The paradox of workplace violence in the intensive care unit: a focus group study.

BACKGROUND: Conflicts with patients and relatives occur frequently in intensive care units (ICUs), driven by factors that are intensified by critical illness and its treatments. A majority of ICU healthcare professionals have experienced verbal and/or physical violence. There is a need to understand how healthcare professionals in ICUs experience and manage this workplace violence. METHODS: A qualitative descriptive analysis of four hospitals in Sweden was conducted using semi-structured focus-group interviews with ICU healthcare professionals. RESULTS: A total of 34 participants (14 nurses, 6 physicians and 14 other staff) were interviewed across the four hospitals. The overarching theme: "The paradox of violence in healthcare" illustrated a normalisation of violence in ICU care and indicated a complex association between healthcare professionals regarding violence as an integral aspect of caregiving, while simultaneously identifying themselves as victims of this violence. The healthcare professionals described being poorly prepared and lacking appropriate tools to manage violent situations. The management of violence was therefore mostly based on self-taught skills. CONCLUSIONS: This study contributes to understanding the normalisation of violence in ICU care and gives a possible explanation for its origins. The paradox involves a multifaceted approach that acknowledges and confronts the structural and cultural dimensions of violence in healthcare. Such an approach will lay the foundations for a more sustainable healthcare system.

Rapid Design of a Student-Centred App for Musculoskeletal Clinical Skills: An Example of a Theoretically Informed Approach to Developing Apps for Learning.

Background and need for innovation: The process to design mobile apps for learning are infrequently reported and focus more on evaluation than process. This lack of clear process for health professional education mobile apps may explain the lack of quality mobile apps to support medical student learning. Goal of innovation: The goal of this project was to develop a student informed ready for production wireframe model of a minimally viable mobile app to support learning of musculoskeletal (MSK) clinical skills. Steps taken for development and implementation of innovation: The Information Systems Research (ISR) framework and Design Thinking were combined for the mobile app design. The process followed the cycles and modes of the combined framework to; systematically review available apps, use a focus group to identify attributes of the app valued by students, define the initial plan for the mobile app, develop an app prototype, and test and refine it with students. Outcomes of innovation: The student focus group data had five themes: 1) interactive usability, 2) environment, 3) clear and concise layout, 4) anatomy and pathology, 5) cultural safety and 'red flags'. The prototyping of the app went through three cycles of student review and improvement to produce a final design ready for app development. Critical reflection on our process: We used a student-centred approach guided by design frameworks to design a minimally viable product mobile app to support learning of MSK clinical skills in ten weeks with a small team. The framework supported nonlinear, iterative, rapid prototyping. Student data converged and diverged with the MSK teaching methods literature. Of note our students requested cultural safety learning in the app design, suggesting mobile apps could support cultural safety learning.

Group-based exercise for Parkinson's: a qualitative study of participants and partners' perceptions of an exercise class delivered through a community-university collaboration.

BACKGROUND: Community-based exercise programmes (CBEPs) offer a practical and viable approach to providing people with Parkinson's disease (PwP) the opportunity to exercise as an ancillary therapeutic benefit to pharmacological management. This study explores the perceptions of exercising participants (PwP) and non-participating partners involved in an exercise class delivered through a community-university partnership. METHODS: Two separate focus group discussions were conducted: one with class participants (PwP: n = 7, H&Y scale I to III), and the other with non-participating partners of PwP (n = 4). RESULTS: Thematic analysis of the data identified that a range of physical, psychological and social factors were perceived to influence engagement: (1) actively taking control, (2) exercise is medicine for the mind and body, and (3) a community working together to promote exercise for parkinson's. Participants and partners felt that the support from the group, including the instructors and student volunteers, empowered and supported PwP to proactively self-manage their health, enjoy exercise in an inclusive group setting, and develop strong social connections with others in the local Parkinson's community. Support to exercise from healthcare professionals was identified as both an enabler and barrier to participation. CONCLUSIONS: This study underscores the significance of a community-university partnership as a complementary therapeutic approach for PwP. It also provides critical reflections on its sustainability, including implications for how exercise is considered as medicine for PwP. Additionally, it offers practical recommendations to galvanise community participation and provide inclusive and viable exercise opportunities for PwP.

