Evaluation of the Effect of a Safe Medication Strategy on Potentially Inappropriate Medications, Polypharmacy and Anticholinergic Burden for People with Dementia: An Intervention Study.

People with dementia (PWD) are at risk for medication-related harm due to their impaired cognition and frequently being prescribed many medications. This study evaluated a medication safety intervention (including pharmacist medication reconciliation and review) for PWD during an unplanned admission to hospital. This article reports the effect of the intervention on polypharmacy, potentially inappropriate medications (PIMs), and anticholinergic burden scores for PWD. A pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. Polypharmacy, PIMs, and anticholinergic burden were measured at admission, discharge, and three months after discharge. There were 628 participants including 289 at the control site and 339 at the intervention site. Polypharmacy was 95% at admission and 90% at discharge. PIMs at admission were 95-98% across timepoints and decreased significantly at discharge. The mean anticholinergic score decreased significantly between admission (2.40-3.15) and discharge (2.01-2.57). Reduced PIMs at discharge were correlated with reduced anticholinergic burden (rho = 0.48-0.55, p < 0.001). No significant differences were identified between the study and control sites for Polypharmacy, PIMs, and anticholinergic burden rates and scores. High rates of polypharmacy and PIMs in this study indicate a study population with multiple comorbidities. This intervention was feasible to implement but was limited due to difficulty recruiting participants and deaths during the study. Future multisite studies should be designed to recruit larger study samples to evaluate interventions for improving medication safety for PWD and improve outcomes for these vulnerable people.

Does telehealth influence the decision to transfer residents of residential aged care facilities to emergency departments? A scoping review.

BACKGROUND: Emergency Departments (ED) can be crowded places and not ideal environments for Residential Aged Care Facilities (RACF) residents awaiting assessment. Assessment and care planning may be made available via telehealth thereby avoiding unnecessary transfer to ED, without compromising the quality of care for the older person. Telehealth is attractive addition to improving healthcare decision-making in RACFs. OBJECTIVES: The aim of this scoping review is to explore the evidence around the use of telehealth and whether it influences the decision to transfer residents of RACF to ED. METHODS: All peer reviewed literature that focused on RACFs, decision-making and assessment of residents using telehealth in real time, was included. All study designs, pilot studies and some systematic reviews were considered. Databases Medline, Embase and CINAHL were used in this search in June 2022. Search terms were a combination of the population: RACF residents, decision-making and assessments using telehealth, and or transfer to the ED. The search was assisted by a senior university research academic librarian/information specialist and reviewed by senior researchers. The PRISMA-ScR guidelines were used to report this study. RESULTS: Of the 124 articles initially identified, 31 were eligible for inclusion for synthesis. The date range of the included studies was 2001 to 2022, with 15 published in the last five years. Critical appraisal was conducted using the Mixed Methods Appraisal Tool. CONCLUSION: This scoping review has mapped evidence that telehealth has been widely used in multiple settings. The association between the use of telehealth with improved clinical outcomes highlights its potential utility in enhancing care delivery for an older population in RACFs. Telehealth has shown that it can improve the decision-making for residents in RACFS, but more robust research designs are needed. IMPLICATIONS FOR PRACTICE: Using video/telehealth appears to improve RACF staff access to expert clinicians who can then assess and jointly plan care/management that can be provided in the resident's home. Knowledge and skills of RACF staff appear to be improved through joint assessment and decision-making with the use of video/telehealth access to expert clinicians.

Experiences of nurses working in RACFs and EDs utilising visual telehealth consultation to assess the need for RACF resident transfer to ED: A qualitative descriptive study.

