Illness perceptions of people living with chronic heart failure and limited community disease management.

AIM: To explore the cognitive representations and emotional responses to living with chronic heart failure of people receiving limited community disease management. BACKGROUND: Individuals living with heart failure face self-care and emotional challenges due to the overwhelming nature of adapting to lifestyle changes, particularly in subtropical areas. DESIGN: Qualitative descriptive. We applied Leventhal's Common Sense Model of Self-Regulation as the framework for interviews and analyses. METHODS: Twenty patients with chronic heart failure were interviewed during a hospital admission for exacerbation of their condition in a tertiary hospital in Thailand. RESULTS: Analysis of the components of Leventhal's model of cognitive representations of illness revealed two themes relating to Illness Identity: (1) lack of knowledge of the diagnosis and how to recognise symptoms of the disease, and (2) recognition of symptoms of an exacerbation of CHF was based on past experience rather than education. These resulted in delays responding to cardiac instability and confusion about the intent of treatment. Participants recognised the chronicity of their disease but experienced it as an unrelenting cycle of relative stability and hospitalisations. Perceived Controllability was low. Two themes were: (1) Low perceived trust in the efficacy of medical treatment and lifestyle changes, and (2) Low perceived trust in their ability to comply with recommended lifestyle changes. The Consequences were significant emotional distress and high burden of disease. The two themes of emotional responses were (1) Frustration and hopelessness with the uncertainty and unpredictability of the disease, and (2) Sense of loss of independence, functional capacity and participation in life's activities. CONCLUSION: Chronically ill patients need support to understand their illness and make better treatment and lifestyle decisions. Improving patients' self-efficacy to manage treatment and symptom fluctuations has the potential to improve their mental well-being and minimise the impact of their condition on suffering and participation in employment and community. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Leventhal's Common Sense Model of Self-Regulation can be used to examine cognitive and emotional elements of illness perceptions, which link to individuals' ability to make informed decisions about disease management and influence health behaviours. Understanding illness perceptions underpins strategies for enhancing and sustaining self-management behaviours. IMPACT: The study findings accentuate the need to establish long-term condition support programs in low-middle income countries where the burden of heart failure is increasing exponentially. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was used to explicitly and comprehensively report our qualitative research. PATIENT OR PUBLIC CONTRIBUTION: Patients contributed to the conduct of the study by participating in the data collection via face-to-face interviews.

Narrative synthesis of the effectiveness and characteristics of heart failure disease self-management support programmes.

A deeper understanding of the key elements that should be included in heart failure (HF) disease self-management support (DSMS) programmes is crucial to enhance programme effectiveness and applicability to diverse settings. We investigated the characteristics and effectiveness of DSMS programmes designed to improve survival and decrease acute care readmissions for people with HF and determine the generalizability and applicability of the evidence to low- and middle-income countries (LMICs). A narrative meta-synthesis approach was used, and systematic reviews of randomized controlled trials (RCTs) of DSMS programmes were included. The Cochrane Database of Systematic Reviews, MEDLINE, and Embase were searched without language restriction and guided by the adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight high-quality systematic reviews were identified representing 250 studies, of which 138 were unique RCTs measuring the outcomes of interest. The findings revealed statistically significant reductions in HF readmissions [relative risk (RR) range 0.64-0.85, P < 0.5, five out of six reviews], all-cause readmissions (RR range 0.85-0.95, P < 0.5, five out of six reviews), and all-cause mortality (RR range 0.67-0.87, P < 0.5, five out of five reviews). Overall, 44.2% (n = 61) of RCTs reduced acute care readmission and improved survival. Studies were categorized according to intensity (low, moderate, moderate+, and high) based on the opportunity for immediate treatment of HF instability; 29.2% (14/48) of low-intensity, 63.6% (21/33) of moderate-intensity, 40% (6/15) of moderate+-intensity, and 47.6% (20/42) of high-intensity interventions were effective. Most effective programmes used moderate-intensity (39.4%, 48%, or 50%, respectively) or high-intensity (33.3%, 36%, and 43.7%, respectively) interventions. The majority of studies (90.6%) were conducted in high-income countries. Programmes that provided opportunities for early recognition and response to HF instability were more likely to reduce acute care readmission and enhance survival. Generalizability and applicability to LMICs are clearly limited. Tailoring HF DSMS programmes to accommodate cultural, resource, and environmental challenges requires careful consideration of intervention intensity, duration of follow-up, and feasibility in low-resource settings.

