Measuring Healthcare Experiences Among People With Intellectual Disability: A Rapid Evidence Synthesis of Tools And Methods.

OBJECTIVES: Patient-reported experience measures (PREMs) collect essential data for service and system-wide quality improvement and performance monitoring toward value-based care. However, the experiences of people with intellectual disability, who have high healthcare utilization couple with poorer outcomes, are often omitted from system-wide PREMs and service-wide PREMs data. The use of PREMs instruments for data collection among people with intellectual disability has not been explored. This review aimed to identify and synthesize measurement tools and approaches that have been used to gather patient-reported experience data from people with intellectual disability. METHODS: Rapid evidence assessment was used, in which comprehensive search strategies were applied to electronic databases and gray literature. Narrative synthesis was used with the included articles to address the review aim. RESULTS: A total of 48 documents were included; 26 peer-reviewed journal articles and 22 articles from gray literature. Patient-reported experiences have been gathered from people with intellectual disabilities in relation to specific services or encounters, predominantly using qualitative methods. To date, there is an absence of targeted service- or system-wide surveys. Existing clinic- and condition-specific instruments provide insight for broader application. CONCLUSIONS: Patient experience assessment among people with intellectual disability requires consideration of (1) how individuals are identified and approached, (2) the content, design and structure of measurement instruments, and (3) the process by which data are collected, and (4) how it may be applied to create change. Despite the collection of patient experience data from people with intellectual disability, there is little research available about how this information is later used to support health service improvement. Applying PREMs for quality improvement is critical to realize the improvements to healthcare provision required for people with intellectual disability toward equitable care quality.

Systematic Review of Outcomes for Assessment of Medication Adherence Enhancing Interventions: An ISPOR Special Interest Group Report.

OBJECTIVES: The lack of universal guidance on outcome measures for evaluating medication adherence enhancing interventions (MAEIs) poses a challenge for assessing their effectiveness. This literature review aimed to provide a systematic overview of outcome measures currently used for the value assessment of MAEIs. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE, PsycINFO, Scopus, CINAHL, and Academic Search Complete for randomized and nonrandomized clinical trials, prospective cohort studies, model-based economic evaluations, and value frameworks published in English between January 2010 and September 2020. Two independent reviewers screened all titles and abstracts, followed by a full-text review. Due to the large number of relevant studies, data extraction was limited to articles published between January 2018 and September 2020. We collected data on the general characteristics of the study, the type of intervention, and the outcomes measured. RESULTS: We screened 14 685 records and identified 308 articles for data extraction. Behavioral interventions were the most common (n = 143), followed by educational interventions (n = 110) and mixed-method interventions (n = 73). Outcomes were clustered into 7 categories with medication adherence (n = 286) being the most frequently measured, followed by clinical outcomes (n = 155), health-related quality of life (n = 57), resource use (n = 43), patient satisfaction (n = 31), economic outcomes (n = 18), and other outcomes (n = 76). CONCLUSIONS: Various outcomes measures have been used to evaluate MAEIs, with only a small number of studies exploring economic and patient-reported outcomes. Future research is warranted to develop a consensus-based set of criteria for assessing MAEIs to facilitate the comparison of interventions and enable informed decision making.

Approaches for enhancing patient-reported experience measurement with ethnically diverse communities: a rapid evidence synthesis.

