Trajectories of job insecurity and the probability of poorer mental health among prime working-age Australian women and men.

Precarious and insecure employment arrangements are important social determinants of health. Prior evidence has consistently found perceived job insecurity to be associated with poorer mental health. Nonetheless, several key under-researched areas remain in the existing evidence base. This study addresses some of these gaps by examining trajectories of job (in)security and assessing the effect of various persistent job security trajectories on subsequent mental health of both men and women. Utilising 15 waves of data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, we employed group-based trajectory modelling (GBTM) to identify trajectories of job (in)security through men and women's prime working years (from baseline age of 28-38yrs to 41-51yrs) across 14 years (waves 5-18), before subsequently examining the associations between these estimated trajectories and mental health at wave 19 (aged 42-52yrs). We identified four distinct trajectories of job (in)security for both men and women: persistently secure, becoming more secure, becoming less secure, and persistently insecure. Examining the association between these trajectories and mental health, we found that chronic exposure to any amount of persistent job insecurity (improving, worsening or persistently insecure) is detrimental to the mental health of both men and women. Furthermore, a somewhat incremental or dose dependant effect was found, with persistent job insecurity associated with the largest declines in mental health scores. Given mental health disorders are a substantial cause of disability globally, our study provides evidence that developing policy and practice interventions to reduce job insecurity (as an increasingly recognised and highly modifiable social determinant of mental health) has considerable potential to enact positive population health improvements.

Unpaid caregiving and mental health during the COVID-19 pandemic-A systematic review of the quantitative literature.

The COVID-19 pandemic imposed additional and specific challenges on the lives and wellbeing of informal unpaid carers. Addressing an important gap in the existing literature, this systematic review (prospectively registered with PROSPERO CRD42022376012) synthesises and evaluates the quantitative evidence examining the association between unpaid caregiving and mental health (compared to non-caring), during the pandemic. Five databases were searched (Medline, PsycInfo, EMBASE, Scopus, Web of Science) from Jan 1, 2020, to March 1, 2023. Population-based, peer-reviewed quantitative studies using any observational design were included, with screening, data extraction and quality assessment (amended NOS) independently conducted by two reviewers. Of the 3,073 records screened, 20 eligible studies (113,151 participants) were included. Overall quality of evidence was moderate. Narrative synthesis was complemented by Effect-direction and Albatross plots (given significant between-study heterogeneity precluded meta-analysis). Results indicate that the mental health of informal carers, already poorer pre-COVID compared to non-caregivers, was disproportionally impacted as a result of the pandemic and its associated public health containment measures. This review highlights the vulnerability of this group and should motivate political will and commensurate policies to ensure unpaid caregivers are better supported now, in the medium term, and crucially if, and when, another global public health emergency emerges.

The gendered associations between precarious employment and mental health in working-age Australians: A longitudinal analysis using 16 waves of the HILDA survey.

Unemployment and precarious employment (PE) are routinely found to be associated with poorer mental health. Importantly, women are over-represented in PE (due to disproportionate unpaid care demands), yet a gender lens has been lacking in much of the extant literature. This study addresses several gaps by reconsidering how PE can be conceptualised from a gender perspective and examining the impact of differing levels of multidimensional PE on the mental health of working-age Australians. Utilising sixteen annual waves (2005-2020) of the HILDA survey, this longitudinal study employed mixed-effects analysis and Mundlak modelling to examine the association between PE and mental health in working-age (25-64yrs) adults. Mental health was assessed using the MHI-5 scale. A multidimensional PE scale (based on objective and subjective indicators) was developed and three levels of precarity were modelled. 19,442 participants were included in the analyses and all models were stratified by gender. We found women experience greater exposure to PE in Australia, and our results showed a ubiquitously strong and negative association between PE and mental health in both women and men, across all levels of PE, with a dose dependent association observed with increasing PE. Additional adjustment for prior mental health slightly attenuated effect sizes, but the strength and direction of all associations were unchanged. This study provides longitudinal evidence of the detrimental impact of PE on the mental health of working age Australians, highlighting the importance of labour regulations and employment policies to minimize PE for all adults. However, given women's differential exposure to PE, this study also reinforces the urgent need for gender-sensitive social policies to address continued inequity in the division of unpaid household labour to promote a more equitable paid labour market into the future.

Reducing Ileostomy Readmissions: Using Implementation Science to Evaluate the Adoption of a Quality Improvement Initiative.