Nurses' motivations and desired learning outcomes of postgraduate critical care studies: A descriptive exploratory study.

BACKGROUND: Education guidelines and professional practice standards inform the design of postgraduate critical care nursing curricula to develop safety and quality competencies for high-quality care in complex environments. Alignment between nurses' motivations for undertaking postgraduate critical care education, and intended course learning outcomes, may impact students' success and satisfaction with programs. OBJECTIVES: The objectives of this study were to explore nurses' motivations and desired learning outcomes on commencement of a postgraduate critical care course and determine how these align with safety and quality professional attributes. METHODS: In this exploratory descriptive study, qualitative data were extracted from survey responses of four cohorts of students enrolled in a graduate certificate-level critical care course between 2013 and 2016 (N = 390, 93%), at one Australian university. Summative qualitative content analysis was used to code and quantify textual content followed by synthesis to identify themes and subthemes. RESULTS: Five themes of motivations were identified: (i) Knowledge development; (ii) Skill development, (iii) Personal outcomes, (iv) Personal professional behaviours, and (v) Interpersonal professional behaviours. Most frequently, students' motivations and desired learning outcomes included 'Understanding' (329 participants [84%], 652 references), 'Development of technical skills' (241 participants [62%], 384 references), 'Development of confidence' (178 participants [46%], 220 references), and 'Career progression' (149 participants [38%], 168 references). Less frequent were motivations related to safety and quality competencies including teamwork, communication, reflective practice, and research skills. CONCLUSION: Findings suggest students' motivations to undertake postgraduate studies most often related to acquisition of new knowledge and technical skills. Desired skills and behaviours were consistent with many, but not all, of the key course outcomes and attributes specified by health professional education guidelines and nurses' professional practice standards. Understanding the differences between students' motivations and desired safety- and quality-related course learning outcomes informs course orientation, teaching activities, and student support to optimise achievement of essential learning outcomes.

A Nurse-Led Multimedia Intervention to Increase Patient Participation in Recovery After Knee Arthroplasty: Hybrid Type II Implementation Study.

BACKGROUND: Advances in digital technology and the use of multimedia platforms to deliver information provide clinicians with a unique opportunity to develop innovative ways to consistently provide high-quality, accessible, and evidence-based information to support patient participation. Introducing new technologies into everyday acute care clinical practice can be difficult. OBJECTIVE: The aim of this paper was to provide a description of an implementation strategy and the subsequent evaluation undertaken to examine the contextual factors important to the successful adoption of new technology by nurses in the context of acute postoperative care. METHODS: Implementation of the intervention and process evaluation was undertaken in 3 phases: phase 1, preimplementation stakeholder engagement and identification of barriers and enablers to implementation; phase 2, supported implementation of the intervention; and phase 3, evaluation of uptake, usability, and acceptability of the intervention in clinical practice. RESULTS: The outcomes of the implementation of the multimedia intervention in the context of acute postoperative care were positive. Of the 104 patients in the intervention group, 103 (99%) received the intervention. All 103 patients completed the 8-item intervention questionnaire and 93.3% (97/103) were interviewed on day 3 to evaluate usability, uptake, and acceptability. Of these 97 patients, almost all (n=94, 91%) found the program easy to use and most (n=64, 62%) could view the MyStay Total Knee Replacement program as often as they wanted. The findings also suggest that the time to implement the program was minimal (5-10 minutes). Collaboration with nurses and patients before and during implementation to identify potential barriers to successful implementation of the intervention was essential to develop timely strategies to overcome these barriers. To ensure end-user engagement, careful consideration was given to nurses' views on who was responsible for facilitating this intervention. CONCLUSIONS: The findings provide evidence that the structured implementation of the multimedia intervention was robust and successful in terms of patient participant recruitment and application; however, it was difficult to assess the level of engagement by nurse clinicians with the program. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614000340639; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614000340639.