BACKGROUND: Patient-reported experience measures (PREMs) are used to drive and evaluate unit and organisational-level healthcare improvement, but also at a population level, these measures can be key indicators of healthcare quality. Current evidence indicates that ethnically diverse communities frequently experience poorer care quality and outcomes, with PREMs data required from this population to direct service improvement efforts. This review synthesises evidence of the methods and approaches used to promote participation in PREMs among ethnically diverse populations. METHODS: A rapid evidence appraisal (REA) methodology was utilised to identify the disparate literature on this topic. A search strategy was developed and applied to three major electronic databases in July 2022 (Medline; PsycINFO and CINAHL), in addition to websites of health agencies in Organisation for Economic Co-operation and Development countries via grey literature searches. A narrative evidence synthesis was undertaken to address the review question. RESULTS: The review resulted in 97 included studies, comprised 86 articles from electronic database searches and 11 articles from the grey literature. Data extraction and synthesis identified five strategies used in PREM instruments and processes to enhance participation among ethnically diverse communities. Strategies applied sought to better inform communities about PREMs, to create accessible PREMs instruments, to support PREMs completion and to include culturally relevant topics. Several methods were used, predominantly drawing upon bicultural workers, translation, and community outreach to access and support communities at one or more stages of design or administration of PREMs. Limited evidence was available of the effectiveness of the identified methods and strategies. PREMs topics of trust, cultural responsiveness, care navigation and coordination were identified as pertinent to and frequently explored with this population. CONCLUSIONS: The findings provide a basis for a maturity model that may guide change to increase participation of ethnically diverse communities in PREMs. In the short-medium term, health systems and services must be able to recognise and respond to cultural and linguistic diversity in the population when applying existing PREMs. In the longer-term, by working in collaboration with ethnically diverse communities, systems and services may co-create adapted or novel PREMs that tackle the factors that currently inhibit uptake and completion among ethnically diverse communities.

Co-design of an intervention to improve patient participation in discharge medication communication.

Patients can experience medication-related harm and hospital readmission because they do not understand or adhere to post-hospital medication instructions. Increasing patient medication literacy and, in turn, participation in medication conversations could be a solution. The purposes of this study were to co-design and test an intervention to enhance patient participation in hospital discharge medication communication. In terms of methods, co-design, a collaborative approach where stakeholders design solutions to problems, was used to develop a prototype medication communication intervention. First, our consumer and healthcare professional stakeholders generated intervention ideas. Next, inpatients, opinion leaders, and academic researchers collaborated to determine the most pertinent and feasible intervention ideas. Finally, the prototype intervention was shown to six intended end-users (i.e. hospital patients) who underwent usability interviews and completed the Theoretical Framework of Acceptability questionnaire. The final intervention comprised of a suite of three websites: (i) a medication search engine; (ii) resources to help patients manage their medications once home; and (iii) a question builder tool. The intervention has been tested with intended end-users and results of the Theoretical Framework of Acceptability questionnaire have shown that the intervention is acceptable. Identified usability issues have been addressed. In conclusion, this co-designed intervention provides patients with trustworthy resources that can help them to understand medication information and ask medication-related questions, thus promoting medication literacy and patient participation. In turn, this intervention could enhance patients' medication self-efficacy and healthcare utilization. Using a co-design approach ensured authentic consumer and other stakeholder engagement, while allowing opinion leaders and researchers to ensure that a feasible intervention was developed.

Co-designing strategies to improve advance care planning among people from culturally and linguistically diverse backgrounds with cancer: iCanCarePlan study protocol.

BACKGROUND: Advance care planning (ACP) describes the process of supporting individuals at any age or stage of health to consider and share their personal values, life goals, and preferences regarding future health care. Engaging in ACP is associated with better-quality of care in which people receive care in lines with their wishes, values and preferences. Direct translations of ACP guides and resources do not attend to the considerable inter- and intra-ethnic variations in cultural and religious or spiritual beliefs that shape preferences among people from culturally and linguistically diverse (CALD) backgrounds. ICanCarePlan is a three-year project that aims to determine the prevalence of ACP documentation among people from CALD backgrounds with cancer, identify resources available and their use to support ACP among CALD communities, identify barriers and facilitators of person-centred ACP, and to develop, through co-design with consumers and clinicians, approaches that enhance the process ACP for people from CALD backgrounds. METHOD: A mixed-method sequential approach will be used comprising of four studies. Study one is retrospective medical record review of approximately 1500 medical records to establish the prevalence of ACP documentation among CALD patient records in cancer services. Study two is a document analysis synthesising the resources available in the Australian health system to support ACP. Study three is a qualitative study with healthcare staff and consumers to explore barriers and enablers of person-centred ACP. Evidence generated from studies one to three will inform the conduct of co-design with stakeholders to develop approaches to improve ACP processes among CALD communities. Language, technical and financial support for meaningful involvement with consumers from CALD backgrounds throughout this project is outlined. A plan for distress management is also made due to sensitive nature of the topic. The research project has also established a project steering group consisting of three consumer members who are from CALD backgrounds. DISCUSSION: The project will address a national priority issue for a growing population of CALD communities in Australia. The project will provide novel evidence of ACP among CALD communities and novel strategies developed with stakeholders to enhance uptake and experiences of ACP.