A Patient Interview-Based Needs Assessment and Evaluation of Experiences with Periviable Pregnancies.

Given the complex ethical and emotional nature of births during the periviable period for both health care providers and families, this investigation sought to identify strategies for improved counseling of pregnant patients facing preterm birth at the cusp of viability at a tertiary care center in Hawai'i. As part of a larger quality improvement project on periviability counseling, 10 patients were interviewed during either individual or small focus groups using a progression of hypothetical scenarios. Interviews were analyzed independently by 3 investigators to identify themes of patient experience and potential areas for improvement when counseling patients who are carrying periviable pregnancies. Several common themes emerged from the interviews. Patients expressed the desire for more information throughout the process delivered in a jargon-free manner with unified messaging from the medical teams, and emotional support. These findings add to a limited body of literature which addresses patient perceptions of interactions with health care providers in the face of uncertainty, particularly in a Pacific Islander population. The authors recommend increasing provider training and developing a more structured process to counsel pregnant women facing periviable pregnancy loss to improve the patient experience.

Recruit Perspectives on Gender Integration at Recruit Training: A Comparison by Service and Gender.

INTRODUCTION: Recruit training is the initial entry for enlisted personnel in the military. The Services execute gender-integrated recruit training differently. The U.S. Marine Corps (USMC) maintains same-gender platoons led by same-gender drill instructors in integrated companies; further integration occurs at select training events. The other Services train recruits in gender-integrated units with mixed-gender drill instructor teams. We examine recruits' experiences and perceptions of gender integration at recruit training, their desired level of integration, and preferences for increasing gender integration, comparing by Service and gender. MATERIALS AND METHODS: Recruit perspectives and experiences were captured in a 19-question survey (n = 632) and 90-min focus groups (n = 260) near graduation from recruit training. Data were collected from June to November 2021. Because of the Coronavirus disease (COVID-19) pandemic restrictions, the Navy and Air Force were not conducting gender-integrated recruit training during data collection. Outcome variables were compared cross-Service by gender and within Service by gender using chi-squared tests or Fisher's exact tests, as appropriate; focus group data were analyzed using initial and secondary coding schemes. Three USMC training models, varied by level of integration, were also analyzed (Male-Only, Series Track, and Integrated Company). RESULTS: Significant gender differences across and within Service emerged in recruits' experience being trained by an opposite-gender instructor. Male recruits had significant differences by Service (P < .001), and USMC female recruits reported being trained by male instructors more than their male peers by female instructors (Series Track P = .002; Integrated Company P < .001). In the focus groups, recruits described common differences with how men and women embodied being a drill instructor. Significant gender differences across (both male and female P < .001) and within Service were reported for closeness of training with opposite-gender peers (Air Force P = .028; U.S. Marine Corps (USMC) Integrated Company P = .010; Army P = .048), an expected finding given varied integration during data collection. Male and female recruits had significant differences by Service in their preference for integration at the lowest unit level (both male and female P < .001), with those who experienced integrated training showing higher levels of endorsement. In the focus groups, recruits articulated benefits and challenges of gender-integrated recruit training. Significant gender differences across Service emerged in preferences for more integration in specific training activities. Within Service, female USMC Integrated Company recruits wanted more integration in tactical/field, physical fitness, and classroom training than their male peers (P < .001 for all). In the focus groups, USMC recruits of both genders desired more integrated training events, particularly those involving combat and tactical skill development. CONCLUSIONS: This study provided an opportunity to examine recruit perspectives on gender-integrated training. Services valuing opposite-gender instructor exposure in recruit training must ensure that male recruits are being taught and led by female instructors given disproportionate demographics. Recruits who experienced integrated training were more supportive of integration, indicating that this experience may increase their support for gender-integrated training units and environments. Today's recruits understand that they are entering gender-integrated working environments, and our results indicate that they expect recruit training to mirror that reality.

Small Steps, Big Vision: using multi-stage qualitative research to develop a grab-and-go guide to support utilisation of the Ambitions for Palliative and End of Life Care framework.

