A mixed-methods study on the pharmacological management of pain in Australian and Japanese nursing homes.

BACKGROUND: Understanding how analgesics are used in different countries can inform initiatives to improve the pharmacological management of pain in nursing homes. AIMS: To compare patterns of analgesic use among Australian and Japanese nursing home residents; and explore Australian and Japanese healthcare professionals' perspectives on analgesic use. METHODS: Part one involved a cross-sectional comparison among residents from 12 nursing homes in South Australia (N = 550) in 2019 and four nursing homes in Tokyo (N = 333) in 2020. Part two involved three focus groups with Australian and Japanese healthcare professionals (N = 16) in 2023. Qualitative data were deductively content analysed using the World Health Organization six-step Guide to Good Prescribing. RESULTS: Australian and Japanese residents were similar in age (median: 89 vs 87) and sex (female: 73% vs 73%). Overall, 74% of Australian and 11% of Japanese residents used regular oral acetaminophen, non-steroidal anti-inflammatory drugs or opioids. Australian and Japanese healthcare professionals described individualising pain management and the first-line use of acetaminophen. Australian participants described their therapeutic goal was to alleviate pain and reported analgesics were often prescribed on a regular basis. Japanese participants described their therapeutic goal was to minimise impacts of pain on daily activities and reported analgesics were often prescribed for short-term durations, corresponding to episodes of pain. Japanese participants described regulations that limit opioid use for non-cancer pain in nursing homes. CONCLUSION: Analgesic use is more prevalent in Australian than Japanese nursing homes. Differences in therapeutic goals, culture, analgesic regulations and treatment durations may contribute to this apparent difference.

Work engagement, psychological empowerment and relational coordination in long-term care: A mixed-method examination of nurses' perceptions and experiences.

Nurse engagement, empowerment and strong relationships among staff, residents and families, are essential to attract and retain a suitably qualified and skilled nursing workforce for safe, quality care. There is, however, limited research that explores engagement, empowerment and relational coordination in long-term care (LTC). Nurses from an older persons' mental health and dementia LTC unit in Australia participated in this study. Forty-one nurses completed a survey measuring psychological empowerment, work engagement and relational coordination. Twenty-nine nurses participated in individual interviews to further explore these concepts. Although nurses reported high psychological empowerment and work engagement, their relationships with key stakeholders varied. Our findings suggest that nurses in LTC require both supports and opportunities to contribute as active members of the multiprofessional care team that includes tailored education, professional development and positive interactions within the care team. Regular support is needed to enable nurses to feel empowered, foster relationships and communication, and facilitate work engagement. Based on these findings, we suggest that it is important to find ways to ensure that all who provide care perceive that they are part of the whole care team and able to contribute to the care and well-being of people in LTC.

Nurses' perceptions of patient pain, delirium, and sedation assessments in the intensive care unit: A qualitative study.

BACKGROUND: Pain, delirium, and sedation should be assessed routinely using validated assessment scales. Inappropriately managed pain, delirium, and sedation in critically ill patients can have serious consequences regarding mortality, morbidity, and increased healthcare costs. Despite the benefits of a bundled approach to pain, delirium, and sedation assessments, few studies have explored nurses' perceptions of using validated scales for such assessments. Furthermore, no studies have examined nurses' perceptions of undertaking these assessments as a bundled approach. OBJECTIVES: The objective of this study was to explore nurses' knowledge, perceptions, attitudes, and experiences regarding the use of validated pain, delirium, and sedation assessment tools as a bundled approach in the intensive care unit (ICU). METHODS: A qualitative exploratory descriptive design was adopted. We conducted four focus groups and 10 individual interviews with 23 nurses from a 26-bed adult ICU at an Australian metropolitan tertiary teaching hospital. Data were analysed using thematic analysis techniques. FINDINGS: Four themes were identified: (i) factors impacting nurses' ability to undertake pain, delirium, and sedation assessments in the ICU; (ii) use, misuse, and nonuse of tools and use of alternative strategies to assess pain, delirium, and sedation; (iii) implementing assessment tools; and (iv) consequences of suboptimal pain, delirium, and sedation assessments. A gap was found in nurses' use of validated scales to assess pain, delirium, and sedation as a bundled approach, and they were not familiar with using a bundled approach to assessment. CONCLUSION: The practice gap could be addressed using a carefully planned implementation strategy. Strategies could include a policy and protocol for assessing pain, delirium, and sedation in the ICU, engagement of change champions to facilitate uptake of the strategy, reminder and feedback systems, further in-service education, and ongoing workplace training for nurses.