Medication administration in aged care facilities: A mixed-methods systematic review.

AIM(S): To synthesize aged care provider, resident and residents' family members' perspectives and experiences of medication administration in aged care facilities; to determine the incidence of medication administration errors, and the impact of medication administration on quality of care and resident-centredness in aged care facilities. DESIGN: A mixed-methods systematic review. PROSPERO ID: CRD42023426990. DATA SOURCES: The AMED, CINAHL, MEDLINE, EMBASE, EMCARE, PsycINFO, Scopus and Web of Science core collection databases were searched in June 2023. REVIEW METHODS: Included studies were independently screened, selected and appraised by two researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed, with the Mixed Methods Appraisal Tool was used for critical appraisal. Convergent synthesis of data, thematic synthesis and meta-analysis were performed. RESULTS: One hundred and twenty-eight studies were included (33 qualitative, 85 quantitative and 10 mixed-methods). Five themes were formulated, including 1) Staffing concerns, 2) The uncertain role of residents, 3) Medication-related decision-making, 4) Use of electronic medication administration records and 5) Medication administration errors. Educational interventions for aged care workers significantly reduced medication administration errors, examined across five studies (OR = 0.37, 95%CI 0.28-0.50, p < .001). CONCLUSIONS: Medication administration in aged care facilities is challenging and complex on clinical and interpersonal levels. Clinical processes, medication errors and safety remain focal points for practice. However, more active consideration of residents' autonomy and input by aged care workers and providers is needed to address medication administration's interpersonal and psychosocial aspects. New directions for future research should examine the decision-making behind dose form modification, aged care workers' definitions of medication omission and practical methods to support residents' and their family members' engagement during medication administration. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: It is important that medication administration in aged care facilities be more clearly acknowledged as both a clinical and interpersonal task. More attention is warranted regarding aged care workers clinical decision-making, particularly concerning dose form modification, covert administration and medication omissions. Resident-centred care approaches that support resident and family engagement around medication administration may improve adherence, satisfaction and quality of care. IMPACT: What Problem Did the Study Address? Medication administration in aged care facilities is a complex clinical and interpersonal activity. Still, to date, no attempts have been made to synthesize qualitative and quantitative evidence around this practice. There is a need to establish what evidence exists around the perspectives and experiences of aged care workers, residents and resident's family members to understand the challenges, interpersonal opportunities and risks during medication administration. What Were the Main Findings? There is a lack of empirical evidence around resident-centred care approaches to medication administration, and how residents and their families could be enabled to have more input. Dose form modification occurred overtly and covertly as part of medication administration, not just as a method for older adults with swallowing difficulties, but to enforce adherence with prescribed medications. Medication administration errors typically included medication omission as a category of error, despite some omissions stemming from a clear rationale for medication omission and resident input. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The findings of this systematic review contribute to aged care policy and practice regarding medication administration and engagement with older adults. This review presents findings that provide a starting point for aged care workers in regards to professional development and reflection on practice, particularly around clinical decision-making on dose form modification, medication administration errors and the tension on enabling resident input into medication administration. For researchers, this review highlights the need to develop resident-centred care approaches and interventions, and to assess whether these can positively impact medication administration, resident engagement, adherence with prescribed medications and quality of care. REPORTING METHOD: This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution to this systematic review.

Health professionals' perceptions of the development needs of incident reporting software: A qualitative systematic review.