BACKGROUND: The Ambitions for Palliative and End of Life Care is a national framework for local action in England co-produced by over 30 partners; little research has been conducted on how the Framework is received and used. This study sought to examine and support how people understand, interpret, and implement the Framework. METHODS: A multi-stage qualitative methodology involving four stages of data collection: (1) case study interviews, (2) focus groups, (3) interactive workshops, and (4) Evidence Cafés. From initial interviews, ongoing thematic data analysis informed the design and focus of subsequent stages as part of a process of knowledge transfer. RESULTS: A practical resource to support service provision and development was produced; a grab-and-go guide called "Small Steps, Big Visions". It focuses on the eight foundations in the Ambitions Framework, with additional guidance on collaboration and partnership working, and sharing learning. Each foundation is presented with a 'what' (definition), 'ask' (prompt questions), and 'examples in action' (drawn from case studies). CONCLUSIONS: Research can contribute to policy implementation to advance palliative and end of life care. The engagement and input of those responsible for implementation is key.

Challenges in recognizing and discussing changes in a resident's condition in the palliative phase: focus group discussions with nursing staff working in nursing homes about their experiences.

BACKGROUND: Most nursing home residents have complex care needs, require palliative care and eventually die in these facilities. Timely recognition of changes in a resident's condition is crucial for providing appropriate care. Observations by nursing staff play a significant role in identifying and interpreting these changes. METHODS: Focus group discussions were conducted with nursing staff from ten nursing homes in the Netherlands to explore their experiences and challenges in recognizing and discussing changes in a resident's condition. These discussions were analysed following the principles of thematic analysis. RESULTS: The analysis of the challenges nursing staff face in identifying and interpreting changes in a resident's condition, resulted in three themes. First, that recognizing changes is considered complex, because it requires specialized knowledge and skills that is generally not part of their education and must partly be learned in practice. This also depends on how familiar the nursing staff is with the resident. Furthermore, different people observe residents through different lenses, depending on their relation and experiences with residents. This could lead to disagreements about the resident's condition. Lastly, organizational structures such as the resources available to document and discuss a resident's condition and the hierarchy between nursing home professionals often hindered discussions and sharing observations. CONCLUSION: Nursing staff's experiences highlight the complexity of recognizing and discussing changes in nursing home residents' conditions. While supporting the observational skills of nursing staff is important, it is not enough to improve the quality of care for nursing home residents with palliative care needs. As nursing staff experiences challenges at different, interrelated levels, improving the process of recognizing and discussing changes in nursing home residents requires an integrated approach in which the organization strengthens the position of nursing staff. It is important that their observations become a valued and integrated and part of nursing home care.

Exploring the lived experiences of individuals with Parkinson's disease and their relatives: insights into care provision experiences, disease management support, self-management strategies, and future needs in Germany (qualitative study).

BACKGROUND: Parkinson's disease (PD) significantly impacts the health-related quality of life of affected individuals and their relatives. In order to support the affected individuals and their families in coping with PD, it is essential to offer comprehensive information about their experiences. A comprehensive understanding of their lived experiences with the disease, the healthcare system, applied self-management strategies and their needs is considered crucial for developing a PD support program. Therefore, we aimed to explore the lived experiences and support needs of individuals with PD and their relatives in Germany. METHODS: This non-interventional, qualitative study conducted an explorative status quo and needs assessment. It generated knowledge through semi-structured focus groups and interviews with individuals with PD at various disease stages and their relatives. The interviews were digitally recorded, transcribed verbatim, and analysed using content analysis. RESULTS: Fifty-two individuals with PD and 29 relatives participated in eight focus groups and 13 paired and 13 individual interviews. Four themes with corresponding subthemes emerged: (1) experiences, revealing individuals' experiences around their diagnosis and with disease-specific care provision; (2) management support offers, clarifying who provides support and the type of support offered; (3) self-management, including comprehensibility, meaningfulness and manageability; and (4) future needs, differentiating between deficits and needs. Most participants expressed a sense of abandonment when obtaining self-management strategies and mastering their lives with PD, often referred to as 'life 2.0'. They identified the lack of structured and adequate provision of information, system orientation and social awareness. CONCLUSIONS: In Germany, there is an urgent need for a comprehensive PD care program that addresses the needs of individuals with PD and their relatives from the start of their care trajectory. It could assist individuals in gaining a comprehensive understanding of the disease, obtaining self-management strategies, building a support network, and becoming experts in self-managing their disease. Moreover, it may positively influence their care trajectory and reduce burdens, such as overburdening, fear of progression, and health anxiety. TRIAL REGISTRATION: German Clinical Studies Register ( https://www.drks.de/DRKS00030090 , No. DRKS00030090, Date of registration: 15.12.2022).

