356 OLDER PERSONS LIVING ALONE IN INTEGRATED CARE: DEPRESSION, LOW EDUCATION AND FUEL POVERTY

Background

An important consequence of population ageing has been the increasing number of older adults who live alone. According to TILDA data, older adults with the lowest levels of education tend to experience most social isolation and there is a strong association between living alone and loneliness. We sought to compare the cohort of patients open to the Integrated Care for Older Persons (ICPOP) team in a University Teaching Hospital serving a community area of approx. 300,000 population, to this national dataset.

Methods

A convenience sample of 174 patients who underwent comprehensive geriatric assessment via domiciliary visit between July 2021-May 2022 by was analysed. Data was anonymised and analysis was performed using SPSS v.27.

Results

The average age was 81.5 (±8.1) with 63% women in the sample. Eighty-five older adults i.e. 49% of the sample either lived alone or spent more than 21 hours alone per 24-hour period. Compared to those who live with someone, those who lived alone had higher rates of likely depression as determined by Geriatric Depression Score (6.6 vs 4.8 p=0.007). They were also likely to have less educational attainment, as determined by years spent in full time education (11.81 vs 10.42 42 p= 0.0016) and those living alone had overall less central heating in their homes than those not living alone (64/85 vs 81/89 p=0.0109). There were no significant differences in the rates of polypharmacy, falls, dementia and home ownership between groups. There were higher levels of frailty in the group living with someone than those living alone as determined by Clinical Frailty Scale (6.14 vs 5.23 p<0.001).

Conclusion

A high proportion of patients seen by our ICPOP team live alone and have complex care needs that require an innovative, multidisciplinary approach. Financial vulnerability in this group is likely to compound isolation and loneliness.

107 LESSONS LEARNED FOLLOWING COVID-19: PLANNING FOR FUTURE INFECTIOUS OUTBREAKS IN A RESIDENTIAL CARE SETTING

Background

During the COVID-19 pandemic, maintaining resident and staff safety was a key priority. This study explored the experiences of the nursing team in a residential care facility for older adults and we report on the lessons learned for future infection control outbreaks.

Methods

Following ethical approval, all members of the nursing team were invited to take part in a one-to-one virtual interview using Microsoft teams. Eleven interviews were conducted. The data were imported into NVIVO data management software and analysed using thematic analysis.

Results

The findings highlight the importance of preparedness in terms of ‘keeping the house in order’ by having policy, guidelines and staff training up-to-date, so that they are easily amended to meet unexpected challenges. Having advanced care planning as part of routine care will ensure that the wishes of the residents are always respected. Keeping the channels of communication open by embracing technology and being technology ready emerged as key to relationship centred care. This was important for maintaining relationships between staff, residents, and family/caregivers, and was essential for resident and family well-being, particularly for residents with cognitive impairment.

Conclusion

Scientific predictions indicate that the next pandemic may come sooner and be deadlier than COVID-19. Health care managers and staff need to be ready to ensure that quality care is maintained. In residential settings, disruption to routine care can be minimised by embedding aspects of care embraced during COVID-19, into routine practice. Advanced care planning, embracing technology, and ensuring staff training, policy and procedures are up-to-date will make sure they can be easily amended to address infection specific requirements and this, will enable health care workers respond to outbreaks efficiently.

The black summer bushfires: impacts and risk factors for livestock bushfire injury in south-eastern Australia

Background

The 2019/2020 Australian bushfires were the largest bushfire event in modern Australian history. While actions to mitigate risk to homes from bushfires are well reported, there is very little research reported on the impacts of bushfires on livestock. With an increasing incidence of bushfires predicted, there is an urgent need to identify how farmers can best protect their livestock.

Objectives

Compare bushfire affected farms with and without injured livestock to identify associations between risk factors and bushfire injury. Infer management approaches that can be used to reduce bushfire injury in livestock.

Method

A case‐control study using a structured interview questionnaire, delivered in late 2020 to cattle and sheep farmers in south‐eastern Australia (New South Wales and Victoria) whose farmland was burnt in the 2019/2020 Australian bushfires. Case farms were farms with bushfires injured or killed livestock. Control farms were farms that had no bushfire injured livestock but that still had fire present on the farm. Interview responses were summarised and information theoretical approaches were used to identify potential risk factors for livestock bushfire injury and protective actions that could inform future fire‐preparation recommendations.