AIM: To systemically identify and synthesize information on health professionals' and students' perceptions regarding the development needs of incident reporting software. DESIGN: A systematic review of qualitative studies. DATA SOURCES: A database search was conducted using Medline, CINAHL, Scopus, Web of Science and Medic without time or language limits in February 2023. REVIEW METHODS: A total of 4359 studies were identified. Qualitative studies concerning the perceptions of health professionals and students regarding the development needs of incident reporting software were included, based on screening and critical appraisal by two independent reviewers. A thematic synthesis was conducted. RESULTS: From 10 included studies, five analytical themes were analysed. Health professionals and students desired the following improvements or changes to incident reporting software: (1) the design of reporting software, (2) the anonymity of reporting, (3) the accessibility of reporting software, (4) the classification of fields and answer options and (5) feedback and tracking of reports. Wanted features included suitable reporting forms for various specialized fields that could be integrated into existing hospital information systems. Rapid, user-friendly reporting software using multiple reporting platforms and with flexible fields and predefined answer options was preferred. While anonymous reporting was favoured, the idea of reporting serious incidents with both patient and reporter names was also suggested. CONCLUSION: Health professionals and students provided concrete insights into the development needs for reporting software. Considering the underreporting of healthcare cases, the perspectives of healthcare professionals must be considered while developing user-friendly reporting tools. Reporting software that facilitates the reporting process could reduce underreporting. REPORTING METHOD: The ENTREQ reporting guideline was used to support the reporting of this systematic review. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution. PROTOCOL REGISTRATION: The protocol is registered in the International Prospective Register of Systematic Reviews with register number CRD42023393804.

Nurses engaging with referral letters and discharge summaries: A qualitative study.

AIMS: To investigate the ways that nurses engage with referral letters and discharge summaries, and the qualities of these documents they find valuable for safe and effective practice. DESIGN: This study comprised a qualitative, case-study design within a constructivist paradigm using convenience sampling. METHODS: Interviews were conducted with nurses to investigate their practices relating to referral letters and discharge summaries. Data collection also involved nurses' examination and evaluation of a diverse range of 10 referral letters and discharge summaries from medical records at two Australian hospitals through focus-group sessions. The data were transcribed and analysed inductively. RESULTS: In all, 67 nurses participated in interviews or focus groups. Nurses indicated they used referral letters and discharge summaries to inform their work when caring for patients at different times throughout their hospitalisation. These documents assisted them with verbal handovers, to enable them to educate patients about their condition and treatment and to provide a high standard of care. The qualities of referral letters and discharge summaries that they most valued were language and communication, an awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. CONCLUSION: Nurses relied on referral letters and discharge summaries to ensure safe and effective patient care. They used these documents to enhance their verbal handovers, contribute to patient care and to educate the patient about their condition and treatment. They identified several qualities of these documents that assisted them in maintaining patient safety including clarity and conciseness of information. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: It is important that referral letters and discharge summaries are written clearly, concisely and comprehensively because nurses use them as key sources of evidence in planning and delivering care, and in communicating with other health professionals in relaying goals of care and implementing treatment plans. IMPACT: Nurses reported that they regularly used referral letters and discharge summaries as valuable sources of evidence throughout their patients' hospitalisation. The qualities of these documents which they most valued were language and communication styles, awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. This research has important impact on the patient experience in relation to encouraging effective referral letter and discharge summary writing. REPORTING METHOD: We have adhered to the relevant EQUATOR guidelines through the SRQR reporting method. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

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

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

Nurse management of noradrenaline infusions in intensive care units: An observational study.

BACKGROUND: Intensive care nurse management of noradrenaline (norepinephrine) infusions is a common and essential clinical competency for patient haemodynamic support. Nurses titrate and wean noradrenaline infusions to a target blood pressure in a dynamic, high-risk, and unpredictable environment. Titration and weaning are complex interventions, and blood pressure goals are often variable. OBJECTIVES: The aim was to examine how nurses used blood pressure targets when escalating, weaning, and titrating noradrenaline in intensive care patients admitted for haemodynamic management and explore patient blood pressure responses to changes in noradrenaline doses. METHODS: In this naturalistic observational study, noradrenaline dose changes were classified as escalation, weaning, and titration changes and analysed to explore nursing practice. The study was undertaken in two adult medical/surgical intensive care units in Melbourne, Australia. Participants included intensive care nurses and patients who received noradrenaline infusions for haemodynamic support. RESULTS: Observations of 14 nurse-patient dyads provided 25 h of blood pressure and noradrenaline dose data. Patient participants received weight-adjusted maximum noradrenaline doses of between 0.06 mcg/kg/min and 0.87 mcg/kg/minute, with those in the escalation group receiving dose increases of up to 5 mcg to achieve blood pressure goals. During weaning, patients maintained or increased their blood pressure as noradrenaline doses were decreased. Nurses consistently maintained blood pressures at higher than target goals, and despite constant fluctuations, they only documented blood pressure readings hourly. CONCLUSIONS: Intensive care nurses managed noradrenaline to achieve mean arterial pressure targets that were variable and not evidence based. The disconnection between observed blood pressure fluctuations and nurse documentation of patient blood pressures was reflected in titration practices. Discrepancies between documented and actual blood pressures raised issues about data used by nurses and doctors to inform clinical practice on noradrenaline management.