Development and psychometric validation of the hospitalized older adults' dignity scale for measuring dignity during acute hospitalization.

AIM: To develop and validate a culturally appropriate patient-reported outcome measure for measuring dignity for older adults during acute hospitalization. DESIGN: A three-phased exploratory sequential mixed-method design was used. METHODS: Domains were identified and items were generated from findings of a recent qualitative study, two systematic reviews and grey literature. Content validity evaluation and pre-testing were undertaken using standard instrument development techniques. Two-hundred and seventy hospitalized older adults were surveyed to test construct and convergent validity, internal consistency reliability and test-retest reliability of the measure. Analysis was performed using Statistical Package for the Social Sciences, version 25. The STROBE checklist was used to document reporting of the study. RESULTS: We established the 15-item Hospitalized Older Adults' Dignity Scale (HOADS) that has a 5-factor structure: shared decision-making (3 items); healthcare professional-patient communication (3 items); patient autonomy (4 items); patient privacy (2 items); respectful care (3 items). Excellent content validity, adequate construct and convergent validity, acceptable internal consistency reliability and good test-retest reliability were demonstrated. CONCLUSION: We established the HOADS is a valid and reliable scale to measure dignity for older adults during acute hospitalization. Future studies using confirmatory factor analysis are needed to corroborate the dimensionality of the factor structure and external validity of the scale. Routine use of the scale may inform the development of strategies to improve dignity-related care in the future. IMPACT: The development and validation of the HOADS will provide nurses and other healthcare professionals with a feasible and reliable scale for measuring older adults' dignity during acute hospitalization. The HOADS advances the conceptual understanding of dignity in hospitalized older adults by including additional constructs that have not been captured in previous dignity-related measures for older adults (i.e. shared decision-making and respectful care). The factor structure of the HOADS, therefore, includes five domains of dignity and offers a new opportunity for nurses and other healthcare professionals to better understand the nuances of dignity for older adults during acute hospitalization. For example, the HOADS enables nurses to identify differences in levels of dignity based on contextual factors and to use this information to guide the implementation of strategies that promote dignified care. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in the generation of items for the scale. Their perspectives and the perspectives of experts were sought in determining the relevance of each item of the scale to patients' dignity.

Patient dignity and dignified care: A qualitative description of hospitalised older adults perspectives.

AIMS AND OBJECTIVES: The aim of this study was to explore older adults' perspectives about dignity and dignified nursing care during acute hospitalisation in Ghana. BACKGROUND: Maintaining hospitalised older adults' dignity is an essential component of nursing care and one of the most important determinants of wellbeing. To date, no study has been published on older adults' perspectives of dignified nursing care in the African context. STUDY DESIGN: A qualitative descriptive research design. METHODS: Twenty hospitalised older adults were purposively selected from the medical and surgical wards of a teaching hospital in Ghana. Data were gathered through semi-structured interviews between April and August, 2021, and analysed using reflexive thematic analysis techniques. The SRQR checklist was used to document reporting of the study. RESULTS: The following four themes were identified: Effective nurse-patient communication, Maintaining patients' privacy, Respectful and compassionate care provision and Providing quality and safe care. Dignity was preserved when patients were treated with respect and compassion, provided privacy, and had close family members involved in physical care. Identified barriers to dignity included inadequate information about their health condition, poor communication by the nurses, lack of autonomy, poorly designed healthcare infrastructure and inadequate privacy. CONCLUSIONS: Several enablers and barriers to dignified nursing care have been identified that have been discussed in previous studies. The unique factors identified in the Ghanaian context were family members' involvement in physical care influenced by cultural and religious beliefs, environmental barriers to privacy and dignity and inadequate involvement in decision making. RELEVANCE TO CLINICAL PRACTICE: Nurses must treat older patients with respect, educate them about the health condition, involve them in care decisions, and identify their preferences regarding provision of hygiene needs, particularly in consideration of religious and cultural beliefs, including involvement of family members. Future planning of healthcare infrastructure needs to consider the importance of private cubicles with disability-accessible ensuite bathrooms for patients' comfort and privacy.