Journey toward Baby-Friendly Hospital Initiative designation: Healthcare professional's view on successful implementation process and maintenance of accreditation.

PROBLEM: The Baby-Friendly Hospital Initiative has yet to achieve widespread global implementation. BACKGROUND: The implementation of the Baby-Friendly Hospital Initiative has been recognised as complex. The challenge has been to maintain accreditation. AIM: To explore and gain a deeper understanding of the healthcare professionals' perceptions of the implementation process and the maintenance of the Baby-Friendly Hospital Initiative. METHODS: A qualitative descriptive study with focus groups (n = 10) of the nurses, midwives and unit leaders (n = 43) perceptions of the implementation process were analysed using inductive thematic analysis. FINDINGS: Analysis of the data revealed five main themes: groundwork for the baby-focused breastfeeding context, management support throughout the process, promoting baby-friendly practices, effective communication ensuring the right track, and supporting the maintenance of BFHI designation. The main themes describe the implementation as a journey of climbing a hill and after reaching the top trying to maintain their position. DISCUSSION: The starting point for implementation was an optimal environment supporting baby-friendly breastfeeding practices. The support of the management of the organisation was an important way of moving the implementation forward. Commitment to the common goal strengthened the baby-friendly approach and with concrete and immediate feedback the right pathway on a journey was ensured. CONCLUSION: Practical ways to support the implementation journey include regular update education on breastfeeding and continuous monitoring, as well as providing statistics to health professionals. Global guidelines on how to sustain change are needed. This will ensure that the work done is not wasted.

Frontline nursing staff's perceptions of intravenous medication administration: the first step toward safer infusion processes-a qualitative study.

OBJECTIVES: Intravenous medication errors continue to significantly impact patient safety and outcomes. This study sought to clarify the complexity and risks of the intravenous administration process. DESIGN: A qualitative focus group interview study. SETTING: Focused interviews were conducted using process mapping with frontline nurses responsible for medication administration in September 2020. PARTICIPANTS: Front line experiened nurses from a Japanese tertiary teaching hospital. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was to identify the mental models frontline nurses used during intravenous medication administration, which influence their interactions with patients, and secondarily, to examine the medication process gaps between the mental models nurses perceive and the actual defined medication administration process. RESULTS: We found gaps between the perceived clinical administration process and the real process challenges with an emphasis on the importance of verifying to see if the drug was ordered for the patient immediately before its administration. CONCLUSIONS: This novel and applied improvement approach can help nurses and managers better understand the process vulnerability of the infusion process and develop a deeper understanding of the administration steps useful for reliably improving the safety of intravenous medications.

The wellbeing shelf: A mixed methods study exploring the impact of a resilience web resource for first year nursing and midwifery students.

BACKGROUND: Nurturing a resilient nursing and midwifery workforce is vital for the National Health Service's sustainability. Higher Education Institutions (HEIs) must support students, given the challenges and attrition rates. Nursing and midwifery education uniquely balances tuition and placements, posing challenges, especially for first-year students, who face stressors including lack of familiarity, knowledge gaps, and emotional exposure. OBJECTIVES: This study aimed to introduce and evaluate a co-designed web-based intervention called 'The Wellbeing Shelf' to enhance resilience among first-year nursing and midwifery students. DESIGN: An exploratory mixed methods approach was employed, combining quantitative pre- and post-intervention questionnaires and qualitative focus groups. SETTINGS AND PARTICIPANTS: The study involved 353 first-year nursing and midwifery students at Queen's University Belfast. METHODS: 'The Wellbeing Shelf' was developed through co-design workshops. Quantitative measures included the Connor Davidson Resilience Scale (CD-RISC) and the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS). Qualitative data were collected through focus group interviews. RESULTS: Quantitative data showed a decrease in both resilience and wellbeing scores over time. The CD-RISC scores decreased significantly from Time 1 to Time 3. Qualitative findings revealed three themes: "Acquiring" knowledge about wellbeing, "Actioning" self-care strategies, and "Advocating" for self-care among peers and family. CONCLUSIONS: The study introduced 'The Wellbeing Shelf' as a resource to enhance resilience among nursing and midwifery students. Whilst the resource offered a variety of activities and fostered a sense of belonging, challenges in resource accessibility and student confidence were identified. The study also highlighted the importance of students advocating for self-care practices. Despite the resource's introduction, resilience and wellbeing scores decreased over time, suggesting a need for further research and potentially a control group. Understanding the initial lower resilience of nursing and midwifery students is crucial for future interventions in this high-demand program.