BACKGROUND: Translating empirical evidence into clinical practice remains challenging. Prevention of morbidity from new ileostomies may serve as an example. Despite evidence demonstrating improvements in electrolyte levels, kidney function markers, and hospital readmissions, widespread adoption of oral rehydration solutions among patients with new ileostomies has not occurred. The causes of low uptake are unknown and likely multifactorial. OBJECTIVE: We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance implementation science framework to identify barriers and facilitators in the adoption of a quality improvement initiative aimed at decreasing emergency department visits and hospital readmissions because of dehydration among patients with new ileostomies using oral rehydration solutions. DESIGN: Qualitative interviews were conducted with stakeholders based on the domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. SETTINGS: Participating community and academic hospitals across Michigan (n = 12). PATIENTS: Convenience sampling was used to recruit 25 key stakeholders, including wound, ostomy, and continence nurses; registered nurses; nurse practitioners; nurse managers; colorectal surgeons; surgery residents; physician assistants; and data abstractors (1-4 participants per site). MAIN OUTCOME MEASURES: Through qualitative content analysis, we located, analyzed, and identified patterns using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS: We identified the following factors to increase the adoption of quality improvement initiatives at the provider level: 1) selection and coaching of champions, 2) broadening of multidisciplinary teams, 3) performing structured patient follow-up, and 4) addressing long-term sustainability concerns regarding cost and equity. LIMITATIONS: Limited to high-volume ileostomy surgery hospitals, did not include in-person site visits to each hospital before and after implementation, and did not consider the hospital- and patient-level factors that impact the widespread adoption of quality improvement initiatives. CONCLUSIONS: Integrating implementation science frameworks to rigorously study quality improvement initiatives may reveal the determinants of the widespread adoption of evidence-based practices. REDUCCIN DE REINGRESOS POR ILEOSTOMA USO DE LA CIENCIA DE LA IMPLEMENTACIN PARA EVALUAR LA ADOPCIN DE UNA INICIATIVA DE MEJORA DE LA CALIDAD: ANTECEDENTES:Traducir la evidencia empírica a la práctica clínica sigue siendo un desafío. La prevención de la morbilidad por nuevas ileostomías puede servir como ejemplo. A pesar de la evidencia que demuestra mejoras en los niveles de electrolitos, marcadores de función renal y reingresos hospitalarios, no se ha producido una adopción generalizada de soluciones de rehidratación oral entre pacientes con nuevas ileostomías. Las causas de la baja captación son desconocidas y probablemente multifactoriales.OBJETIVO:Empleamos Alcance, Eficacia, Adopción, Implementación y Mantenimiento, un marco de las ciencias de implementación, para identificar barreras y facilitadores en la adopción de una iniciativa de mejora de la calidad destinada a disminuir las visitas al departamento de emergencias y los reingresos hospitalarios debido a la deshidratación entre los pacientes con nuevos ileostomías utilizando soluciones de rehidratación oral.DISEÑO:Se realizaron entrevistas cualitativas con las partes interesadas basadas en los dominios del marco de Alcance, Efectividad, Adopción, Implementación y Mantenimiento.CONFIGURACIÓN:Hospitales académicos y comunitarios participantes a través de Michigan (n = 12).PARTICIPANTES:Se utilizó un muestreo por conveniencia para reclutar a 25 partes interesadas clave, incluyendo enfermeras de heridas, ostomía y continencia; enfermeras registradas; enfermeras practicantes; gerentes de enfermera; cirujanos colorrectales; residentes de cirugía; asistentes médicos; y extractores de datos (1-4 participantes por sitio).PRINCIPALES MEDIDAS DE RESULTADO:A través del análisis de contenido cualitativo, localizamos, analizamos e identificamos patrones utilizando el marco de Alcance, Eficacia, Adopción, Implementación y Mantenimiento.RESULTADOS:Identificamos los siguientes factores para aumentar la adopción de iniciativas de mejora de la calidad a nivel de proveedores: 1) selección y entrenamiento de campeones, 2) ampliación de equipos multidisciplinarios, 3) seguimiento estructurado de pacientes y 4) abordaje a largo plazo. preocupaciones de sostenibilidad con respecto al costo y la equidad.LIMITACIONES:Limitado a hospitales de cirugía de ileostomía de alto volumen, incapaz de realizar visitas en persona a cada hospital antes y después de la implementación, no considera los factores a nivel del hospital y del paciente que afectan la adopción generalizada de iniciativas de mejora de la calidad.CONCLUSIONES:La integración de marcos científicos de implementación para estudiar rigurosamente las iniciativas de mejora de la calidad puede revelar los determinantes de la adopción generalizada de prácticas basadas en la evidencia. (Traducción-Dr. Aurian Garcia Gonzalez ).

