms, incorporating design sciences and public service approaches. A governance committee supported the process. The codesigners ( n = 12) included teachers, teacher assistants, parents, and allied health professionals. Process and outcome evaluation data were used; data collected were from verbatim transcripts of codesign workshop discussions ( n = 11), documents, Self-Report Level of Participation Surveys, and individual interviews ( n = 11). Thematic and descriptive analysis methods were used to describe the codesign processes, experiences, and outcomes. The key processes were identifying the issues through storytelling, voicing frustrations, being vulnerable, sharing insider knowledge, challenging other people’s roles, and deliberation and decision-making. Codesigners’ experiences and outcomes identified strengths and challenges in the method. A conceptual model is presented demonstrating interrelationships between processes, subprocesses, and codesigners’ experiences and outcomes. Codesign involves multiple, interrelated processes that support deliberation and creative design. Skills and resources are required to effectively facilitate what can be a meaningful, creative, and social process.

Descriptive study. To determine the effect of respiratory event rule-set changes on the apnoea hypopnoea index, and diagnostic and severity thresholds in people with acute and chronic spinal cord injury. Eleven acute spinal cord injury inpatient hospitals across Australia, New Zealand, Canada and England; community dwelling chronic spinal cord injury patients in their own homes. Polysomnography of people with acute (n = 24) and chronic (n = 78) tetraplegia were reanalysed from 1999 American Academy of Sleep Medicine (AASM) respiratory scoring, to 2007 AASM ‘alternative’ and 2012 AASM respectively. Equivalent cut points for published 1999 AASM sleep disordered breathing severity ranges were calculated using receiver operator curves, and results presented alongside analyses from the able-bodied. In people with tetraplegia, shift from 1999 AASM to 2007 AASM ‘alternative’ resulted in a 22% lower apnoea hypopnoea index, and to 2012 AASM a 17% lower index. In people with tetraplegia, equivalent cut-points for 1999 AASM severities of 5,15 and 30 were calculated at 2.4, 8.1 and 16.3 for 2007 AASM ‘alternative’ and 3.2, 10.0 and 21.2 for 2012 AASM. Interpreting research, prevalence and clinical polysomnography results conducted over different periods requires knowledge of the relationship between different rule-sets, and appropriate thresholds for diagnosis of disease. This project was proudly supported by the Traffic Accident Commission (Program grant) and the National Health and Medical Research Council (PhD stipend 616605).