A retrospective descriptive study of medical record documentation of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds.

INTRODUCTION: Communication between clinicians and family members of patients about treatment limitation practices is essential to care-planning and decision-making. For patients and family members from culturally diverse backgrounds, there are additional considerations when communicating about treatment limitations. OBJECTIVE: The objective of this study was to explore how treatment limitations are communicated with family members of patients from culturally diverse backgrounds in intensive care. METHODS: A descriptive study using a retrospective medical record audit was undertaken. Medical record data were collected from patients who died in 2018 in four intensive care units in Melbourne, Australia. Data are presented using descriptive and inferential statistics and progress note entries. RESULTS: From 430 adult deceased patients, 49.3% (n = 212) of patients were born overseas, 56.9% (n = 245) identified with a religion, and 14.9% (n = 64) spoke a language other than English as their preferred language. Professional interpreters were used in 4.9% (n = 21) of family meetings. Documentation about the level of treatment limitation decisions were present in 82.1% (n = 353) of patient records. Nurses were documented as present for treatment limitation discussions for 49.3% (n = 174) of patients. Where nurses were present, nurses supported family members, including reassurance that end-of-life wishes would be respected. There was evidence of nurses coordinating healthcare activities and attempting to address and resolve difficulties experienced by family members. CONCLUSIONS: This is the first known Australian study to explore documented evidence of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds. Many patients have documented treatment limitations, yet there are a proportion of patients who die before treatment limitations can be discussed with family, which may influence the timing and quality of end-of-life care. Where language barriers exist, interpreters should be used to better ensure effective communication between clinicians and family. Greater provision for nurses to engage in treatment limitation discussions is required.

Associations between potentially inappropriate prescribing and increased number of medications with postdischarge health outcomes among geriatric rehabilitation inpatients: RESORT study.

AIMS: Older adults are vulnerable to medication-related harm mainly due to high use of medications and inappropriate prescribing. This study aimed to investigate the associations between inappropriate prescribing and number of medications identified at discharge from geriatric rehabilitation with subsequent postdischarge health outcomes. METHOD: RESORT (REStORing health of acutely unwell adulTs) is an observational, longitudinal cohort study of geriatric rehabilitation inpatients. Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were measured at acute admission, and at admission and discharge from geriatric rehabilitation, using Version 2 of the STOPP/START criteria. RESULTS: In total, 1890 (mean age 82.6 ± 8.1 years, 56.3% female) were included. The use of at least 1 PIM or PPO at geriatric rehabilitation discharge was not associated with 30-day and 90-day readmission and 3-month and 12-month mortality. Central nervous system/psychotropics and fall risk PIMs were significantly associated with 30-day hospital readmission (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.09-2.15), and cardiovascular PPOs with 12-month mortality (AOR 1.34; 95% CI 1.00-1.78). Increased number of discharge medications was significantly associated with 30-day (AOR 1.03; 95% CI 1.00-1.07) and 90-day (AOR 1.06; 95% CI 1.03-1.09) hospital readmissions. The use and number of PPOs (including vaccine omissions) were associated with reduced independence in instrumental activities of daily living scores at 90-days after geriatric rehabilitation discharge. CONCLUSION: The number of discharge medications, central nervous system/psychotropics and fall risk PIMs were significantly associated with readmission, and cardiovascular PPOs with mortality. Interventions are needed to improve appropriate prescribing in geriatric rehabilitation patients to prevent hospital readmission and mortality.