Efficacy and cost-effectiveness of an online mindfulness program (MindOnLine) to reduce fear of recurrence among people with cancer: study protocol for a randomised controlled trial.

INTRODUCTION: Fear of cancer recurrence (FCR) is a common condition among cancer survivors that can lead to significant levels of distress, anxiety and depression. Online mindfulness programmes may provide the mechanism to support cancer survivors manage FCR and distress, and improve people's well-being over the short, medium and long term. The primary aim of this study is to determine the potential efficacy of MindOnLine, a 9 session mindfulness-based programme for survivors of breast, prostate and colorectal cancer. A formal economic programme will also be conducted. METHODS AND ANALYSIS: A single-blind randomised controlled trial to determine the efficacy and cost-efficacy of a MindOnLine programme for cancer survivors. A total of 400 people living with cancer will be recruited via online advertisements on social media platforms, peak consumer advocacy groups or through outpatient services at healthcare providers across Victoria, Australia. People will be randomly allocated to either the MindOnLine programme (n=200) or waitlist control (n=200). Participant assessments will occur at baseline, at 9 weeks and 9-month follow-up. The primary outcome is change in Fear of Recurrence Index Score total score between baseline and 9 weeks; secondary outcomes are changes in depression and anxiety, quality of life and mindfulness. The economic analysis comprises a cost-consequences analysis where all outcomes will be compared with costs. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Peter MacCallum Cancer Centre (20-53) and Deakin University (2020-284). All participants will be required to provide written informed consent. Findings will be disseminated in peer reviewed journals and among key stakeholder organisations including hospitals, cancer and community organisations and Government. If successful the project will be rolled out nationally with a formal implementation plan. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (12620000645954); Pre-results. Registered 6 June 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379520&isReview=true.

Low dose mobility and functional status outcomes in hospitalized older general medicine patients.

Emerging evidence suggests hospitalized older adults should walk at least 20-minutes daily to minimize functional decline. A single-institution case study conducted in a tertiary-referral centre in Melbourne, Australia, aimed to examine functional change and describe characteristics of older patients' in-hospital mobility. From 526 older patients vulnerable to functional decline, a sample of 41 patients (Mean age = 83.6, SD = 6.1 years) participated in 6-hour naturalistic observations. Functional change was measured at 2-weeks preadmission, admission and discharge with the revised Measurement System of Functional Autonomy (SMAF). Nearly 25% (n = 10) of observed patients functionally declined between preadmission and discharge and five patients died (12.2%). Thirty-two patients (78%) mobilized in 133 episodes accounting for 3.1% of the 246-hours observed. A daily walking-exercise dose equivalent to 20-min was associated with less functional decline in older adults with moderate to high walking capability supporting the effectiveness of this daily walking-exercise dose in minimizing functional decline.

Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals.

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a "Reduced" (<3%) or "Eliminated" (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