AIMS AND OBJECTIVES: This study aimed to explore whether an intervention using visual telehealth improves care outcomes for residents in residential aged care facilities during acute illness events from the perspective of the nurses from residential aged care facilities and emergency departments. The intervention was the addition of visual telehealth, to an already existing outreach service called Aged Care Emergency. BACKGROUND: Older people who are residents of residential aged care facilities commonly experience potentially avoidable visits and hospitalisations. Adopting visual telehealth or telemedicine has emerged as a care transition solution across several domains in health care, including residential aged care. METHOD: This study used an interpretive descriptive methodological approach and was part of a larger study called the PACE-IT project that implemented a visual telehealth assisted model of care in four emergency departments and 16 residential aged care facilities to prevent unnecessary resident presentations to emergency departments. We report findings from six focus groups that explored key issues relating to the experiences of emergency department and residential aged care nurses who participated in the PACE-IT project. This study adhered to COREQ research guidelines. RESULTS: There were four overarching themes that emerged from the six focus groups; facilitated person centred care; built confidence, relationships and trust; enabled bidirectional communication that strengthens decision making, but there were issues with technology access, connectivity and usability between the acute care setting and the residential aged care facility. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences of residential aged care facility and emergency nurses' experiences when using visual telehealth will better inform practice development in aged care, in particular enhancing decision making and increasing safe practices using telehealth. The knowledge gained in this study in terms of enhanced assessments for residents will provide policy makers with valuable insights for future health care planning and implementation of telehealth. TRIAL REGISTRATION: ACTRN12619001692123.

Nurses' recognition and response to unsafe practice by their peers: A qualitative descriptive analysis.

BACKGROUND: Unsafe practice is an important issue for the nursing profession however few studies have sought to identify how nurses recognise and respond to unsafe practice. OBJECTIVES: To identify the behaviours and cues that registered nurses recognise as indications of unsafe practice, perceived factors that contribute to unsafe practice and action nurses take in response. DESIGN: Qualitative descriptive study. SETTINGS: New Zealand health care settings. PARTICIPANTS: New Zealand registered Nurses (n = 13). METHODS: Data were collected via semi-structured interviews and analysis was conducted using constant-comparative and thematic analysis. RESULTS: Nurses identified a range of behaviours, cues, contributing factors and responses to unsafe practice. Three themes emerged from the data: Uncertainty, 'sensing' unsafe practice and disrupted professionalism. CONCLUSION: Understanding the challenges nurses face every day in recognising and responding to unsafe practice in increasingly complex nursing contexts is key to understanding how unsafe practice may be further addressed in clinical practice. Nurses in this study recognised overtly unsafe behaviour and subtle cues as indications of unsafe practice. Participants also identified factors which they perceived contributed to the occurrence of unsafe practice including high workloads and poor skill mix as well as organisational cultures that failed to support safe practice.

Nurses' responses to adolescent distress in an acute child and adolescent mental health inpatient unit: A qualitative interpretive descriptive study.

PURPOSE: To describe observed nursing responses and interventions to adolescent inpatients experiencing distress. METHODS: Thorne's interpretive descriptive approach guided data collection and analysis of nonparticipant observations of a purposive sample of adolescents, and nurses. FINDINGS: Three major themes are presented: engagement: responses and interventions for working with distress; adolescent reactions and nurses' clinical decision making to manage distress; and outcomes: escalation or resolution of distress. CONCLUSIONS: The TAR3 conceptual model developed from this study can guide nurses' responses to distressed adolescents and promote safety, enhance positive outcomes, and reduce the use of coercive interventions.

COVID-19 preparedness in aged care: A qualitative study exploring residential aged care facility managers experiences planning for a pandemic.