Methodological quality of dignity-related patient reported outcome measures used in acute hospital settings: A systematic review using the COSMIN methodology.

AIMS AND OBJECTIVE: The aim of this systematic review was to examine the methodological quality of dignity-related patient reported outcome measures (PROMs) used to measure patients' dignity during acute hospitalisation using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology for systematic review of PROMs. BACKGROUND: Previous scoping review studies on the methodological quality of dignity-related PROMs lack specificity for dignity during acute hospital admission. They included PROMs that were developed to measure constructs of care other than patient dignity or designed to measure dignity in contexts outside of the acute hospital setting. STUDY DESIGN: A systematic review based on COSMIN methodology. METHODS: A systematic search was undertaken using five databases (CINAHL Complete, Medline Complete, EMBASE, PsycINFo and AgeLine) for articles published between 2000 and 2022. Relevant papers were identified using strict adherence to eligibility criteria, and studies that included development of dignity-related PROMs for use in acute hospital settings were selected. Two reviewers independently screened the identified papers, extracted data and examined the quality of studies. RESULTS: Six papers met the inclusion criteria. Two PROMs, the 25-item Patient Dignity Inventory and the 34-item Inpatient Dignity Scale, met the COSMIN quality criteria because of their sufficient quality of evidence for content validity and reliable internal consistency. None of the PROMs met the quality criteria for assessment of measurement error, criterion validity, cross-cultural validity and responsiveness. CONCLUSION: We recommend the Patient Dignity Inventory and the Inpatient Dignity Scale as the PROMs of choice for evaluating patients' dignity and/or dignified care during acute hospital admissions. These PROMs were developed using robust procedures with sufficient overall quality for content validity, internal consistency reliability and other measurement properties, and with moderate to high quality of evidence for these measurement properties. Researchers and clinicians who wish to use other dignity-related PROMs identified in this review should consider the methodological limitations of these PROMs, as highlighted in the present systematic review. RELEVANCE TO CLINICAL PRACTICE: The review findings will guide healthcare professionals about their choice of patient reported outcome measures for evaluating patients' dignity or dignified care during acute hospitalisation.

Self-reported dignity and factors that influence dignity in hospitalised older adults: A cross-sectional survey.

OBJECTIVE: This study examined levels of self-reported dignity and explored factors expected to influence dignity experienced by older adults during acute hospitalisation in Ghana. BACKGROUND: Dignified care has been recognised as inseparable from quality nursing care and maintaining patients' dignity has been highlighted in professional codes of conduct for nurses. However, there is a lack of research on self-reported dignity and the factors that influence the dignity of older adults during acute hospitalisation in Africa. SETTING: A large teaching hospital in the northern region of Ghana. PARTICIPANTS: Hospitalised older adults. METHODS: A cross-sectional survey was used to gather data from a convenience sample of 270 older inpatients, using the Hospitalized Older Adults' Dignity Scale. Data were analysed using descriptive statistics and stepwise ordinal logistic regression to investigate stratified dignity outcomes. The study was reported following the STROBE checklist. RESULTS: More than half of the older adults surveyed reported low to moderate levels of dignity. Demographic characteristics such as age, marital status, religious status, occupation, level of education and type of hospital ward did not show any significant associations with dignity levels. However, there was a significant association found between dignity levels and sex and the number of hospitalisations. CONCLUSION: Most older adults in a Ghanian hospital experienced loss of dignity during their acute hospitalisation. Male older adults reported higher dignity levels during acute hospitalisation than their female counterparts. Further, older adults who were admitted to hospital for the second time reported less dignity compared to those admitted three or more times. RELEVANCE TO CLINICAL PRACTICE: The results emphasise the importance of healthcare professionals having the necessary knowledge and skills to provide gender-sensitive care, which ultimately promotes the dignity of all patients. Additionally, the results underscore the urgency of implementing measures that guarantee patients' dignity during all hospital admissions. PATIENT OR PUBLIC CONTRIBUTION: Survey questionnaires were completed by hospitalised older adults at the study setting.