BACKGROUND: Efforts to ensure safe and optimal medication management are crucial in reducing the prevalence of medication errors. The aim of this study was to determine the associations of person-related, environment-related and communication-related factors on the severity of medication errors occurring in two health services. METHODS: A retrospective clinical audit of medication errors was undertaken over an 18-month period at two Australian health services comprising 16 hospitals. Descriptive statistical analysis, and univariate and multivariable regression analysis were undertaken. RESULTS: There were 11,540 medication errors reported to the online facility of both health services. Medication errors caused by doctors (Odds Ratio (OR) 0.690, 95% CI 0.618-0.771), or by pharmacists (OR 0.327, 95% CI 0.267-0.401), or by patients or families (OR 0.641, 95% CI 0.472-0.870) compared to those caused by nurses or midwives were significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of double-checking of medication orders compared to single-checking (OR 0.905, 95% CI 0.826-0.991) was significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of electronic systems for prescribing (OR 0.580, 95% CI 0.480-0.705) and dispensing (OR 0.350, 95% CI 0.199-0.618) were significantly associated with reduced odds of possibly or probably harmful medication errors compared to the absence of these systems. Conversely, insufficient counselling of patients (OR 3.511, 95% CI 2.512-4.908), movement across transitions of care (OR 1.461, 95% CI 1.190-1.793), presence of interruptions (OR 1.432, 95% CI 1.012-2.027), presence of covering personnel (OR 1.490, 95% 1.113-1.995), misread or unread orders (OR 2.411, 95% CI 2.162-2.690), informal bedside conversations (OR 1.221, 95% CI 1.085-1.373), and problems with clinical handovers (OR 1.559, 95% CI 1.136-2.139) were associated with increased odds of medication errors causing possible or probable harm. Patients or families were involved in the detection of 1100 (9.5%) medication errors. CONCLUSIONS: Patients and families need to be engaged in discussions about medications, and health professionals need to provide teachable opportunities during bedside conversations, admission and discharge consultations, and medication administration activities. Patient counselling needs to be more targeted in effort to reduce medication errors associated with possible or probable harm.

Evaluation of the effectiveness of an eLearning program in the nursing observation and assessment of acute surgical patients: A naturalistic observational study.

AIM/OBJECTIVE: The aim of this study was to evaluate the effectiveness of an eLearn program in changing surgical nurses' approach to clinical assessment. BACKGROUND: Nurses need to have the knowledge and skills to recognise and respond to changes in patients' physiological condition in a timely manner. A private health service in Melbourne, Australia developed an online (eLearn) program highlighting the importance of clinical assessment and provided nurses with an overview of the Airway,Breathing, Circulation, Disability, Exposures ('ABCDE') approach. DESIGN: A before and after study design that involved naturalistic observation of nurse-patient interactions and nurses' performing patient clinical assessments was undertaken on two surgical wards. METHODS: The intervention ward nurses received standard education and exposure to the eLearning program. The comparison ward nurses received standard workplace education on patient assessment. The nurses were observed from May to August 2018. RESULTS: Following completion of the eLearn, intervention ward nurses were observed to spend more time with their patients conducting clinical assessment. On both wards, not all nurses performed comprehensive ABCDE assessment and there was variability associated with the sequencing of ABCDE assessment. CONCLUSIONS: This study provides some evidence that completion of an eLearn can change clinical practice, however the intensity of the intervention was insufficient to achieve optimal practice in the conduct of clinical assessments.

Inter-rater reliability and predictive accuracy of the Shkuratova Assessment of Falls-risk in Rehabilitation (SAFER) tool.

Despite the recognised importance of falls prevention in rehabilitation settings, there is limited research focusing on falls risk assessment tools designed to guide both patient screening and therapy. This study evaluated the predictive accuracy and inter-rater reliability of the Shkuratova Assessment of Falls-risk in Rehabilitation settings (SAFER) tool. The study was conducted at a subacute rehabilitation facility in Australia. Patient assessments were performed on admission to subacute care by trained physiotherapists, and the incidence of falls was documented prospectively. Of the 147 patients, 45 had at least one fall and were compared to 102 who had no falls. The inter-rater reliability of the SAFER tool when used by trained physiotherapists was high with the level of agreement for individual items ranging from 74 to 99%. Thirty-two (76%) patients who experienced a fall during their admission and 46 (44%) who did not fall were identified as having a high falls-risk. Using a SAFER tool cut-off of 12/26: sensitivity is 69%, specificity is 66%, area under the curve 0.71 (95% confidence interval: 0.62-0.80). The high negative predictive values at a range of cut-offs provided strong evidence that patients identified as having a low falls-risk were unlikely to experience a fall. Performing a comprehensive assessment of specific deficits in gait, balance and mobility on admission provided a streamlined approach to identification of patients who would benefit from tailored falls prevention interventions.