Results and discussion

Of 46 farms in the case‐control study, 21 (46%) reported bushfire injured or killed livestock. Apparent protective factors identified included: preparation (having a bushfire plan and more than two farm bushfire fighting units), backburning and receiving assistance from fire authorities. Combined beef and sheep grazing enterprises appeared to have an increased risk of bushfire injury to livestock.

132 GERIATRIC REHABILITATION IN THE COVID-19 ERA: SERVICE INNOVATION AND PATIENT OUTCOMES

Background

Methods

Results

Conclusion

108 COMBATTING CONFUSION: SIMULATION-BASED MEDICAL EDUCATION FOR DEALING WITH DELIRIUM

Background

Delirium is a complex, costly, and common clinical syndrome. Simulation-based medical education has been shown to be effective in enhancing the confidence, knowledge and skills of healthcare professionals in the management of delirium. We piloted an inter-professional education simulation on delirium in an acute hospital setting. The session’s design was informed by participating in ‘Sim Stars’, a regional simulation development competition.

Methods

We iteratively developed a low-fidelity simulation scenario on the recognition, prevention and management of delirium. The resulting simulation was piloted during an hour-long multidisciplinary departmental teaching session in a lecture hall setting. A candidate was asked to review an acutely confused patient (played by a ‘confederate’) on call. The candidate was expected to screen for delirium using the 4AT tool; assess for possible causes of delirium; and implement an appropriate management plan. After the session, qualitative feedback from the participants and audience was sought.

Results

This pilot simulation included one candidate (medical Senior House Officer); two confederates (Consultant Geriatrician, Advanced Nurse Practitioner); two facilitators (Consultant Geriatrician, Advanced Nurse Practitioner); and an audience of 17 members. Feedback indicated that learners and trainers found this a helpful and enjoyable pedagogical method. Areas for improvement were highlighted, including providing advance notice for learners of the topic to be simulated; a more structured introduction defining the learning outcomes and declaring a ‘blame free’ environment; improved script for the patient confederate; and that having a team of learners (rather than specialists) to play ‘confederates’ may help improve team-building and reduce learner anxiety.

Conclusion

This pilot simulation received positive appraisals from the team, and plans are underway to incorporate simulation more regularly into departmental teaching. Suggestions to improve future simulations were welcomed. Given its low-fidelity, this scenario can easily be used at any site for simulation-based training.

56 EFFICACY OF AN ELECTIVE PERIOD OF IN-PATIENT REHABILITATION FOR PATIENTS LIVING WITH PARKINSON’S DISEASE AND FRAILTY: A PILOT STUDY

Background

Frailty and Parkinson’s disease (PD) are more common with increasing age and are associated with syndromes such as falls, immobility, cognitive dysfunction and incontinence. PD may directly cause or co-exist with and compound frailty. A coordinated, multidisciplinary approach to care has been shown to optimize outcomes in both of these conditions. This pilot study aims to examine the short-term effects of an elective two-week in-patient rehabilitation program on frail PD patients’ function, mobility, and self-reported quality of life (QOL).

Methods

This prospective cohort study included all frail PD patients admitted for elective rehabilitation since the program’s conception. Patients included must be able to mobilize independently with or without an aid, or with assistance of one person. They also must be cognitively able to participate in rehabilitation. Patients received consultant-led Comprehensive Geriatric Assessment and attended daily physiotherapy and occupational therapy sessions. Functional outcome and health related QOL measurements were collected on admission and discharge and compared using a paired t-test. Frailty was quantified by the Clinical Frailty Index.

Results

Twelve patients completed the program (58% male). The average age was 79 (range 70–86) and average clinical frailty score was 5.6 indicating mild to moderate frailty. Performance in activities of daily living (Barthel Index: 64 vs 73, p = 0.005), overall mobility (Elderly Mobility Scale: 10.6 vs 12.9, p = 0.004), gait speed (Timed Up and Go: 35 vs 29 seconds, p = 0.05), and balance (Berg Balance Scale: 25 vs 32, p = 0.002) significantly improved from admission to discharge from the program. Health-related QOL also improved (EQ-5D: 44 vs 66, p = 0.004).

Conclusion

Early data suggests that a short elective in-patient rehabilitation program has highly significant benefits for frail PD patients on mobility, performance of activities of daily living, and QOL. Longer term follow-up is required to assess sustainability of these improvements and cost-effectiveness of this intervention.