A systematic review comparing cardiovascular disease among informal carers and non-carers.

Exposure to chronic stress increases the risk of cardiovascular disease (CVD). Providing informal care is known to be a stressful activity, but it is not clear whether informal caregiving is associated with CVD risk. This systematic review aimed to summarise and assess the quantitative evidence examining the association between providing informal care to others and CVD incidence in comparison with non-carers. Eligible articles were detected by searching six electronic literature databases (CINAHL, Embase, Global Health, OVID Medline, Scopus, and Web of Science). Two reviewers appraised 1887 abstracts and 34 full-text articles against a set of a priori eligibility criteria to identify articles for inclusion. Quality assessment of included studies was performed using the ROBINS-E risk of bias tool. Nine studies were identified that quantitatively assessed the association between providing informal care and CVD incidence in comparison to not providing informal care. Overall, there was no difference in the incidence of CVD between carers and non-carers across these studies. However, within the subgroup of studies that examined care provision intensity (hours/week) higher CVD incidence was observed for the most intense caregiving group compared to non-carers. One study examined only CVD-related mortality outcomes, observing a reduction in mortality for carers compared to non-carers. More research is required to explore the relationship between informal care and CVD incidence.

The association between unpaid labour and mental health in working-age adults in Australia from 2002 to 2020: a longitudinal population-based cohort study.

BACKGROUND: Unpaid labour is a daily part of most people's lives, none more so than for women. Yet, in comparison to paid work, the effect of unpaid labour on mental health is an under-researched area. This study aims to address key gaps in the extant literature, examining how unpaid labour is associated with mental health in working-age men and women, and whether gender differences exist. METHODS: In this longitudinal population-based cohort study, 19 waves of the Household, Income, and Labour Dynamics in Australia (HILDA) survey were used to employ a fixed effects regression analysis to examine the associations between unpaid labour and mental health in working-age (aged 25-64 years) Australian adults. Mental health was assessed using the MHI-5 scale. Both the individual and the combined effects of four different domains of unpaid labour (household work, childcare, care for adults, and outdoor tasks) were interrogated, as were the gender differences. FINDINGS: Of the 37 352 participants (297 036 observations) in waves 2002-20 of the HILDA Survey, 22 832 people (190 207 observations) were aged 25-64 years, and after excluding participants with missing data, 21 014 participants (150 163 observations) were included in the analysis. Increasing time in household work was negatively associated with mental health in both men (ß coefficient=-0·026 [95% CI -0·04 to -0·01]) and women (ß coefficient=-0·009 [-0·02 to 0·001]), as was care for adults (disabled or older people) in women (ß coefficient=-0·027 [-0·04 to -0·01]). Conversely, increasing time in childcare for women (ß coefficient=0·016 [0·01 to 0·02]) and outdoor tasks for men, was positively associated with mental health (ß coefficient=0·067 [0·04 to 0·09]). A null finding for the overall cumulative total unpaid labour exposure for both men and women was probably attributable to the opposing direction of effects between the individual domains that constituted the total load. INTERPRETATION: This study reveals considerable variance and nuance in how different domains of unpaid labour affect mental health, as well as continued inequity in the division of unpaid labour in households, with women doing considerably more unpaid labour than men. This study also exposes important challenges associated with measuring and understanding total (combined) unpaid labour as a determinant of health. FUNDING: University of Melbourne Research Training Scholarship, Australian Research Council Discovery Early Career Award, Australian Research Council Linkage Project.

Gender identity and sexual orientation: a glossary.

Gender and sexually diverse populations remain understudied and under-represented in research. This is attributable not only to significant and ongoing data collection limitations, where large population-based studies fail to ask adequate questions around gender and sexuality, but also due to continuously evolving terminology in this space. This glossary takes a preliminary step in rectifying these issues by defining and clarifying the application and understanding of key terms related to gender, gender identity, expression and sexuality. In doing so, this glossary provides a point of reference for understanding key differences in gender and sexually diverse terminology to (1) help guide researchers and practitioners in the use and understanding of terms and (2) facilitate the utility of more respectful, inclusive and consistent language application across the public health arena.