The management of pain during pediatric hematopoietic stem cell transplantation: A qualitative study of contextual factors that influenced pain management practices.

BACKGROUND: Children hospitalized following hematopoietic stem cell transplantation (HSCT) experience complex and prolonged pain in response to the intensity of this treatment. OBJECTIVES: To describe how pain was managed for children during HSCT therapy and how contextual factors related to the clinical environment influenced healthcare providers' and parents' pain management practices. METHODS: A qualitative case study was conducted and involved semi-structured interviews at two time points following transplantation (30 and 90 days) with parents (n = 10) and naturalistic observations of pain-related care provided to children (n = 29) during HSCT therapy by their healthcare providers (n = 10). Semi-structured interviews were also conducted with healthcare providers (n = 14). RESULTS: The effectiveness of pain management interventions was hindered by the multifactorial nature of pain children experienced, a gap in the provision of psychosocial interventions for pain and a lack of evidence-based guidelines for the sustained, and often long-term, administration of opioids and adjuvant medications. Misconceptions were demonstrated by healthcare providers about escalating pain management according to pain severity and differentiating between opioid tolerance and addiction. Parents were active in the management of pain for children, especially the provision of nonpharmacological interventions. Collaboration with external pain services and the impact of caring for children in protective isolation delayed timely management of pain. CONCLUSIONS: There is a pressing need to create evidence-based supportive care guidelines for managing pain post transplantation to optimize children's relief from pain. If parents and children are to be involved in managing pain, greater efforts must be directed toward building their capacity to make informed decisions.

Use of General Practitioner Telehealth Services During the COVID-19 Pandemic in Regional Victoria, Australia: Retrospective Analysis.

BACKGROUND: In March 2020, the Australian Government expanded general practitioner (GP) telehealth services in response to the COVID-19 pandemic. OBJECTIVE: This study sought to assess use patterns of GP telehealth services in response to changing circumstances (before and during the COVID-19 pandemic and with or without a lockdown) in regional Victoria, Australia. METHODS: We conducted a secondary analysis of monthly Medicare claims data from July 2019 to June 2021 from 140 regional GP practices in Western Victoria. The longitudinal patterns of proportion of GP telehealth consultations stratified by type of consultation (ie, videoconference vs telephone) and by geographical, consumer, and consultation characteristics were analyzed. RESULTS: Telehealth comprised 25.8% (522,932/2,025,615) of GP consultations over the 2-year period. After the introduction of the Australian telehealth expansion policy in March 2020, there was a rapid uptake in GP telehealth services (including telephone and video services), from 0% before COVID-19 to 15% (11,854/80,922) of all consultations in March 2020, peaking at 55% (50,828/92,139) in August 2020. Thereafter, the use of telehealth declined steadily to 31% (23,941/77,344) in January 2021 and tapered off to 28% (29,263/103,798) in June 2021. Telephone services and shorter consultations were the most dominant form, and those aged 15-64 years had higher telehealth use rates than younger or older age groups. The proportion of video consultations was higher during periods with government-imposed lockdowns and higher in the most socioeconomically advantaged areas compared to less socioeconomically advantaged areas. CONCLUSIONS: Our findings support the continuation of telehealth use in rural and regional Australia post pandemic. Future policy must identify mechanisms to reduce existing equity gaps in video consultations and consider patient- and system-level implications of the dominant use of short telephone consultations.

The influence of intensive care unit culture and environment on nurse decision-making when managing vasoactive medications: A qualitative exploratory study.