A systematic review of patient-reported dignity and dignified care during acute hospital admission.

AIMS: To synthesize quantitative evidence on levels of dignity during acute hospital admission and identify barriers and facilitators to patients' dignity or dignified care from the perspective of hospitalized patients. The secondary aim was to examine the relationship between dignity and demographic, clinical and psychological characteristics of patients. DESIGN: A systematic review based on the protocol of the Preferred Reporting Items for Systematic reviews and Meta-Analyses guideline for reporting systematic reviews. DATA SOURCES: Five electronic databases (PubMed, CINAHL, Embase, PsycINFO, AgeLine) were searched in February 2021, followed by backward-forward searching using Web of Science and Scopus databases. REVIEW METHODS: Potentially eligible articles were scrutinized by two reviewers. Articles that met the eligibility criteria were appraised for quality using the Critical Appraisal Tool for Cross-Sectional Studies. Two reviewers extracted data for the review and resolved differences by consensus. RESULTS: Out of 3052 potentially eligible studies, 25 met the inclusion criteria. Levels of dignity for hospitalized patients vary widely across geographic locations. Patients' dignity is upheld when healthcare professionals communicate effectively, maintain their privacy, and provide dignity therapy. Patients' perceptions of dignity were, in some studies, reported to be associated with demographic (e.g. age, marital status, gender, employment, educational status), clinical (e.g. hospitalization, functional impairment, physical symptoms) and psychological (e.g. depression, anxiety, demoralization, coping mechanisms) variables whilst other studies did not observe such associations. CONCLUSION: Patients in acute care settings experience mild to a severe loss of dignity across different geographic locations. Patients' dignity is influenced by several demographic, clinical and psychological characteristics of patients. IMPACT: The findings of the review support impetus for improvement in dignified care for hospitalized patients, addressing factors that facilitate or impede patients' dignity. Measures aimed at alleviating suffering, fostering functional independence and addressing patients' psychosocial needs can be used to promote dignity.

A brief intervention to standardize postanesthetic clinical handoff.

This naturalistic, pre- and post-design study explored the feasibility and acceptability of a brief patient safety intervention to introduce a tool to standardize interdisciplinary communication processes at patient handoff between anesthetists and postanesthesia nurses in the postanesthetic care unit. Observation and interview data were collected pre- and post-intervention from a convenience sample of 27 nurses and 23 anesthetists in a large tertiary hospital in Melbourne, Australia. Following the intervention, significant improvement was observed in nurses' performance of several patient safety behaviors, but trends in nurses' interdisciplinary communication behaviors such as asking questions and escalation of care were nonsignificant. This research provides evidence that tools to standardize clinical handoff communication may empower nurses to perform desired patient safety behaviors during interprofessional handoff. It underpins future research to explore strategies to empower nurses to advocate for patient safety during interdisciplinary communication, and provides a foundation for patient handoff improvement, education, and further research.

Resuscitation status and characteristics and outcomes of patients transferred from subacute care to acute care hospitals: A multi-site prospective cohort study.