Rescue Improvement Conference: A Novel Tool for Addressing Failure to Rescue.

OBJECTIVE: To understand the effectiveness of Rescue Improvement Conference, a forum that addresses FTR. SUMMARY OF BACKGROUND DATA: Every year over 150,000 patients die after elective surgery in the United States. FTR is the phenomenon whereby delayed recognition and/or response to serious surgical complications leads to a progressive cascade of adverse events culminating in death. Rescue Improvement Conference is an adapted version of the Ottawa-style morbidity and mortality conference, designed to address common contributors to FTR: ineffective communication and inadequate problem solving. METHODS: Mixed methods data were used to evaluate Rescue Improvement Conference, a bi-monthly forum that was first introduced in our academic medical center in 2018. Conference effectiveness data were collected via survey and open-text responses after 5 conferences between September 2018 and February 2020. We focused on 5 indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and actionable opportunities for improvement. Twelve surgical faculty and house staff also provided feedback during semi-structured interviews. Qualitative data were analyzed using thematic analysis. RESULTS: Conference attendees (N = 140) felt that Rescue Improvement Conference was effective-all 5 indicators had mean scores above 5 on Likert scales. The qualitative data supports the quantitative findings, and 3 additional themes emerged: Rescue Improvement Conference enables the representation of diverse voices, promotes interdisciplinary collaboration, and encourages multilevel problem solving. CONCLUSIONS: Rescue Improvement Conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications by providing stakeholders a forum to identify and discuss factors that contribute to FTR.

Prioritizing evidence-based practices for acute respiratory distress syndrome using digital data: an iterative multi-stakeholder process.

BACKGROUND: Evidence-based practices (EBPs) for patients receiving invasive mechanical ventilation vary in the quality of their underlying evidence and ease of implementation. RESEARCH QUESTION: How do researchers and clinicians prioritize EBPs to help guide clinical decision-making and focus implementation efforts to improve patient care using existing, validated measures? STUDY DESIGN AND METHODS: We developed a 4-step rapid method using existing criteria to prioritize EBPs associated with lower mortality and/or shorter duration of invasive mechanical ventilation for patients suffering from acute respiratory failure or acute respiratory distress syndrome. Using different types of data including surveys, we (1) identified relevant EBPs, (2) rated EBPs using the Guideline Implementability Appraisal (GLIA) tool, (3) surveyed practicing ICU clinicians from different hospital systems using a subset of GLIA criteria, and (4) developed metrics to assess EBP performance. In this paper, we describe steps 2 and 3. RESULTS: In step 2, we prioritized 11 EBPs from an initial list of 30, using surveys and ratings among a small group of clinician researchers. In step 3, 42 clinicians from 8 different hospital systems provided assessments of these 11 EBPs which inform the final step of metric development. INTERPRETATION: Our prioritization process allowed us to identify 11 EBPs out of a larger group that clinicians perceive is most likely to help optimize invasive mechanical ventilation and improve the outcomes of this vulnerable patient population. While this method was developed in critical care related to adults receiving invasive mechanical ventilation, it is adaptable to other health contexts.

Longitudinal association between informal unpaid caregiving and mental health amongst working age adults in high-income OECD countries: A systematic review.

Background: Informal unpaid caregivers provide most of the world's care needs, experiencing numerous health and wealth penalties as a result. As the COVID-19 pandemic has highlighted, informal care is highly gendered. Longitudinal evidence is needed to assess the causal effect of caregiving on mental health. This review addresses a gap by summarising and appraising the longitudinal evidence examining the association between unpaid caregiving and mental health among working age adults in high-income Organisation for Economic Co-operation and Development (OECD) countries and examining gender differences. Methods: Six databases were searched (Medline, PsycInfo, EMBASE, Scopus, Web of Science, Econlit) from Jan 1, 2000 to April 1, 2022. Population-based, peer-reviewed quantitative studies using any observational design were included. Population of interest was working age adults. Exposure was any unpaid caregiving, and studies must have had a non-caregiving comparator for inclusion. Mental health outcomes (depression, anxiety, psychological distress/wellbeing) were measurable by validated self-report tools or professional diagnosis. Screening, data extraction and quality assessment (ROBINS-E) were conducted by two reviewers. The study was prospectively registered with PROSPERO (CRD42022312401). Findings: Of the 4536 records screened; 13 eligible studies (133,426 participants) were included. Overall quality of evidence was moderate. Significant between-study heterogeneity precluded meta-analysis, so albatross and effect-direction plots complement the narrative synthesis. Results indicate a negative association between informal unpaid care and mental health in adults of working age. Importantly, all included studies were longitudinal in design. Where studies were stratified by gender, caregiving had a consistently negative impact on the mental health of women. Few studies examined men but revealed a negative effect where an association was found. Interpretation: Our review highlights the need to mitigate the mental health risks of caregiving in working age adults. Whilst men need to be included in further scholarship, reducing the disproportionate caregiving load on women is a crucial requirement for policy development. Funding: Melbourne School of Population and Global Health, Targeted Research Support Grant.