Communities of reflection in nurse education programs: A qualitative multi-methods study.

BACKGROUND: Nursing students often face challenges reconciling theoretical concepts with clinical realities. This study examines a novel concept 'Communities of Reflection' designed and tested to enhance coherency between theory and practice. The concept involves reflection groups comprising students, preceptors, and faculty during clinical placements. AIM: To examine the meaning of 'Communities of Reflection' regarding the coherency between theory and practice as perceived by the involved participants. METHOD: A qualitative multi-methods approach involved nursing students, preceptors, and faculty members who participated in 'Communities of Reflection.' Data collection methods included interviews, focus groups, written reflections, and observations. FINDINGS: The content analysis revealed that 'Communities of Reflection' facilitate a shared engagement in nursing, fostering a deeper level of reflection. Creating a safe space and embracing vulnerability are key aspects of this shared engagement. CONCLUSION: 'Communities of Reflection' offer a valuable framework for promoting coherency between theory and practice. It appears to be crucial to students' outcomes that a well-established, equitable theory-practice partnership is the solid foundation, acknowledging that emotions can serve as a catalyst for the development of professional expertise.

Implementation and evaluation of a national quality improvement initiative in cancer surgery.

BACKGROUND: In 2017, the Canadian Partnership Against Cancer, a Canadian federally sponsored organisation, initiated a national multijurisdictional quality improvement (QI) initiative to maximise the use of synoptic data to drive cancer system improvements, known as the Evidence for Surgical Synoptic Quality Improvement Programme. The goal of our study was to evaluate the outcomes, determinants and learning of this nationally led initiative across six jurisdictions in Canada, integrating a mix of cancer surgery disease sites and clinicians. METHODS: A mixed-methods evaluation (surveys, semistructured interviews and focus groups) of this initiative was focused on the ability of each jurisdiction to use synoptic reporting data to successfully implement and sustain QI projects to beyond the completion of the initiative and the lessons learnt in the process. Resources provided to the jurisdictions included operational funding, training in QI methodology, national forums, expert coaches, and ad hoc monitoring and support. The programme emphasised foundational concepts of the QI process including data literacy, audit and feedback reports, communities of practice (CoP) and positive deviance methodology. RESULTS: 101 CoP meetings were held and 337 clinicians received feedback reports. There were 23 projects, and 22 of 23 (95%) showed improvements with 15 of 23 (65%) achieving the proposed targets. Enablers of effective data utilisation/feedback reports for QI included the need for clinicians to trust the data, have comparative data for feedback, and the engagement of both data scientists and clinicians in designing feedback reports. Enablers of sustainability of QI within each jurisdiction included QI training for clinicians, the ability to continue CoP meetings, executive and broad stakeholder engagement, and the ability to use pre-existing organisational infrastructures and processes. Barriers to continue QI work included lack of funding for core team members, lack of automated data collection processes and lack of clinician incentives (financial and other). CONCLUSION: Success and sustainability in data-driven QI in cancer surgery require skills in QI methodology, data literacy and feedback, dedicated supportive personnel and an environment that promotes the process of collective learning and shared accountability. Building these capabilities in jurisdictional teams, tailoring interventions to facility contexts and strong leadership engagement will create the capacity for continued success in QI for cancer surgery.

Codesign and refinement of an optimised antenatal education session to better inform women and prepare them for labour and birth.