A landscape classification map of Ireland and its potential use in national land use monitoring

This study presents a novel landscape classification map of the Republic of Ireland and is the first to identify broad landscape classes by incorporating physiographic and land cover data. The landscape classification responds to commitments to identify and classify the Irish landscape as a signatory to the European Landscape Convention. The methodology applied a series of clustering iterations to determine an objective multivariate classification of physiographic landscape units and land cover datasets. The classification results determined nine statistically significant landscape classes and the development of a landscape classification map at a national scale. A statistical breakdown of land cover area and diversity of each class was interpreted, and a comparison was extended using independent descriptive variables including farmland use intensity, elevation, and dominant soil type. Each class depicts unique spatial and composition characteristics, from coastal, lowland and elevated, to distinct and dominating land cover types, further explained by the descriptive variables. The significance of individual classes and success of the classification is discussed with particular reference to the wider applicability of the map. The transferability of the methodology to other existing physiographic maps and environmental datasets to generate new landscape classifications is also considered. This novel work facilitates the development of a strategic framework to efficiently monitor, compare and analyse ecological and other land use data that is spatially representative of the distribution and extent of land cover in the Irish countryside.

Urinary tract imaging in infants with spina bifida: a selective approach to a baseline DMSA

INTRODUCTION

There is no general agreement among paediatric urologists on how infants with spina bifida (SB) should be investigated after birth. Recently the EUA/ESPU guidelines have been published recommending a baseline DMSA scan in the first year of life and a Voiding Cystourethrogram (VCUG) or Videourodynamic (VUD) between the second and third month of life.

OBJECTIVE

The aim of this study was to evaluate the outcome of renal investigations in the first year of life in infants with SB to verify if an early DMSA scan is indicated in the management of this group of patients.

METHODS

All renal imaging, Renal and Bladder Ultrasound (RBUS), VCUGs, VUDs and DMSA were reviewed by two independent assessors to evaluate outcome.

RESULTS

Seventy patients with spina bifida (40 girls) were enrolled between June 2015 and February 2020. An early VUD detected vesico-ureteral reflux (VUR) in 8/49 (16%) of patients. An early VUD also gave additional information on detrusor under or over activity, bladder trabeculation, end filling detrusor pressure (EFDP) and sphincteric incompetence. DMSA scan detected renal scarring in 4/68 (6%) patients. Three of these 4 patients had significant history of febrile UTIs while the fourth patient had grade 2 left sided VUR.

CONCLUSIONS

The initial assessment of a newborn with myelodysplasia includes a Renal and Bladder Ultrasound during birth hospitalization. This study confirms the recently published EUA/ESPU guidelines on the management of neurogenic bladder in children and adolescents, which recommend a VUD or VCUG & Cystomanometry with Electromyogram (CMG) (if VUD not available) in the first 6-12 weeks of life. A selective approach to DMSA scan only in infants with SB who either had a febrile UTI or vesico-ureteric reflux would not have missed any scarring or dysplasia and would have saved 58 unnecessary nuclear scans.

The Nab experiment: A precision measurement of unpolarized neutron beta decay

Neutron beta decay is one of the most fundamental processes in nuclear physics and provides sensitive means to uncover the details of the weak interaction. Neutron beta decay can evaluate the ratio of axial-vector to vector coupling constants in the standard model, λ = gA/gV, through multiple decay correlations. The Nab experiment will carry out measurements of the electron-neutrino correlation parameter a with a precision of δa/a = 10−3 and the Fierz interference term b to δb = 3 × 10−3 in unpolarized free neutron beta decay. These results, along with a more precise measurement of the neutron lifetime, aim to deliver an independent determination of the ratio λ with a precision of δλ/λ = 0.03% that will allow an evaluation of Vud and sensitively test CKM unitarity, independent of nuclear models. Nab utilizes a novel, long asymmetric spectrometer that guides the decay electron and proton to two large area silicon detectors in order to precisely determine the electron energy and an estimation of the proton momentum from the proton time of flight. The Nab spectrometer is being commissioned at the Fundamental Neutron Physics Beamline at the Spallation Neutron Source at Oak Ridge National Lab. We present an overview of the Nab experiment and recent updates on the spectrometer, analysis, and systematic effects.