Gender differences in the association between unpaid labour and mental health in employed adults: a systematic review.

Globally, billions of hours are spent on unpaid labour every year, a burden that is disproportionately carried by women. However, the potential health effects of unpaid labour have largely been unexplored. This Review examines the gendered association between unpaid labour and mental health among employed adults. We did a search of six databases and examined the association between different forms of unpaid labour and mental health. 19 studies (totalling 70 310 participants) were included. We found substantial heterogeneity, and low-to-moderate methodological quality, in the existing research. Our Review indicates substantial gender differences in exposure to unpaid labour and confirms persistent inequities in the division of unpaid work. Overall, our findings indicate that, among employed adults, unpaid labour is negatively associated with women's mental health, with effects less apparent for men. Globally, women spend a greater number of hours on unpaid labour; this review suggests that inequities in the division of unpaid labour expose women to greater risk of poorer mental health than men.

Mental health of young informal carers: a systematic review.

PURPOSE: This systematic review aims to assess and evaluate quantitative evidence on the association between informal caregiving and mental health in young people. METHODS: This review was registered in PROSPERO (CRD42021251666). We conducted our search in the following four databases: Medline (PubMed and OVID), EMBASE, PsycInfo and Web of Science. The last search was performed on the 17th of March of 2021. Quantitative studies that focused on carers aged 25 years or less and compared the mental health status of carers and non-carers were eligible for inclusion. Two reviewers independently assessed articles for eligibility and performed the quality assessment using the Risk of Bias tool in Non-Randomised Studies of Exposures (ROBINS-E). RESULTS: We identified a total of ten eligible articles. Mental health outcomes included depression, anxiety and other mental or emotional problems. Nine out of the ten studies showed that being a young carer was consistently associated with poor mental health. However, the overall quality of evidence was low, and longitudinal data were limited to three articles. The primary sources of bias were confounding and outcome measurement. CONCLUSION: Young carers experience poorer mental health outcomes than their non-caring peers. However, we identified an overall lack of quantitative evidence of high methodological rigour. To establish if young caring leads to poor mental health, future research should focus on addressing the identified methodological limitations and understanding the mechanisms explaining these associations. Addressing these gaps can better inform the allocation of appropriate support and resources to optimise the mental health of young carers.

Time-limited trials in the ICU: a mixed-methods sequential explanatory study of intensivists at two academic centres.

OBJECTIVE: To understand intensivist perceptions of the appropriateness of time-limited trials (TLTs)-a strategy to align life-sustaining care with patient goals and values in the midst of clinical uncertainty. DESIGN: We conducted a mixed-methods sequential explanatory study of intensive care unit (ICU) intensivists regarding appropriateness of utilising TLTs in three vignettes centred on invasive mechanical ventilation (IMV); continuous renal replacement therapy (CRRT); and heated high-flow nasal cannula (HHFNC). Semistructured interviews were conducted using the Tailored Implementation of Chronic Diseases framework. Data were analysed using thematic and matrix analysis. SETTING: Two academic medical centres in the USA participated in the randomised surveys and one centre participated in the semistructured interviews. PARTICIPANTS: Pulmonary and critical care intensivists and fellows. PRIMARY AND SECONDARY OUTCOMES: To understand intensivists perceptions of the appropriateness in using TLTs. RESULTS: Of 115 physicians surveyed, 71 initiated the survey and 44 completed the entire survey with a response rate of 38% (N=44/115) and a completion rate of 62% (N=44/71). While 35% (N=23/66) of intensivists had never heard of a TLT, of the intensivists who had heard of a TLT, 77% (N=33/43) had participated in one. In response to the vignettes, appropriateness of using a TLT varied (IMV: 74% (N=46/62); CRRT 78% (N=49/63); HHFNC 92% (N=56/61) as did the durations of the TLT. Semistructured interviews with 11 intensivists revealed having clarity about patient goals and clinical endpoints facilitated successful TLTs while lack of an evidenced-based framework was a barrier. CONCLUSION: More than half of the physicians who responded had conducted or participated in a TLT. To increase the use of TLTs in the ICU, clinicians desire a more robust, evidence-based framework on how to conduct TLTs.