AIMS AND OBJECTIVES: To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital. BACKGROUND: Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%). DESIGN: This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. METHODS: Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect. FINDINGS: Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care. CONCLUSIONS: Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients. RELEVANCE TO CLINICAL PRACTICE: As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.

Characteristics and outcomes of emergency interhospital transfers from subacute to acute care for clinical deterioration.

OBJECTIVE: To describe characteristics and outcomes of emergency interhospital transfers from subacute to acute hospital care and develop an internally validated predictive model to identify features associated with high risk of emergency interhospital transfer. DESIGN: Prospective case-time-control study. SETTING: Acute and subacute healthcare facilities from five health services in Victoria, Australia. PARTICIPANTS: Cases were patients with an emergency interhospital transfer from subacute to acute hospital care. For every case, two inpatients from the same subacute care ward on the same day of emergency transfer were randomly selected as controls. Admission episode was the unit of measurement and data were collected prospectively. MAIN OUTCOME MEASURES: Patient and admission characteristics, transfer characteristics and outcomes (cases), serious adverse events and mortality. RESULTS: Data were collected for 603 transfers in 557 patients and 1160 control patients. Cases were significantly more likely to be male, born in a non-English speaking country, have lower functional independence, more frequent vital sign assessments and experience a serious adverse event during first acute care or subacute care admissions. When adjusted for health service, cases had significantly higher inpatient mortality, were more likely to have unplanned intensive care unit admissions and rapid response team calls during their entire hospital admission. CONCLUSIONS: Patients who require an emergency interhospital transfer from subacute to acute hospital care have hospital admission rates and in-hospital mortality. Clinical instability during the first acute care admission (serious adverse events or increased surveillance) may prompt reassessment of patient suitability for movement to a separate subacute care hospital.

The Impact of Social Support Networks on Family Resilience in an Australian Intensive Care Unit: A Constructivist Grounded Theory.

PURPOSE: This article discusses the findings of a grounded theory of family resilience in an Australian intensive care unit (ICU) with a specific focus on families' experiences of their interactions with other members within their own family, and the families of other patients in the ICU. DESIGN: A constructivist grounded theory methodology was adopted. Data were collected using in-depth interviews with 25 family members of 21 critically ill patients admitted to a tertiary-level ICU in Australia. FINDINGS: The core category regaining control represents the families' journey toward resilience when in ICU. The major categories represent facilitators for, and barriers to, regaining control. One of the main facilitators is drawing strength, and it explains the manner with which families receive social support from their own and other family members to help them cope. CONCLUSIONS: This study offers a framework to improve patient- and family-centered care in the ICU by facilitating families' ability to manage their situation more effectively. Social support offered by family members facilitates the families' ability to regain control. An ICU family resilience theoretical framework, situated within the context of the Australian healthcare system, adds to what is currently known about the families' experiences in the ICU. CLINICAL RELEVANCE: The relationships that develop between families in the ICU may provide a source of social support; however, not all families welcome interactions with other ICU families, and it may cause further emotional distress. Further research is warranted to determine whether families suffer a secondary stress reaction from incidental interactions with other patients' families in the ICU. Furthermore, when family members pull together and offer social support to each other, they are better able to regain control. This process contributes to an ICU family resilience framework.

Searching for meaning: A grounded theory of family resilience in adult ICU.