AIMS AND OBJECTIVES: The study aims to understand the changing context of RACFs and the role of RACF managers in preparing to confront the COVID-19 pandemic and to provide insights into how the use of visual telehealth consultation might be incorporated to assist with managing whatever might arise. DESIGN: An interpretive descriptive study design was employed, and data were collected using semi-structured interviews conducted via telephone or videoconference. Purposive recruitment targeted clinical managers responsible for the COVID-19 response in RACFs. METHODS: RACF clinical managers were invited to discuss their responses to COVID-19 including the management of RACF and staff. Semi-structured interviews explored the COVID-19-related challenges, the response to these challenges and how telehealth might assist in overcoming some of these challenges. This study followed Thorne's (2008) three-stage process of interpretive description. The COREQ checklist was used in preparing this manuscript. RESULTS: Two main themes were identified. The first theme 'keeping people safe' was comprised of three subthemes; fear and uncertainty, managing the risks and retaining and recruiting staff. The second theme was 'keeping people connected', had two subthemes; being disconnected and isolated and embracing technology. CONCLUSION: Findings from this study provide valuable insight into understanding the context and the challenges for RACFs and the staff as they attempt to keep residents safe and connected with healthcare providers and the outside world. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences of RACF managers in preparing to respond to the pandemic will better inform practice development in aged care in particular the use of telehealth and safe practices during COVID-19. Increased awareness of the challenges faced by RACFs during a pandemic provides policymakers with valuable insights for future planning of pandemic responses.

Nurses' perspectives of recognising and responding to unsafe practice by their peers: A national cross-sectional survey.

AIMS: This study aimed to identify behaviours and cues that nurses recognise as indications of unsafe practice, perceived factors that contribute to unsafe practice and actions nurses take in response. DESIGN: Cross-sectional survey. METHODS: National cross-sectional survey of a random sample of registered nurses (n = 231) in New Zealand, in 2017-2018. The STROBE Checklist was used to report this study. RESULTS: Nurses reported a high rate of episodes of unsafe practices and recognised a range of behaviours and cues that alerted them to the potential for unsafe practice. Several organisational issues were perceived to contribute to unsafe practice occurring. The reporting of episodes of unsafe practice and perceived organisational support was low for nurses compared with managers. CONCLUSION: Failure to recognise and respond to unsafe practice may indicate a tolerance for substandard practice by individual nurses, or by the organisation. Nurses who recognise unsafe practice must be supported by the organisation.

Evaluation of a safe medication strategy intervention for people with dementia with an unplanned admission: Results from the Safe Medication Strategy Dementia Study.

OBJECTIVE: To evaluate whether a safe medication strategy compared with usual care, provided to people with dementia during an unplanned admission, reduces readmissions to hospital and re-presentation to emergency departments within three months. METHODS: A prospective, controlled pre-/post-trial conducted at two regional hospitals in New South Wales, Australia. RESULTS: No treatment effect was seen for time to first re-presentation or readmission within three months (P = .3). Compliance with six strategies applicable for all participants in the intervention phase was 58%. There was no treatment effect for secondary outcomes including dose administration aid use, home medicines review (HMR) requests by general practitioners and completed HMRs; however, they were significantly higher at the intervention site in both phases. CONCLUSION: A bundle of care to improve medication safety in people with dementia did not reduce re-presentations or readmissions within three months.

Evaluation of Carer Strain and Carer Coping with Medications for People with Dementia after Discharge: Results from the SMS Dementia Study.

This study reports carer strain and coping with medications for people with dementia with an unplanned admission to hospital, and it evaluates the impact of a safe medication intervention on carer coping and carer strain. This was a quasi-experimental pre/post-controlled trial that included a survey of carers about managing medications for people with dementia after discharge. For 88 carers who completed surveys, 33% were concerned about managing medications, and 40% reported difficulties with medication management, including resistive behaviours by people with dementia. Dose administration aids were used by 72% of carers; however, only 15% reported receiving a recent home medicines review by a community pharmacist. High carer strain was reported by 74% of carers. Carer comments described many issues that contributed to high carer stress, as well as their engagement in vigilant activities to maintain medication safety. Strategies that can contribute to carers managing medications and reducing their strain include an increased use of dose administration aids, increased provision of home medicines reviews, and increased education of health professionals to provide adequate support and education about managing medications.

PACE-IT study protocol: a stepped wedge cluster randomised controlled trial evaluating the implementation of telehealth visual assessment in emergency care for people living in residential aged-care facilities.