Perceived roles and barriers to nurses' engagement in antimicrobial stewardship: A Thai qualitative case study.

BACKGROUND: Antimicrobial stewardship is the practice of ensuring the optimal use of antibiotics to prevent antimicrobial resistance. A multidisciplinary approach is considered best practice; however, little is known about nurses' contribution. OBJECTIVES: To explore how organisational multidisciplinary leaders and clinical nurses perceive nurses' roles in AMS in a single organisational site case study based in Thailand, within the current governance, educational and practice context, and the barriers to nurses' engagement in AMS. METHODS: A qualitative descriptive study using thematic analysis approach was conducted in a 1000-bed university hospital in Bangkok, Thailand. The combined number of organisational leaders and nurses was 33 including 15 individual organisational leader interviews and three focus groups involving 18 nurses. RESULTS: Nurses currently participate in AMS by supporting system processes, monitoring safety and optimal antibiotic use and patient education. A lack of clear articulation of nurses' role and traditional professional hierarchies limits active participation. Inconsistent engagement was perceived as due to a failure to prioritise AMS activities, a lack of formal policies and a need for further education. CONCLUSION: Nurses do engage in AMS but there are significant governance, hierarchical and educational impediments. These gaps need to be addressed before clearly defined nurse roles in AMS can be developed and embedded into clinical practice.

Diagnostic Accuracy of a Two-Stage Sequential Screening Strategy Implemented by Community Health Workers (CHWs) to Identify Individuals with COPD in Rural India.

PURPOSE: Undiagnosed Chronic Obstructive Pulmonary Disease (COPD) results in high morbidity, disability and mortality in India. Effective strategies for active COPD screening in community settings are needed to increase early identification, risk reduction and timely management. The objective of this study was to test the diagnostic accuracy of a sequential two-step screening strategy to detect COPD, implemented by community health workers (CHWs), among adults aged ≥40 years in a rural area of North India. PATIENTS AND METHODS: Trained CHWs screened all consenting (n=3256) eligible adults in two villages using the Lung Function Questionnaire (LFQ) to assess their COPD risk and conducted pocket spirometry on 268 randomly selected (132 with high risk ie LFQ score ≤18 and 136 with low risk ie LFQ score >18) individuals. Subsequently, trained researchers conducted post-bronchodilator spirometry on these randomly selected individuals using a diagnostic quality spirometer and confirmed the COPD diagnosis according to the Global Initiative for Obstructive Lung Disease (GOLD) criteria (FEV1/FVC ratio <0.7). RESULTS: This strategy of using LFQ followed by pocket spirometry was sensitive (78.6%) and specific (78.8%), with a positive predictive value of 66% and negative predictive value of 88%. It could accurately detect 67% of GOLD Stage 1, 78% of GOLD Stage 2, 82% of GOLD Stage 3 and 100% of GOLD Stage 4 individuals with airflow limitation. CONCLUSION: COPD can be accurately detected by trained CHWs using a simple sequential screening strategy. This can potentially contribute to accurate assessment of COPD and thus its effective management in low-resource settings.

Evaluation of the validity and reliability of the Nurses' Responsibility in Healthcare Quality Questionnaire: An instrument design study.

Nurses' awareness and acceptance of their professional responsibilities across the full breadth of safety and quality-related practices and behaviors are critical for high quality healthcare delivery. The purpose of this study was to develop and psychometrically test a new instrument to measure nurses' perceptions of their responsibilities related to healthcare quality. Participants were registered nurses, enrolled in a postgraduate program at an Australian university, who completed the Likert scale instrument with items developed from nurses' professional practice standards. Steps of pilot testing, item reduction, and confirmatory factor analysis resulted in a five-subscale, 55-item instrument with acceptable goodness-of-fit indices and good internal consistency reliability. Test-retest reliability demonstrated acceptable temporal stability. The Nurses Responsibilities in Healthcare Quality Questionnaire demonstrated acceptable validity and reliability. The instrument may assist education providers and health service managers to identify gaps between nurses' beliefs and professional role expectations, and evaluate the impact of educational and clinical initiatives designed to develop nurses' knowledge, skills, and attitudes related to healthcare quality.