A case of Capnocytophaga canimorsus meningitis and bacteraemia

Capnocytophaga canimorsus is a commonly detectable commensal in the oral flora of dogs and cats, found in 25.5% and 15%, respectively, by culture and 70% and 55%, respectively, by molecular methods [1]. Formerly known as dysgonic fermenter 2 (DF-2), it was first reported in 1976 as a Gram-negative bacillus causing septicaemia and meningitis following dog bites [2]. It causes a spectrum of clinical syndromes from wound infections to bacteraemia and meningitis, especially in those with hyposplenism and alcoholism. We report a case of C. canimorsus meningitis and bacteraemia, and give a review of the relevant literature.

Characteristics of Mycobacterium bovis infected herds tested with the interferon-gamma assay

The IFN-γ (interferon gamma) assay is used in Ireland as an ancillary diagnostic test to the single intradermal comparative tuberculin test (SICTT) to maximise the detection of Mycobacterium bovis infected animals (bTB) in cattle herds. Understanding the relationships between herd and animal risk factors and IFN-γ test results is critical to enable the development and evaluation of policy measures on how best to use the test. In this study, we set out to characterise Irish herds with IFN-γ test positive animals in terms of herd size, number of SICTT reactors and number of IFN-γ positive tests, and to evaluate the IFN-γ test in terms of the test cut-off values. The results showed that larger herds with more SICTT reactors were likely to have more IFN-γ positives in the herd, and herds with an IFN-γ test positive animal that was also positive for bTB lesions at post-mortem had higher numbers of IFN-γ positive animals in the herd. Raising the cut-off values for the IFN-γ test only marginally decreased the combined sensitivity of the IFN-γ and the SICTT for diagnosis of bTB lesioned animals. The analysis has provided valuable information on the performance of the IFN-γ test as it is used under current bTB infection levels in Ireland.

An EAACI task force report: recognising the potential of the primary care physician in the diagnosis and management of drug hypersensitivity

Adverse drug reactions include drug hypersensitivity reactions (DHRs), which can be immunologically mediated (allergy) or non-immunologically mediated. The high number of DHRs that are unconfirmed and often self-reported is a frequent problem in daily clinical practice, with considerable impact on future prescription choices and patient health. It is important to distinguish between hypersensitivity and non-hypersensitivity reactions by adopting a structured diagnostic approach to confirm or discard the suspected drug, not only to avoid life-threatening reactions, but also to reduce the frequent over-diagnosis of DHRs. Primary care physicians are often the first point of contact for the sufferer of a reaction, as such they have a key role in deciding whether to discard the diagnosis or send the patient for further investigation. In this review, we highlight the importance of diagnosing DHRs, analysing in detail the role of primary care physicians. We describe the common patterns of DHRs and signs of its progression, as well as the indications and contraindications for referring the patient to an allergist. The diagnostic process is described and the possible tests are discussed, which often depend on the drug involved and the type of DHR suspected. We also describe recommendations regarding the avoidance of medication suspected to have caused the reaction and the use of alternatives.

Developing, delivering and evaluating interprofessional clinical risk training in mental health services

Aims and Method

The need for training to prepare mental health professionals to assess and manage risks is now well established. This paper reports on the development, delivery and evaluation of interprofessional clinical risk training in Salford and Manchester since 1998. A training-needs analysis was carried out, followed by post-training evaluation and an impact-monitoring questionnaire.

Results

The training was very well received by participants, with over 90% of them meeting the objectives and 100% of respondents reporting that the training had a positive impact on their clinical practice more than 12 months afterwards.

Clinical Implications

The evaluation of the training demonstrates that a properly planned and delivered 2-day clinical risk assessment course can have a positive impact on the practice of clinicians in mental health services. However, this should be seen only as an introductory course, as more advanced risk training is required. This is currently being delivered and planned.