BACKGROUND: Transfer of residential aged-care facility (RACF) residents to Emergency Departments (ED) is common, risky and expensive. RACF residents who present to ED are more likely to have hospital readmissions, longer stays and face major risks related to hospital acquired complications. Aged Care Emergency services (ACE) is a nurse led, protocol- guided, telephone RACF/ED outreach model that has been shown to be effective in reducing hospitalisation and length of hospital stay for RACF residents in the Hunter New England Local Health District, New South Wales (NSW). The Partnerships in Aged-Care Emergency services using Interactive Telehealth (PACE-IT) project enhances ACE by incorporating interactive video assessment and consultation. The PACE-IT project's primary aim is to assess whether augmentation of ACE services through the addition of protocol-guided interactive Visual Telehealth Consultation (VTC) for clinical decision-making, plus telephone follow-up, reduces RACF resident transfers to ED. METHODS: A stepped-wedge cluster randomised controlled trial will be conducted. The intervention will be delivered sequentially to 8 clusters; each cluster comprises one ED and two RACFs in NSW, Australia. The 16 RACFs in the study will be selected for order of implementation using a computer-generated randomisation sequence. A 2-step randomisation process will be undertaken, randomising the hospital EDs first and then randomising the RACFs aligned with each hospital. The PACE-IT intervention comprises: an initial phone call by RACFs to the ACE service in the ED; the ACE service in ED responds with a protocol-guided VTC, a management plan agreed between all participants; an automated consultation summary letter to the General Practitioner and the RACF; a post VTC 24 h follow-up phone call to the RACF. DISCUSSION: If shown to be effective, the intervention has the potential to improve the clinical care and quality of life for residents. Findings will provide high level evidence that will inform sustainable change and broad translation into practice across NSW. It will show how the change has been achieved and highlight success factors for scalability and sustainability. It will inform review of processes, the development of policy and guidelines that will integrate PACE-IT into existing service models in NSW. TRIAL REGISTRATION: The trial is registered with the Australian New Zealand Clinical Trials Registry (Trial ID ACTR N12619001692123 ) 02/12/2020.).

Exploring academics beliefs about the meaning of life to inform mental health clinical practice.

The aim of this research was to understand academic's beliefs about the meaning of life to gain knowledge to inform mental health clinical practice and research. Qualitative research was conducted using descriptive text and interviews from a sample of Australian midlife academic staff from one university who described their beliefs about the meaning of life. Their beliefs included that: life is a journey of self-development, is about religious or non-religious beliefs, is about living well, is about family, love and relationships, and is about making a difference. These findings may be used by mental health clinicians to help clients explore their beliefs about the meaning of life. Consumers with depression may suffer from meaninglessness, existential crises, severe depression and risk suicide. Working on understanding their beliefs about the meaning of life may result in better mental health outcomes for these people.

An evaluation of general practice nurses' knowledge of chronic kidney disease risk factors and screening practices following completion of a case study-based asynchronous e-learning module.

National and international guidelines recommend opportunistic screening for chronic kidney disease to allow for early detection and management. Despite these guidelines, screening for chronic kidney disease in general practice settings is often suboptimal. This paper reports the results of a study that evaluated: (a) the effect of an asynchronous web-based e-learning module on general practice nurses' knowledge about chronic kidney disease risk factors and screening practices; and (b) general practice nurses' perceived satisfaction with the e-learning module. Changes in chronic kidney disease knowledge were assessed using a pre-test and post-test evaluative design, and satisfaction scores were measured on completion of the module. Participants' baseline knowledge scores were poor, with mean pre-test scores of 3.77 (s.d. 1.66) out of 10. Post-test scores revealed a significant improvement (mean difference 1.81, (95% CI: 1.53 - 2.09), P < 0.01); however, overall final scores remained inadequate. Participants highly rated their satisfaction with the design of the module. Our results suggest that an asynchronous web-based e-learning module can improve general practice nurses' knowledge about chronic kidney disease risk factors and screening practice. Efforts are required to increase practice nurses' access to educational opportunities designed to improve knowledge in this area with the aim of increasing opportunistic screening for chronic kidney disease in the general practice setting.