AIM: To explore families' experiences of their interactions in an Australian adult intensive care unit (ICU) to develop a grounded theory that can be used by critical care nurses to improve patient- and family-centred care (PFCC). BACKGROUND: Families in ICU play an important role in the patient's recovery and outcomes. However, families are at risk of significant psychological morbidity due to their experiences in ICU. Although many ICU patients can make their own decisions, a large proportion are unconscious or chemically sedated and unable to contribute to decisions about their care, leaving the decision-making role to the family. Therefore, the families' psychosocial and emotional well-being must be supported by implementing evidence-based interventions that align with a PFCC approach. This study describes the findings of a grounded theory of family resilience in ICU, of which the core category is Regaining control. The focus of this paper is on the major category: Searching for meaning. METHODS: We adopted a constructivist grounded theory method. Twenty-five adult family members (n = 25) of 21 patients admitted unexpectedly to an ICU in metropolitan Australia were recruited. In-depth interviews were used to collect the data, and the analytical processes of constructivist grounded theory underpinned the development of a core category and related subcategories. RESULTS: When adult family members experience the unexpected admission of a relative to ICU, they move towards a state of being beyond emotional adversity and regaining control when facilitated to search for meaning in their situation. When families were able to make sense of their situation and find a purpose by contributing to their relative's recovery, it encouraged them to cope and be resilient. CONCLUSIONS: Our findings can be used to promote PFCC in ICU, which considers a collaborative approach to meet the patient's needs while providing emotional and psychosocial support to their families.

Co-development of "BRAIN-TRK": Qualitative examination of acceptability, usability and feasibility of an App to support nurses' care for patients with behavioural and psychological symptoms of neurocognitive disorders in hospital.

AIMS AND OBJECTIVES: (a) Describe the co-development of a point-of-care App to promote uptake of best practice recommendations and consolidate nurses' knowledge for managing symptoms of neurocognitive disorders. (b) Report acceptability, usability and feasibility of the App to nurses for patient care in hospital. BACKGROUND: Strategies used in hospitals to reduce symptoms, risk of harm, or complications of behavioural and psychological symptoms associated with neurocognitive disorders are frequently inconsistent with best practice recommendations. DESIGN: Three-stage, mixed-methods, process and outcome evaluation. METHODS: The App was co-developed with experts, nurse end-users and a consumer. Evaluation data were collected from a convenience sample of nurses observed during delivery of 80.5 hr of care to 38 patients; the App (n = 32 patients); and individual and focus group interviews with nurses (n = 25). Reporting adhered to an adapted STROBE checklist. RESULTS: The App included three components: cognition and risk assessment; tailored evidence-based strategies; and monitoring and evaluation of effectiveness. Observation data captured nurses using the App with 44.7% (n = 17) of eligible inpatients. Cognitive screening was completed at least once for each patient, with 146 risk assessments recorded. Interview data indicated the App's acceptability was enhanced by familiarity and perceived benefits, but hindered by perceived increases in workload, inconsistent use, pressure to use the App and resistance to change. Feasibility and usability were enhanced by easy navigation, and clear and useful content, but hindered by unclear expectations, unfamiliarity and device-related factors. CONCLUSIONS: The App provided an evidence-based tool that was, overall, considered feasible and acceptable to support best practice. Findings provide guidance to enhance usability for future implementation. RELEVANCE TO CLINICAL PRACTICE: Co-development using best evidence and key stakeholders enabled creation of a novel, feasible and acceptable technology. Real-time access to assessment tools and tailored knowledge supported nurses' clinical decision-making; workload and unfamiliarity were barriers to use.

Fostering trusting relationships with older immigrants hospitalised for end-of-life care.

BACKGROUND: Trust has been identified as a vital value in the nurse-patient relationship. Although increasingly the subject of empirical inquiries, the specific processes used by nurses to foster trust in nurse-patient relationships with older immigrants of non-English speaking backgrounds hospitalised for end-of-life care have not been investigated. AIMS: To explore and describe the specific processes that nurses use to foster trust and overcome possible cultural mistrust when caring for older immigrants of non-English speaking backgrounds hospitalised for end-of-life care. RESEARCH DESIGN: A qualitative descriptive approach was used. Twenty-two registered nurses were recruited from four metropolitan health services in Melbourne, Australia. Ethical considerations: Research approval was granted by the Human Research Ethics Committees of the host institution and four participating health services. FINDINGS: Thematic analysis revealed that fostering trust encompassed the following three commensurate stages: establishing trust, strengthening trust and sustaining trust. Underpinning the successful achievement of these stages was the nurses' moral commitment (reflected in their intentional, conscious and conscientious approach) to fostering trust as an essential ingredient of quality end-of-life care. DISCUSSION: This study has shown that while professional competencies are important to providing quality end-of-life care to older immigrant patients of non-English speaking backgrounds, it is a nurse's moral commitment to fostering trust that may ultimately lay the foundations for a trusting quality care relationship to be established and sustained. CONCLUSION: This study has captured the processes used by nurses to foster trust as an essential element of quality end-of-life care in older immigrants. The characteristics of trust and the different factors influencing its expression in diverse cultural contexts are, however, under-researched. Accordingly, gaps remain in the knowledge and understanding of the specific cultural nuances and manifestations of trust across and within different cultures. This is an area that is germane to further cross-cultural and international collaborative scholarly inquiry and research.