The performance of the interferon gamma assay when used as a diagnostic or quality assurance test in Mycobacterium bovis infected herds

There are two different contexts in the Irish bTB eradication programme in which the interferon-gamma assay (IFN-γ) is applied. Firstly, the IFN-γ assay is applied routinely to high risk cohorts in herds with four or more reactors to the SICTT. The IFN-γ test is then carried out on blood samples submitted to the laboratory within 8h of collection (diagnostic testing). Secondly, the use of the IFN-γ assay has recently been extended to test SICTT reactors as part of a general quality assurance (QA) scheme to monitor the performance of the SICTT. Blood samples from reactors are tested one day after blood collection (QA testing). In this study, we analysed the relative performance of the SICTT and IFN-γ when used in parallel as an 8h diagnostic test and as a 24h QA test on SICTT reactors. A total of 17,725 IFN-γ tests were included in the analysis (11,658 diagnostic tests and 6067 QA tests). Of the samples submitted for diagnostic testing, the proportion positive to IFN-γ decreased with the severity of interpretation of the SICTT result. Of the standard reactors that were tested with IFN-γ in the QA programme, 92.2% were positive to the IFN-γ test. Among animals that were SICTT -ve/IFN-γ +ve, 18.9% were positive at post-mortem compared to 11.8% of those that were SICTT +ve (standard reactor)/IFN-γ -ve. These results highlight the risk associated with retaining SICTT -ve/IFN-γ +ve animals, and suggest that prompt removal of these animals is necessary to reduce the potential for future transmission.

Group B streptococcal PCR testing in comparison to culture for diagnosis of late onset bacteraemia and meningitis in infants aged 7-90 days: a multi-centre diagnostic accuracy study

The aim of this study was to compare an in-house real-time PCR assay, with bacterial culture as the reference, for the diagnosis of late onset group B Streptococcal (GBS) disease. This was a retrospective review. All children aged 7-90 days presenting to four paediatric centres that had a blood or CSF sample tested by GBS PCR were included. Of 7,686 blood and 2,495 cerebrospinal fluid (CSF) samples from patients of all ages received for PCR testing, 893 and 859 samples were eligible for the study, respectively. When compared to culture, the sensitivity of blood PCR was 65% (13/20) in comparison to the CSF PCR test which was 100% (5/5). Ten of 23 PCR-positive blood samples and 17 of 22 PCR-positive CSF samples were culture negative. The median threshold Ct values for culture-positive/PCR-positive CSF samples was lower than that of culture-negative/PCR-positive CSF samples (p = 0.08). Clinical details of 17 available cases that were culture negative/PCR positive were reviewed; seven were deemed to be definite cases, eight were probable and two were possible. The results showed that detection of GBS by PCR is useful for CSF samples from infants aged 7-90 days with suspected meningitis; however, analysis of blood samples by PCR is of limited value as a routine screening test for late onset GBS sepsis and should not replace bacterial culture.

Rapid identification and antimicrobial susceptibility testing of positive blood cultures using MALDI-TOF MS and a modification of the standardised disc diffusion test: a pilot study

AIMS

In an era when clinical microbiology laboratories are under increasing financial pressure, there is a need for inexpensive, yet effective, rapid microbiology tests. The aim of this study was to evaluate a novel modification of standard methodology for the identification and antimicrobial susceptibility testing (AST) of pathogens in positive blood cultures, reducing the turnaround time of laboratory results by 24 h.

METHODS

277 positive blood cultures had a Gram stain performed and were subcultured and incubated at 37°C in a CO2 atmosphere for 4-6 h. Identification of the visible growth was performed using matrix-assisted laser desorption time of flight mass spectrometry (MALDI-TOF MS). Taking a modified approach to the Clinical and Laboratory Standards Institute-standardised AST methodology, an inoculum density of 0.5 McFarland was prepared from the early growth for disc diffusion testing. The standard AST method was also performed on the 18-24 h culture.

RESULTS

96% (n=73/76) of gram-negative organisms were correctly identified by MALDI-TOF MS. Comparative analysis of the rapid and standard AST results showed an overall interpretive category error rate of 7.7% (6.7% minor errors, 0.6% major errors and 0.4% very major errors). 100% of Staphylococcus aureus (n=41) and enterococcus isolates (n=9) were correctly identified after 4-6 h incubation. The overall AST categorical agreement was also 100% for these isolates.

CONCLUSIONS

An incubation of 4-6 h directly from positive blood cultures allowed for both a rapid species identification and an antimicrobial susceptibility result approximately 24 h earlier than is possible using standard methodology.

Animal attack: an unusual case of multiple trauma in childhood

A 2½ year old girl attended our facility following attack by a tapir at a city zoo. She sustained multiple injuries including a forearm laceration and multiple perforating wounds to her abdominal wall. She had several procedures, including bowel resection, performed under the care of the General Paediatric Surgery and Plastic Surgery teams and was treated with a course of IV antibiotics. She recovered well and to date has suffered no long-term adverse outcome.