Adolescents' experiences of distress on an acute mental health inpatient unit: A qualitative study.

Adolescents admitted to acute mental health inpatient units can experience episodes of distress for numerous reasons. Little is known about how they attempt to cope with this distress. This paper explores adolescent experiences of distress in an acute mental health inpatient unit. Fifty hours of non-participant observations were conducted and documented using a critical incident technique (CIT) framework. An interpretive descriptive approach was used to analyse the observation data collected. Nineteen episodes of adolescent distress were observed and five themes emerged, of which two will be explored in this paper: clinical contexts and triggers, and coping or help-seeking actions. The findings of this study will help mental health nurses working on acute adolescent units understand how adolescents attempt to cope with, and seek help for, episodes of distress, and enhance early responses to prevent escalation of distress.

Comparison of Potentially Inappropriate Medications for People with Dementia at Admission and Discharge during An Unplanned Admission to Hospital: Results from the SMS Dementia Study.

People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication problems, and unplanned admission to hospital presents an opportunity to address polypharmacy, potentially inappropriate medications (PIMs) and anticholinergic burden. This study aimed to compare PIMS and other medication data for PWD to determine whether these changed during hospitalization. Medications documented in patient's records at admission and discharge were evaluated for PWD recruited to phase one of a prospective quasi-experimental pre/post-controlled trial that was conducted at two regional hospitals in NSW, Australia. The study sample included PWD or cognitive impairment having an unplanned admission to hospital. Data were collected using a purpose developed audit tool for medications and PIMs, and a Modified Anticholinergic Burden Scale. Total participants were 277, and results determined that the cognitive status of PWD is not always detected during an unplanned admission. This may make them more vulnerable to medication problems and poor outcomes. Polypharmacy and PIMS for PWD were high at admission and significantly reduced at discharge. However, PWD should be routinely identified as high risk at admission; and there is potential to further reduce polypharmacy and PIMs during admission to hospital, particularly psychotropic medications at discharge. Future studies should focus on evaluating targeted interventions designed to increase medication safety for PWD.

Registered nurses' experience of mentoring undergraduate nursing students in a rural context: a qualitative descriptive study.

Background: Registered nurses in a rural context are expected to support undergraduate students during clinical placement, however, they may experience challenges that are unique to the rural context. Aim: To describe the registered nurses' experience of mentoring undergraduate nursing students on clinical placements in a rural context. Design: Qualitative descriptive study. Method: Data were collected from nine participants at two rural hospitals in Australia. Individual semi-structured interviews were conducted and content analysis was used to analyse data. Findings: Four categories emerged from the data: 'The challenges of mentoring', 'Supporting students and facilitating learning', 'Supporting registered nurses who mentor undergraduate nursing students' and 'The rewards of mentoring'. Conclusion: The experience of the rural registered nurse mentor is affected by limited staffing and skill mix, the generalist nature of their work, time constraints and lack of information about students. They need flexible strategies, improved communication and information about students attending clinical placements.

Health professionals' perspectives on the discharge process and continuity of care for stroke survivors discharged home in regional Australia: A qualitative, descriptive study.

Many stroke patients are discharged home due to advances in treatment approaches and reduced residual disability. The aim of this study was to understand health professionals' perspectives on the discharge process and continuity of care during the transition between hospital and home for stroke survivors. In this qualitative, descriptive study, we used focus groups with 25 health professionals involved in discharge processes for transition from hospital to home in 2014, in a regional area of Australia. Discontinuity in the discharge process was affected by pressure to discharge patients, discharge medications and associated risks, inadequate or late discharge summaries, and challenges involving carers. Discontinuity in post-discharge services and follow up was affected by availability of post-discharge services, number of services arranged at the time of discharge, general practitioner follow up after discharge, delays and waiting lists, carer problems, and long-term follow up. There were complex organizational barriers to the continuity of care for stroke survivors discharged home. It is important to address these deficits so that stroke survivors and their carers can make the transition home with minimal risk and adequate support following a stroke.