Mobilisation alarm triggers, response times and utilisation before and after the introduction of policy for alarm reduction or elimination: A descriptive and comparative analysis.

BACKGROUND: Mobilisation alarms are a falls prevention strategy used in hospitals to alert staff when an at risk patient is attempting to mobilise. Mobilisation alarms have an estimated annual cost of $AUD58MIL in Australia. There is growing evidence from randomised controlled trials indicating mobilisation alarms are unlikely to prevent falls. AIM: The primary aim of this study was to describe the rate of mobilisation alarm false triggers and staff response time across different health services. The secondary aim was to compare pre to post mobilisation alarm utilisation following the introduction of policy to reduce or eliminate mobilisation alarms. METHODS: This descriptive and comparative study was conducted through Monash Partners Falls Alliance across six health services in Melbourne, Australia. This study described true and false alarm triggers and trigger response times across three health services and usual care mobilisation alarm utilisation across six health services; and then compared alarm utilisation across two health services following the introduction of policy to reduce (<2.5%) or eliminate (0.0%) mobilisation alarms in the acute and rehabilitation settings. RESULTS: The most frequent observation was a false alarm (n = 74, 52%), followed by a true alarm (n = 67, 47%) and no alarm (n = 3, 2%). Time to respond to the true and false alarms was an average of 37 seconds (SD 92) and this included 61 occasions of 0 seconds as a member of staff was present when the alarm triggered. If the 61 occasions of staff being present when the alarm triggered were removed, the average time to respond was 65 seconds (SD114). Usual care mobilisation alarm utilisation in acute was 7% (n = 171/2,338) and in rehabilitation was 11% (n = 286/2,623). Introducing policy for reduced and eliminated mobilisation alarm conditions was successful with a reduced utilisation rate of 1.8% (n = 11/609) and an eliminated utilisation rate of 0.0% (n = 0/521). CONCLUSION: Half of mobilisation alarm triggers are false and when alarms trigger without staff present, staff take about a minute to respond. While usual care has one in fourteen patients in acute and one in nine patients in rehabilitation using a mobilisation alarm, it is possible to introduce policy which will change practice to reduce or eliminate the use of mobilisation alarms, providing evidence of feasibility for future disinvestment effectiveness studies that it is feasible to disinvest in the alarms.

End-of-life care and intensive care unit clinician involvement in a private acute care hospital: A retrospective descriptive medical record audit.

INTRODUCTION: More Australians die in the hospital than in any other setting. This study aimed to (i) evaluate the quality of end-of-life (EOL) care in the hospital against an Australian National Standard, (ii) describe the characteristics of intensive care unit (ICU) clinician involvement in EOL care, and (iii) explore the demographic and clinical factors associated with quality of EOL care. METHOD: A retrospective descriptive medical record audit was conducted on 297 adult inpatients who died in 2017 in a private acute care hospital in Melbourne, Australia. Data collected related to 20 'Processes of Care', considered to contribute to the quality of EOL care. The decedent sample was separated into three cohorts as per ICU clinician involvement. RESULTS: The median age of the sample was 81 (25th-75th percentile = 72-88) years. The median tally for EOL care quality was 16 (25th-75th percentile = 13-17) of 20 care processes. ICU clinicians were involved in 65.7% (n = 195) of cases; however, contact with the ICU outreach team or an ICU admission during the final inpatient stay was negatively associated with quality of EOL care (coefficient = -1.51 and -2.07, respectively). Longer length of stay was positively associated with EOL care (coefficient = .05). Specialist palliative care was involved in 53% of cases, but this was less likely for those admitted to the ICU (p < .001). Evidence of social support, bereavement follow-up, and religious support were low across all cohorts. CONCLUSION: Statistically significant differences in the quality of EOL care and a negative association between ICU involvement and EOL care quality suggest opportunities for ICU outreach clinicians to facilitate discussion of care goals and the appropriateness of ICU admission. Advocating for inclusion of specialist palliative care and nonclinical support personnel in EOL care has merit. Future research is necessary to investigate the relationship between ICU intervention and EOL care quality.