BACKGROUND: Nurses working in intensive care units make autonomous decisions to manage high-risk vasoactive medications in critically ill patients. Noradrenaline (norepinephrine) is a vasoactive medication commonly administered to patients in intensive care units. The influence of unit culture and environment on nurse-decision-making on noradrenaline (norepinephrine) management is unknown. AIMS: The study aimed to investigate nurses' perceptions of the impact of interpersonal interactions, socialisation, and the intensive care environment on decision-making when managing noradrenaline (norepinephrine). MATERIALS & METHODS: An exploratory qualitative study applied thematic analysis to focus group data. A purposive sample of nineteen nurses participated in four focus groups at two intensive care units in Melbourne, Australia, from March to June 2021. The COREQ checklist was used to guide study development and no patients or members of the public were involved in focus groups. RESULTS: Three themes were generated from the researcher's interaction with data, Nursing and Medications; Culture and Decision-making; and a Safe Practice Environment. Nurses reported decision-making challenges associated with learning to manage noradrenaline (norepinephrine) early in their intensive care career and discussed feelings of isolation due to staffing resources, and the configuration of the intensive care environment. Nurses developed titration and weaning strategies to support decision-making in the absence of evidence-based algorithms. DISCUSSION: Empathetic patient allocation early in nurses' intensive care careers facilitated a safer learning environment, and reduced isolation inherent in single room intensive care units. Nurses developed and used titration and weaning strategies, often learnt from other clinicians to manage practice uncertainty. CONCLUSIONS: Management of noradrenaline (norepinephrine) is core business for intensive care nurses worldwide. Development of titration and weaning strategies by nurses indicated unmet need for guidelines to support decision-making. Identifying contextual elements that impact nurse management of high-risk medications can guide development of environments, resources and policies that support nurse decision-making, and reduce nurse anxiety and disempowerment.

Associations of postoperative delirium with activities of daily living in older people after major surgery: A prospective cohort study.

AIMS: To assess the association of postoperative delirium developed in the post-anaesthetic care unit (PACU) with older patients' ability to perform activities of daily living (ADL) during the first five postoperative days. BACKGROUND: Previous studies have focused on the association between postoperative delirium and long-term function decline, however the association between postoperative delirium and the ability to perform ADL, particularly in the immediate postoperative period, needs further investigation. DESIGN: A prospective cohort study. METHODS: A total of 271 older patients who underwent elective or emergency surgery at a tertiary care hospital in Victoria, Australia, participated in the study. Data were collected between July 2021 and December 2021. Delirium was assessed using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The Katz Index of Independence in Activities of Daily Living (KATZ ADL) scale was used to measure ADL. ADL was assessed preoperatively and daily during the first five postoperative days. The STROBE checklist was used to report this study. RESULTS: Results showed that 44 (16.2%) patients developed new episode of delirium. Postoperative delirium was independently associated with decline in ADL (RR = 2.83, 95% CI = 2.71-2.97; p < 0.001). CONCLUSIONS: Postoperative delirium was associated with a decline in ADL among older people during the first five postoperative days. Screening for delirium in the PACU is essential to identify delirium during the early stages of postoperative period and implement a timely comprehensive plan. RELEVANCE TO CLINICAL PRACTICE: Delirium assessment of older patients in the PACU, and for at least the first five postoperative days, is strongly recommended. We also recommend engagement of patients in a focused physical and cognitive daily activity plan, particularly for older patients undergoing major surgery. PATIENT OR PUBLIC CONTRIBUTION: Patients and nurses helped in data collection at a tertiary care hospital.

Impacts of technology implementation on nurses' work motivation, engagement, satisfaction and well-being: A realist review.

AIM: To examine current literature for causal explanations on how, why and under what circumstances, implementation of a new hospital electronic medical record system or similar technology impacts nurses' work motivation, engagement, satisfaction or well-being. BACKGROUND: Implementation of new technology, such as electronic medical record systems, affects nurses and their work, workflows and inter-personal interactions in healthcare settings. Multiple individual and organisational-level factors can affect technology adoption by nurses and may have negative consequences for nurses and patient safety. DESIGN: Five-step realist review method and Realist And Meta-narrative Evidence Syntheses: Evolving Standards checklist was used to guide this review. Eight initial theories (programme theories) were used as the basis to explore, examine and refine literature from a range of sources. DATA SOURCES: Literature from five databases (APA PsycInfo, CINAHL, Embase, IEEE Xplore and MEDLINE Complete) and grey literature (from 1 January 2000 to 31 October 2021) were systematically searched and retrieved on 4 November 2021. RESULTS: In all, 8980 records were screened at the title and abstract level, of which 1027 full texts were screened and 10 were included in the review. Seven studies assessed concepts in both pre- and post-technology implementation. Most common contexts related to knowledge, rationale and skills to use new technology. Mechanisms that impacted nurses or nursing care delivery included: nurses' involvement in technology implementation processes; nurses' perceptions, understanding and limitations of technology impact(s) on patient care delivery; social supports; skills; implementation attitude and hardware. Work satisfaction was the most frequently examined outcome. An analysis led to nine final programme theories (including two original, six revised and one new programme theory). CONCLUSION: Nurses must be informed about the rationale for new technology and have the knowledge and skills for its use. Understanding nurses' work motivation and attitudes related to technology adoption in the workplace can support work engagement, satisfaction and well-being. IMPLICATIONS FOR THE PROFESSION: Complex contexts and mechanisms play a role in nurses' work motivation, engagement, satisfaction and well-being with the implementation of new technology into healthcare settings. RELEVANCE TO CLINICAL PRACTICE: Nurses, their work and workflows are all influenced by the implementation of new technologies (such as electronic medical records), which in turn has consequences for patient safety and quality of care. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. PROSPERO REGISTRATION NUMBER: CRD42020131875 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131875).