Barriers to families' regaining control in ICU: Disconnectedness.

BACKGROUND: The nature of interactions between health care professionals and families may have a significant impact on families' experience and outcomes of critical illness. The value of encouraging positive relationships with families is well documented; however, it is argued that the lack of theoretical frameworks to guide practice in this area may be a barrier to improving patient- and family-centred care. AIMS: The study on which this paper is based aimed to understand families' experiences of their interactions when a relative is admitted unexpectedly to an Australian intensive care unit and to generate a substantive theory that represents families' interactions that can be used to guide critical care nursing practice when caring for patients' families in this context. DESIGN AND METHODS: A grounded theory methodology was adopted for the study. Data were collected between 2009 and 2013 using in-depth interviews with 25 family members of 21 critically ill patients admitted to a metropolitan, tertiary-level intensive care unit (ICU) in Australia. FINDINGS: A core category of regaining control has been generated from our study. This paper focuses on Disconnectedness, which leads to increased emotional vulnerability and is also a barrier to families' regaining control. Families feel disconnected when staff emotionally and physically disengage from them, when staff interact insensitively and in a manner that offers families limited hope. CONCLUSION: Our findings offer an in-depth understanding of staff engagement with families and its impact on the families' ability to regain control. Although some themes have been previously identified in the literature in isolation, the interrelationships of the categories within a theoretical framework to represent family resilience in the context of an ICU situated in the Australian health care system are a novel finding. RELEVANCE TO CLINICAL PRACTICE: The findings can be used to support patient- and family-centred care interventions in the ICU.

Exercise Benefits and Barriers: The Perceptions of People Receiving Hemodialysis.

Negative perceptions of people receiving hemodialysis towards exercise have been proposed as barriers to exercise. The aims of this study were to explore perceptions of patients on hemodialysis concerning exercise and to investigate whether exposure to an exercise program was associated with patients' perceptions. Participants (n=274) from 10 hemodialysis clinics completed an adapted English-language version of the Dialysis Patient-Perceived Exercise Benefits and Barriers Scale. Most patients agreed that exercise was positive towards preventing muscular wasting, bone disease, keeping body weight at a steady level, improving mood and quality of life, and enhancing their selfcare activities. Reported barriers to exercise were treatment side effects, fear of falling, family burden, exercise knowledge, and vascular access. The majority perceived exercise as positive for them and for people receiving hemodialysis. Patients who had witnessed or participated in an exercise program were more positive towards exercise than those who had not.

Tri-focal Model of Care Implementation: Perspectives of Residents and Family.