OBJECTIVE: Our objective was to codesign, implement, evaluate acceptability and refine an optimised antenatal education session to improve birth preparedness. DESIGN: There were four distinct phases: codesign (focus groups and codesign workshops with parents and staff); implementation of intervention; evaluation (interviews, questionnaires, structured feedback forms) and systematic refinement. SETTING: The study was set in a single maternity unit with approximately 5500 births annually. PARTICIPANTS: Postnatal and antenatal women/birthing people and birth partners were invited to participate in the intervention, and midwives were invited to deliver it. Both groups participated in feedback. OUTCOME MEASURES: We report on whether the optimised session is deliverable, acceptable, meets the needs of women/birthing people and partners, and explain how the intervention was refined with input from parents, clinicians and researchers. RESULTS: The codesign was undertaken by 35 women, partners and clinicians. Five midwives were trained and delivered 19 antenatal education (ACE) sessions to 142 women and 94 partners. 121 women and 33 birth partners completed the feedback questionnaire. Women/birthing people (79%) and birth partners (82%) felt more prepared after the class with most participants finding the content very helpful or helpful. Women/birthing people perceived classes were more useful and engaging than their partners. Interviews with 21 parents, a midwife focus group and a structured feedback form resulted in 38 recommended changes: 22 by parents, 5 by midwives and 11 by both. Suggested changes have been incorporated in the training resources to achieve an optimised intervention. CONCLUSIONS: Engaging stakeholders (women and staff) in codesigning an evidence-informed curriculum resulted in an antenatal class designed to improve preparedness for birth, including assisted birth, that is acceptable to women and their birthing partners, and has been refined to address feedback and is deliverable within National Health Service resource constraints. A nationally mandated antenatal education curriculum is needed to ensure parents receive high-quality antenatal education that targets birth preparedness.

Feelings and thoughts of midwifery students during their first birth suite placement: A qualitative study.

This descriptive qualitative study aimed to understand the feelings and thoughts experienced by 4th year midwifery students during the first birth they attended during clinical practice. Focus group interviews were conducted with 22 final year midwifery students in Istanbul, Türkiye December 2020. The transcribed data were analyzed by the descriptive qualitative analysis method. The students experienced not only negative feelings such as fear, torment, anxiety but also positive feelings such as hope, excitement, and curiosity during the first birth practice. The situations that caused negative feelings and thoughts were not only the feelings of the students but also the conditions that negatively affected the care provided to the patient in the clinic. The clinical practice environment affects the feelings and thoughts of midwifery students about the birth process. For this reason, improving the clinical practice environment and supporting students throughout the education process may contribute to the development of positive feelings and thoughts when attending as a student for their first birth suite placement.

Regional perspectives on patient safety policies and initiatives: a focus group study with patient safety leaders in the Middle East and Asian regions.

Preventing and reducing risks and harm to patients is of critical importance as unsafe care is a leading cause of death and disability globally. However, the lack of consolidated information on patient safety policies and initiatives at regional levels represents an evidence gap with implications for policy and planning. The aim of the study was to answer the question of what patient safety policies and initiatives are currently in place in the Middle East and Asian regions and what were the main strengths, weaknesses, opportunities and threats in developing these. A qualitative approach using online focus groups was adopted. Participants attended focus groups beginning in August 2022. A topic guide was developed using a strengths, weaknesses, opportunities and threats framework analysis approach. The Consolidated Criteria for Reporting Qualitative Research checklist was used to ensure the recommended standards of qualitative data reporting were met. 21 participants from 11 countries participated in the study. Current patient safety policies identified were categorised across 5 thematic areas and initiatives were categorised across a further 10 thematic areas. Strengths of patient safety initiatives included enabling healthcare worker training, leadership commitment in hospitals, and stakeholder engagement and collaboration. Weaknesses included a disconnect between health delivery and education, implementation gaps, low clinical awareness and buy-in at the facility level, and lack of leadership engagement. Just culture, safety by design and education were considered opportunities, alongside data collection and reporting for research and shared learning. Future threats were low leadership commitment, changing leadership, poor integration across the system, a public-private quality gap and political instability in some contexts. Undertaking further research regionally will enable shared learning and the development of best practice examples. Future research should explore the development of policies and initiatives for patient safety at the provider, local and national levels that can inform action across the system.

Perils and payoffs for patients in serious illness conversations as described by physicians: a qualitative study.