Predicting carotid artery disease and plaque instability from cell-derived microparticles

OBJECTIVES

Cell-derived microparticles (MPs) are small plasma membrane-derived vesicles shed from circulating blood cells and may act as novel biomarkers of vascular disease. We investigated the potential of circulating MPs to predict (a) carotid plaque instability and (b) the presence of advanced carotid disease.

METHODS

This pilot study recruited carotid disease patients (aged 69.3 ± 1.2 years [mean ± SD], 69% male, 90% symptomatic) undergoing endarterectomy (n = 42) and age- and sex-matched controls (n = 73). Plaques were classified as stable (n = 25) or unstable (n = 16) post surgery using immunohistochemistry. Blood samples were analysed for MP subsets and molecular biomarkers. Odds ratios (OR) are expressed per standard deviation biomarker increase.

RESULTS

Endothelial MP (EMP) subsets, but not any vascular, inflammatory, or proteolytic molecular biomarker, were higher (p < .05) in the unstable than the stable plaque patients. The area under the receiver operator characteristic curve for CD31(+)41(-) EMP in discriminating an unstable plaque was 0.73 (0.56-0.90, p < .05). CD31(+)41(-) EMP predicted plaque instability (OR = 2.19, 1.08-4.46, p < .05) and remained significant in a multivariable model that included transient ischaemic attack symptom status. Annexin V(+) MP, platelet MP (PMP) subsets, and C-reactive protein were higher (p < .05) in cases than controls. Annexin V(+) MP (OR = 3.15, 1.49-6.68), soluble vascular cell adhesion molecule-1 (OR = 1.64, 1.03-2.59), and previous smoking history (OR = 3.82, 1.38-10.60) independently (p < .05) predicted the presence of carotid disease in a multivariable model.

CONCLUSIONS

EMP may have utility in predicting plaque instability in carotid patients and annexin V(+) MPs may predict the presence of advanced carotid disease in aging populations, independent of established biomarkers.

Compensatory strategies for people with traumatic brain injury

This article will describe the development and use of compensatory strategies for people with traumatic brain injury. Brain injury results in a wide variety of physical, cognitive, communication and behavioural deficits which impact on daily living skills, work and recreation. Because of these problems, strategy development may be required to address many aspects of a client's life. As this article shows, the compensatory strategies incorporated into one community-based, real-Life rehabilitation programme in Philadelphia, Pennsylvania, are as varied as the challenges they seek to address.

The transfer of antibiotic resistance from food to humans: facts, implications and future directions

The food chain, from production to the consumer's kitchen, can be an important contributor to the development, persistence and dissemination of antibiotic-resistant (ART) microbes, including both ART foodborne pathogens and commensal bacteria. Many factors in the food chain, such as the antimicrobial compounds used and how they were used, microbial co-selection, fitness and persistence mechanisms, host lifestyle, and food treatment conditions, influence the antibiotic resistance (AR) cycle. Targeted mitigation strategies, such as those used in the dairy processing industry, can be effective in reducing the AR gene pool.

Hodges' Health Career Model and its role and potential application in forensic mental health nursing

Forensic mental health nursing is increasingly recognized as a speciality of mental health nursing. Despite this, there are limited examples of theoretical models to underpin this specialism. This paper describes a conceptual framework known as the Hodges' Health Career - Care Domains - Model, hereafter referred to as the Health Career Model (HCM). Readers will learn of the model's origins, development, structure and content together with its application in forensic mental health nursing. Created in the 1980s, the model was developed in the North West of England by Brian E. Hodges. Overall, the purpose of the paper is to demonstrate the model's potential in forensic mental health nursing, its flexibility, adaptability and its increasing relevance to the problems of 21st century health, social care and well-being. Forensic nursing is discussed and the rationale for a nursing model is made. Hodges' model is introduced by explaining its original purposes, structure, its four knowledge (care) domains, its current status, publications and resources. The model's relevance and application in forensic nursing is explored, in particular the demands and unique constraints of this care environment as exercised upon service users, the multidisciplinary team, families, carers and other stakeholders. Future implications for research and recovery-orientated practice are discussed.