PURPOSE: To explore residents' and family members' perceptions of partnership-centered long-term care (LTC) associated with implementation of the Tri-focal Model of Care. The Model promotes partnership-centered care, evidence-based practice, and a positive environment. Its implementation is supported by a specifically designed education program. METHODS: The Model was implemented over approximately 12 months in seven LTC facilities in Victoria, Australia. A qualitative exploratory-descriptive approach was used. Data were collected using individual and focus group interviews with residents and family members prior to and following implementation of the Model. Data were analyzed thematically. FINDINGS: Prior to implementation of the Model, residents described experiencing a sense of disempowerment, and emphasized the importance of communication, engagement, and being a partner in the staff-resident care relationship. Following implementation, residents reported experiencing improved partnership approaches to care, although there were factors that impacted on having a good experience. Family members described a desire to remain involved in the resident's life by establishing good communication and rapport with staff. They acknowledged this was important for partnership-centered care. Following implementation, they described experiencing a partnership with staff, giving them confidence to assist staff and be included in decisions about the resident. CONCLUSIONS: The Tri-focal Model of Care can enable residents, family members, and staff to be partners in resident care in LTC settings. CLINICAL RELEVANCE: With an ageing population, an increasing demand for complex, individualized LTC exists. Delivery of high-quality LTC requires a strategy to implement a partnership-centered approach, involving residents, family members, and staff.

Barriers to regaining control within a constructivist grounded theory of family resilience in ICU: Living with uncertainty.

AIMS AND OBJECTIVES: To discuss families' experiences of their interactions when a relative is admitted unexpectedly to an Australian intensive care unit. BACKGROUND: The overwhelming emotions associated with the unexpected admission of a relative to an intensive care unit are often due to the uncertainty surrounding the condition of their critically ill relative. There is limited in-depth understanding of the nature of uncertainty experienced by families in intensive care, and interventions perceived by families to minimise their uncertainty are not well documented. Furthermore, the interrelationships between factors, such as staff-family interactions and the intensive care unit environment, and its influence on families' uncertainty particularly in the context of the Australian healthcare system, are not well delineated. DESIGN: A grounded theory methodology was adopted for the study. METHODS: Data were collected between 2009-2013, using in-depth interviews with 25 family members of 21 critically ill patients admitted to a metropolitan, tertiary-level intensive care unit in Australia. RESULTS: This paper describes the families experiences of heightened emotional vulnerability and uncertainty when a relative is admitted unexpectedly to the intensive care unit. Families uncertainty is directly influenced by their emotional state, the foreign environment and perceptions of being 'kept in the dark', as well as the interrelationships between these factors. CONCLUSION: Staff are offered an improved understanding of the barriers to families' ability to regain control, guided by a grounded theory of family resilience in the intensive care unit. RELEVANCE TO CLINICAL PRACTICE: The findings reveal in-depth understanding of families' uncertainty in intensive care. It suggests that intensive care unit staff need to focus clinical interventions on reducing factors that heighten their uncertainty, while optimising strategies that help alleviate it. Families are facilitated to move beyond feelings of helplessness and loss of control, and cope better with their situation.

Engaging patients and families in communication across transitions of care: an integrative review protocol.

AIM: To describe an integrative review protocol to analyse and synthesize peer-reviewed research evidence in relation to engagement of patients and their families in communication during transitions of care to, in and from acute care settings. BACKGROUND: Communication at transitions of care in acute care settings can be complex and challenging, with important information about patients not always clearly transferred between responsible healthcare providers. Involving patients and their families in communication during transitions of care may improve the transfer of clinical information and patient outcomes and prevent adverse events during hospitalization and following discharge. Recently, optimizing patient and family participation during care transitions has been acknowledged as central to the implementation of patient-centred care. DESIGN: Integrative review with potential for meta-analysis and application of framework synthesis. REVIEW METHOD: The review will evaluate and synthesize qualitative and quantitative research evidence identified through a systematic search. Primary studies will be selected according to inclusion criteria. Data collection, quality appraisal and analysis of the evidence will be conducted by at least two authors. Nine electronic databases (including CINAHL and Medline) will be searched. The search will be restricted to 10 years up to December 2013. Data analysis will include content and thematic analysis. DISCUSSION: The review will seek to identify all types of patient engagement activities employed during transitions of care communication. The review will identify enablers for and barriers to engagement for patients, families and health professionals. Key strategies and tools for improving patient engagement, clinical communication and promoting patient-centred care will be recommended based on findings.