Effects of adverse events in health care on acute care nurses in an Australian context: A qualitative study.

Adverse events in health care significantly impact health professionals who become the second victims of medical error. The aim of the present study was to understand the effects of adverse events in health care on nurses in acute health-care settings in an Australian context. In this qualitative, descriptive study, we used purposeful sampling and recruited 10 acute care nurses. Interviews were conducted from 2011 to 2012 and were recorded, transcribed, and returned to participants to verify their accuracy. Data were categorized and analyzed to determine four emergent themes and subthemes. The four themes were: rescuing patients, effects on nurses, professional responsibility, and needs of nurses. Our analysis indicated that nurses need organizational responses to adverse events, including the provision of information and collegial support after adverse events occur. This will minimize the psychological trauma associated with these events for second victims and support effective communication and collegial working relationships.

Practices and Processes Used in the Return to Work of Injured New South Wales nurses: Are These Consistent With RTW Best Practice Principles?

Purpose Workplace injury and illness rates are high within the nursing profession, and in conjunction with current nursing shortages, low retention rates, and the high cost of workplace injury, the need for effective return to work (RTW) for injured nurses is highlighted. This study aimed to identify current practices and processes used in the RTW of injured nurses, and determine if these are consistent with the seven principles for successful RTW as described by the Canadian Institute for Work & Health. Method As part of a larger cross-sectional study, survey data were collected from New South Wales nurses who had sustained a major workplace injury or illness. Survey questions were coded and matched to the seven principles for successful RTW. Results Of the 484 surveys eligible for analysis, most were from Registered Nurses (52%) in the Public Hospital Sector (48%). Responses indicated four main areas of concern: a commitment to health and safety by the workplace; early and considerate employer contact; provision of modified work; and individual knowledge of and involvement in the RTW process. Positive participant responses to co-worker and supervisor involvement were identified as areas consistent with best practice principles. Conclusions These findings suggest the practices and processes involved in the RTW of injured nurses are inconsistent with best practice principles for RTW, highlighting the need for interventions such as targeted employer education and training for improved industry RTW outcomes.

An exploration of emergency nurses' understanding of the ageing process and knowledge of their older patient: A comparison between regional and metropolitan nurses in Australia.

AIMS: The aims of the present study were to report and compare regional and metropolitan Australian ED nurses' knowledge and understanding of age related characteristics of the older person. BACKGROUND: ED nurses, who have a duty of care to deliver best practices for managing the older person, can be challenged due to the complexities and co-morbidities associated with older person presentations in the ED. Nurses in regional areas may have limited access to continuing education programmes and limited opportunities to attend such programmes. DESIGN: A cross-sectional survey using previously validated instruments (OPACS and Palmore's Facts of Ageing Quiz) was conducted to measure emergency nurses knowledge and perceptions of physical, physiologic, and age related characteristics of older people; and aspects of hospitalisation that affect older people. METHODS: Members of the College of Emergency Nursing Australasia (CENA) were invited to participate in the present study. There were 371 (39%) completed and valid surveys returned. RESULTS: The OPACS results indicate that 66% of ED nurses had a basic knowledge about physical aspects and hospitalisation issues that affect older people. There were 59% correct responses for the Palmore's Facts of Ageing Quiz items measuring knowledge of physiologic and age related characteristics of older people. There were few differences between regional and metropolitan nurses. CONCLUSION: Increased knowledge of ageing is required for emergency nurses to continue to provide adequate care to older patients presenting to the ED to avoid adverse outcomes for these people.