Collaborative practice in type 2 diabetes management in a developing country: A qualitative study of perceptions and attitudes of key stakeholders.

AIMS AND OBJECTIVES: To explore collaborative practice and perceptions and attitudes of key stakeholders on collaboration in type 2 diabetes management in a tertiary care setting. BACKGROUND: Understanding collaborative practice in diabetes care in developing countries helps to design and provide patient-centred and cost-effective care. DESIGN: An exploratory qualitative study. METHODS: Interviews were undertaken with 30 patients and 18 health professionals and policymakers. Thematic data analysis was undertaken to explore collaborative practice and examine participant perspectives on collaboration in diabetes management. We compared the findings with D'Amour's Collaboration Framework to determine the level of collaboration. RESULTS: Most participants reported a lack of collaborative practice in diabetes management, while they appreciated its importance in improving care. Perceptions varied with respect to what constituted collaborative practice. Three themes were identified: (1) perspectives of key stakeholders on current practice of collaboration; (2) impediments to collaborative practice; (3) strategies to improve collaborative practice. Analyses of the themes using D'Amour's Collaboration Framework indicated a low level of collaboration among physicians, nurses, pharmacists and policymakers, which was attributed to workload and time pressures on health professionals, power dynamics and lack of role clarity of all actors in collaborative action. Participants commented on the need to improve collaboration by establishing strong leadership and governance at different healthcare structure levels, which is committed to coordinating collaboration and developing collaborative frameworks and policies that guide collaborative undertaking. CONCLUSIONS: Perceived shortcomings of collaboration were attributed to inadequate resources, power dynamics, a lack of strong team functioning and policies. Participants' positive perceptions provide an opportunity to improve collaborative practice through incorporation of collaborative frameworks and policies. RELEVANCE TO CLINICAL PRACTICE: The findings in this study inform development of tailored and patient-centred diabetes care in tertiary care settings in sub-Saharan Africa. REPORTING METHOD: The study was reported in accordance with the COREQ checklist. PATIENT OR PUBLIC CONTRIBUTION: Patients or the public were not involved in the design, analysis or interpretation of the data in this study. However, patients and healthcare providers participated in pilot interviews, which helped refine the interview guides. The summary of the findings of the study was also discussed with patients and healthcare providers, where they provided feedback.

Applying terror management theory as a framework to understand the impact of heightened mortality salience on children, adolescents, and their parents: A systematic review.

Terror Management Theory (TMT) posits that controlling death anxiety is a driving force behind many aspects of social behavior. The objective in this systematic review was to explore how TMT is used to explain children's, adolescents', and parents' behavior when exposed to situations that increase mortality salience. A systematic search identified 2484 papers; 14 studies met eligibility criteria. Key topics explored were mortality salience, death thoughts, and distal defenses. Findings indicate that adolescents comprehend death and have mortality salience reactions like adults, highlighting the potential for TMT to be used to explain children's and adolescents' social behavior in high-stress situations.

Staff experiences, perceptions of care, and communication in the intensive care unit during the COVID-19 pandemic in Australia.

BACKGROUND: In 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission. AIM: The aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale. METHODS: This was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis. FINDINGS: Four major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods. CONCLUSION: The results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.