BACKGROUND: The Serious Illness Care Programme was developed to promote more, better and earlier serious illness conversations. Conversations about goals and values are associated with improved experiences and outcomes for seriously ill patients. Clinicians' attitudes and beliefs are thought to influence the uptake and performance of serious illness conversations, yet little is known about how clinicians perceive the impact of these conversations on patients. This study aimed to explore physicians' perceptions regarding the impact of serious illness conversations for patients. METHODS: The Serious Illness Care Programme was implemented as a quality improvement project in two hospitals in Southern Sweden. Focus group evaluation discussions were conducted with 14 physicians and inductive thematic analysis was undertaken. RESULTS: The results revealed that physicians considered potential perils and optimised potential payoffs for patients when engaging in serious illness conversations. Potential perils encompassed inappropriate timing, damaging emotions and shattering hopes. Potential payoffs included reflection time, secure space, and united understandings. CONCLUSIONS: Physicians depicted a balance in evaluating the perils and payoffs of serious illness conversations for patients and recognised the interrelation of these possibilities through continual assessment and adjustment.

Consensus-based recommendations for the development and expansion of palliative day care clinics in Germany: results of a Delphi study.

BACKGROUND: Needs-based, patient-oriented palliative care includes palliative day care clinics as a specialized semi-inpatient care offer. However, the establishment and development of these facilities has been unsystematic. Research is needed to strengthen their transparency and ensure their accessibility, quality, and structural adequacy. A national Delphi study was conducted to generate appropriate recommendations for the establishment and development of palliative day care clinics in Germany. METHODS: Recommendations were formulated from focus group data on the development and expansion of palliative day care clinics in Germany. Experts on in- and outpatient palliative care rated 28 recommendations for relevance and feasibility, respectively, using a 4-point Likert-type scale. Suggestions for improvement were captured via free text comments. Items were considered consented when more than 80% of the experts scored them 4 (strongly agree) or 3 (somewhat agree), regarding both relevance and feasibility. RESULTS: A total of 23 experts (32% response rate) completed three Delphi rounds. Following the first round, 10 of 28 recommendations were revised according to participants' comments; 1 recommendation was rejected. After the second round, 3 of these 10 recommendations were revised, while 3 were rejected. Consensus was achieved after the third round for 22 of the initial recommendations. CONCLUSIONS: The Delphi-consented recommendations provide a basis for the targeted evidence- and needs-based development of palliative day care clinics. The findings show a need for standards setting and the meaningful integration of these clinics into existing structures. TRIAL REGISTRATION: The present study was prospectively registered on April 20, 2020, with the German Clinical Trials Register (DRKS00021446).

Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives.

BACKGROUND: Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects. METHODS: We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences. RESULTS: The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes. CONCLUSION: The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.

Toward enhanced decentralized palliative care services in Neno District, Malawi: a qualitative study.

BACKGROUND: Palliative care remains key in assisting patients who have life-threatening conditions. In most low- and middle-income countries, it is often offered through a centralized system with limitations, including Malawi. In 2014, the World Health Organization called for improving palliative care access through primary health care and community models. Malawi and Neno District subsequently decentralized palliative care delivery to local health centers. This qualitative study explored the decentralization of palliative care services in Neno District, Malawi. METHODS: The descriptive qualitative study was conducted between 2021 and 2022 in two conveniently selected health centers providing palliative care in the Neno District. Fourteen healthcare workers were purposefully selected to participate in two focus groups. Fifteen patients were conveniently selected and participated in three focus groups. Data was analyzed using deductive and inductive approaches. Focused group discussions were conducted in Chichewa (Malawi's official local language), audio recorded, transcribed, translated into English, and analyzed thematically. RESULTS: Four main themes emerged from the focus groups. Patients described positive relationships with healthcare workers built on trust and holistic care over time. Accessing care included transport, social support, time constraints, and distance issues. Facilities effectively responded to needs through coordinated care and follow-up. Decentralization was perceived to benefit patients by reducing travel challenges and improving local access to efficient and inclusive palliative care services. However, challenges with resources, distance, and social support remained. Limitations in sampling and missing participant details necessitate further research with broader sampling. CONCLUSION: Overall, the study provides empirical evidence that can optimize palliative care delivery in similar low-resource contexts by informing policies to address barriers through decentralized approaches.