Six-year trends in postoperative prescribing and use of multimodal analgesics following total hip and knee arthroplasty: A single-site observational study of pain management.

BACKGROUND: Guidelines for acute postoperative pain management recommend administering analgesics in multimodal combination to facilitate synergistic benefit, reduce opioid requirements and decrease side-effects. However, limited observational research has examined the extent to which multimodal analgesics are prescribed and administered postoperatively following joint replacement. METHODS: In this longitudinal study, we used three-point prevalence surveys to observe the 6-year trends in prescribing and use of multimodal analgesics on the orthopaedic wards of a single Australian private hospital. We collected baseline postoperative data from total hip and knee arthroplasty patients in May/June 2010 (Time 1, n = 86), and follow-up data at 1 year (Time 2, n = 199) and 5 years (Time 3, n = 188). During the follow-up, data on prescribing practices were presented to anaesthetists. RESULTS: We found a statistically significant increase in the prescribing (p < 0.001) and use (p < 0.001) of multimodal analgesics over time. The use of multimodal analgesics was associated with lower rest pain (p = 0.027) and clinically significant reduction in interference with activities (p < 0.001) and sleep (p < 0.001). However, dynamic pain was high and rescue opioids were likely under-administered at all time points. Furthermore, while patients reported high levels of side-effects, use of adjuvant medications was low. CONCLUSIONS: We observed significant practice change in inpatient analgesic prescribing in favour of multimodal analgesia, in keeping with contemporary recommendations. Surveys, however, appeared to identify a clinical gap in the bedside assessment and management of breakthrough pain and medication side-effects, requiring additional targeted interventions. SIGNIFICANCE: Evaluation of 6-year trends in a large Australian metropolitan private hospital indicated substantial growth in postoperative multimodal analgesic prescribing. In the context of growing global awareness concerning multimodal analgesia, findings suggested diffusion of best-evidence prescribing into clinical practice. Findings indicated the effects of postoperative multimodal analgesia in real-world conditions outside of experimental trials. Postoperative multimodal analgesia in the clinical setting was only associated with a modest reduction in rest pain, but substantially reduced interference from pain on activities and sleep.

Evaluation of a blended learning approach to developing specialty-nursing practice. An exploratory descriptive qualitative study.

BACKGROUND: An ageing population and a transitioning workforce is creating demands on healthcare workforces. Clinical and procedural knowledge deficits cause anxieties in new and experienced nurses alike when integrating into new teams. Overcoming these boundaries can be achieved with Introductory programs. These develop knowledge, technical skills and non-technical skills. Investigating nurses drive to undertake such programs, and the benefits they perceive for themselves, will help to tailor future programs. OBJECTIVES: To explore post-registration nurses' motivations for undertaking an introductory program that utilised a blended learning methodology. Identifying changes in participants understanding and clinical behaviours. METHODS: An exploratory descriptive qualitative study design was used to evaluate the Introduction to Specialty Practice (ISP) program that is run by a large private healthcare provider in Melbourne, Australia. The health service includes eight campuses and four intensive care units across the group. Twelve participants from a mixture of critical care and acute care clinical areas were consented. They were interviewed using a semi-structured questionnaire. Responses were transcribed verbatim and thematic analysis of the transcripts then occurred. RESULTS: The study demonstrated intrinsic and extrinsic factors influenced participant's desires to undertake this program. Three major themes were evident: 1) that caring without knowledge was daunting, 2) that participants needed to create a clinical and professional identity and 3) that participant's perspective on their delivery of care improved, along with their professional aptitude. CONCLUSION: Maintaining currency with knowledge, skills, and technological developments is crucial for nurses to consistently deliver high-level care. The demands that nurses' face within their clinical areas affects their intention to stay within the workforce and their ability to deliver care. Introductory programs that utilise blended learning strategies have a role to play in enabling nurses to create their professional identity, find their position in clinical teams, and meet the requirements of organisations.