The double burden of poverty and marital loss on the mental health of older Australian women; a longitudinal regression analysis using 17 annual waves of the HILDA cohort.

PURPOSE: Compared to men, older women have poorer mental health and are more vulnerable to poverty, especially when living alone. However, few studies have examined how gender, marital status and poverty are inter-related and are associated with mental health. This study examines the gendered associations between relative poverty, marital status and mental health in older Australians. METHODS: Drawing on 17 waves of the HILDA Survey, fixed-effects longitudinal regression analysis was utilised to examine the association between: (1) relative poverty (< 50% median household income) and mental health (MHI-5); (2) marital status and poverty, in a cohort of Australians aged 65 + years. We then examined effect modification of the association between relative poverty and mental health by marital status. RESULTS: Within-person associations, stratified by gender, showed that women in relative poverty reported poorer mental health than when not in relative poverty, however no association was observed for men. Being divorced/separated was associated with increased odds of relative poverty for women, but not men. Widowhood was strongly associated with relative poverty in women, and also among men, albeit a smaller estimate was observed for men. There was no evidence of effect modification of the relationship between relative poverty and mental health by marital status for either men or women. CONCLUSION: This study provides evidence that relative poverty is a major determinant of mental health in older Australian women. Addressing gender inequities in lifetime savings, as well as in division of acquired wealth post marital loss, may help reduce these disparities.

Psychological Safety in Intensive Care Unit Rounding Teams.

Rationale: Psychological safety is the condition by which members of an organization feel safe to voice concerns and take risks. Although psychological safety is an important determinant of team performance, little is known about its role in the intensive care unit (ICU). Objectives: To identify the factors associated with psychological safety and the potential influence of psychological safety on team performance in critical care. Methods: We performed daily surveys of healthcare providers in 12 ICUs within an integrated health system over a 2-week period. Survey domains included psychological safety, leader familiarity, leader inclusiveness, role clarity, job strain, and teamwork. These data were linked to daily performance on lung-protective ventilation and spontaneous breathing trials. We used regression models to examine the antecedents of psychological safety as well as the influence of psychological safety on both perceived teamwork and actual performance. Results: We received 553 responses from 270 unique providers. At the individual provider level, higher leader inclusiveness (adjusted ß = 0.32; 95% confidence interval [CI], 0.24 to 0.41) and lower job strain (adjusted ß = -0.07, 95% CI, -0.13 to -0.02) were independently associated with greater psychological safety. Higher psychological safety was independently associated with greater perception of teamwork (adjusted ß = 0.30; 95% CI, 0.25 to 0.36). There was no association between team psychological safety and performance on either spontaneous breathing trials (incident rate ratio for each 1-unit change in team psychological safety, 0.85; 95% CI, 0.81 to 1.10) or lung-protective ventilation (incident rate ratio, 0.77; 95% CI, 0.57 to 1.04). Conclusions: Psychological safety is associated with several modifiable factors in the ICU but is not associated with actual use of evidence-based practices.

Evidence-Based Practices for Acute Respiratory Failure and Acute Respiratory Distress Syndrome: A Systematic Review of Reviews.