The relationship between the undergraduate clinical learning environment and work readiness in new graduate nurses: A pre-post survey study.

BACKGROUND: Due to projected nurse shortages, it is necessary that undergraduate programs optimise work readiness outcomes in new graduate nurses. Research that quantitatively evaluates characteristics of clinical nursing programs that predict increased work readiness is required. OBJECTIVES: To explore the relationship between the undergraduate clinical learning environment and nurse perceptions of work readiness prior to and following, commencement as a new graduate nurse. DESIGN: A pre-post follow-up study. Undergraduates were surveyed at the end of their Bachelor's degree (baseline) and at 8-10 weeks after commencement as a graduate nurse (Time 1). SETTING: A multi-site, metropolitan private hospital in Victoria, Australia. PARTICIPANTS: Nursing graduates who completed a university fellowship program (n = 26), or were undertaking their graduate year and had completed placement blocks within (n = 18) or outside (n = 31) the healthcare organisation. METHODS: Participants self-completed the Clinical Learning Environment Inventory (CLEI) and Work Readiness Scale for Graduate Nurses (WRS-GN) at baseline and Time 1. Multiple regression analyses were performed. RESULTS: CLEI scores significantly predicted work readiness outcomes (all p-values<.05), accounting for 16-36% and 17-28% of the variance of WRS-GN scores at baseline and Time 1, respectively. After adjusting for clustering due to clinical placement groups, CLEI Individualisation (p = .023) and Valuing Nurses Work (p = .01) predicted improved Time 1 WRS-GN Organisational Acumen. CLEI Innovative and Adaptive Culture scores predicted poorer Time 1 Organisational Acumen (p = .001). CONCLUSIONS: Learning environments that offered high levels of individualised attention and valued nurses' work appeared to facilitate post-graduation engagement and identification with nursing practice. However, highly innovative and adaptive education may detract from optimal work readiness. Findings revealed that while important, the clinical learning environment only accounted for a small-to-moderate degree of nursing graduates' work readiness. To facilitate robust evidence-based improvement of clinical nursing education, future research should attempt to empirically establish the value of additional facilitators of work readiness.

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

OBJECTIVE: To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care. DESIGN: Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting. SETTING: Cardiac surgical unit in New Zealand. PARTICIPANTS: Culturally diverse patients in hospital undergoing heart surgery. MAIN OUTCOMES: A definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort. RESULTS: Comfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients' personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment. CONCLUSIONS: These findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

Opportunities for patients to engage in postoperative recovery following cardiac surgery: A systematic narrative review.

OBJECTIVE: To compare patient booklets with clinical guidelines and care pathways to assess: gaps in content and depth of information delivered, opportunities for patients participation and to review the trajectory of care to inform recovery. METHODS: A systematic review of the grey literature was conducted using Google search engine and a variety of terms related to cardiac surgery, patient outcomes and recovery pathways. Patient books and care pathways were obtained from major hospitals in Melbourne. Resources were included if they were published between January 2013-August 2018 and written in English. RESULTS: A total of 31 resources were included in the review, (n = 14 patient booklets, n = 17 clinician guides). Twenty-one topics of recovery were identified. Patient booklets provided information on more topics of recovery than clinician guides (50 % and 24 % respectively). Clinician guides provided more depth on information on topics of recovery than patient booklets (85 % and 73 % respectively). The majority of patient booklets outlined patient participation was in five topics of recovery. CONCLUSIONS: Gaps in the type and depth of information exist between patient and clinician guidelines. Clearer guidelines on how patients can participate in care are needed. PRACTICE IMPLICATIONS: Nurses are key drivers in facilitating patient participation in postoperative recovery.