BACKGROUND: The recent pandemic highlights the essential nature of optimizing the use of invasive mechanical ventilation (IMV) in complex critical care settings. This review of reviews maps evidence-based practices (EBPs) that are associated with better outcomes among adult patients with acute respiratory failure or ARDS on the continuum of care, from intubation to liberation. RESEARCH QUESTION: What EPBs are recommended to reduce the duration of IMV and mortality rate among patients with acute respiratory failure/ARDS? STUDY DESIGN AND METHODS: We identified an initial set of reports that links EBPs to mortality rates and/or duration of IMV. We conducted a review of reviews, focusing on preappraised guidelines, meta-analyses, and systematic reviews. We searched Scopus, CINAHL, and PubMed from January 2016 to January 2019 for additional evidence that has not yet been incorporated into current guidelines. RESULTS: Our initial search produced 61 publications that contained 42 EBPs. We excluded 42 manuscripts during the data extraction process, primarily because they were not associated with improved patient outcomes. The remaining 19 preappraised guidelines, meta-analyses, and systematic reviews met our full inclusion criteria and spanned the continuum of IMV care from intubation to liberation. These contained 20 EBPs, a majority of which were supported with moderate levels of evidence. Of these, six EBPs focused on intubation and escalation of care, such as ventilator management and synchrony; ten EBPs reduced complications associated with IMV, which included spontaneous awakening and breathing trials and early mobility protocols; and four EBPs promoted timely extubation and postextubation recovery. INTERPRETATION: This review describes EBPs that are associated with fewer ventilator days and/or lower mortality rates among patients who received IMV for acute respiratory failure/ARDS. Many of these EBPs are connected across the care continuum, which indicates the need to promote and assess effective implementation jointly, rather than individually.

An acceptability pilot of the facilitating active management in lung illness with engaged surrogates (FAMILIES) study.

Approximately half of the surrogate decision makers of critically ill adults are at risk for negative emotional burden. Decision support and effective surrogate-clinician communication buffers against such experiences. The objective of this study is to evaluate the acceptability of a new surrogate-targeted educational tool that promotes engagement with clinicians and advocacy for 2 evidence-based practices in the provision of mechanical ventilation for acute respiratory failure: spontaneous awakening and breathing trials.A panel of 44 former patients and surrogates of a 20-bed medical intensive care unit in a large academic hospital responded to an online survey. Acceptability was measured on 3 dimensions: attitudes toward the content and delivery of information, objective knowledge translation, and subjective knowledge acquisition.More than 80% of participants found the tool to be easy to read, and over 90% felt that the tool provided actionable recommendations. A significant number of previously unsure participants were able to identify what spontaneous awakening and breathing trials are and when they occur, and 16% to 36% reported significant improvements in their subjective understanding of the target evidence-based practices, after being exposed to the educational tool.This line of work seeks to reduce surrogates' negative emotional burden while also promoting quality critical care. The educational tool provides a promising new way to promote surrogate-clinician communication, by increasing surrogates' knowledge about and encouraging advocacy for evidence-based practices in the provision of mechanical ventilation.

Factors Associated With Nurses' Knowledge of and Perceived Value in Evidence-Based Practices.

BACKGROUND: Little is known about how the education and specialty certification of intensive care unit nurses influence patients' outcomes. OBJECTIVE: To examine the relationships between critical care nurses' education level and specialty certification, their individual psychosocial beliefs about their place on the intensive care unit team (in relation to 3 factors: professional identity, self-efficacy, and role clarity), and their perceptions of evidence-based practices used in the intensive care unit. METHODS: A cross-sectional survey was emailed to nurses in 12 adult intensive care units within 6 hospitals in a single, integrated health care system. RESULTS: Of 268 respondents, 180 (71%) had a bachelor of science degree or higher, and 71 (26%) had critical care certification. Compared with noncertified nurses, certified nurses reported greater knowledge of spontaneous breathing trials (4.6 vs 4.4 on a 5-point scale, P = .03) and lung-protective ventilation (4.2 vs 3.9, P = .05). Certified nurses reported significantly higher self-efficacy (4.5 vs 4.3 on a 5-point scale, P = .001) and role clarity (4.4 vs 4.2, P = .05) than noncertified nurses. Certification was also associated with greater perceived value in specific practices (daily interruption of sedation: adjusted odds ratio 2.5 [95% CI, 1.0-6.3], P = .05; lung-protective ventilation: adjusted odds ratio, 1.9 [95% CI, 1.1-3.3], P = .03). Education level was not associated with greater knowledge of or perceived value in evidence-based practices. CONCLUSIONS: Nursing specialty certification was associated with nurses' individual psychosocial beliefs and their perceptions of evidence-based practices in the intensive care unit, whereas education level was not. Supporting nurses in obtaining specialty certification could assist with the adoption of evidence-based practices as a means to improve quality of care in the intensive care unit.