Supporting ethical end-of-life care during pandemic: Palliative care team perspectives.

BACKGROUND: Italy was the first European country to be involved with the COVID-19 pandemic. As a result, many healthcare professionals were deployed and suddenly faced end-of-life care management and its challenges. AIMS: To understand the experiences of palliative care professionals deployed in supporting emergency and critical care staff during the COVID-19 first and second pandemic waves. RESEARCH DESIGN: A qualitative descriptive design was adopted, and in-depth interviews were used to investigate and analyse participants' perceptions and points of view. PARTICIPANTS AND RESEARCH CONTEXT: Twenty-four healthcare professionals (physicians, nurses, psychologists, physiotherapists, and spiritual support) from the most affected areas of Italy were recruited via the Italian society of palliative care and researchers' network. ETHICAL CONSIDERATIONS: The University Institutional Board granted ethical approval. Participants gave written informed consent and agreed to be video-recorded. FINDINGS: The overarching theme highlighted participants' experience supporting health professionals to negotiate ethical complexity in end-of-life care. Crucial topics that emerged within themes were: training emergency department professionals on ethical dimensions of palliative and end-of-life care, preserving dying patients' dignity and developing ethical competence in managing end-of-life care. CONCLUSIONS: Our study showed palliative care teams' challenges in supporting health professionals' ethical awareness in emergencies. However, while they highlighted their concerns in dealing with the emergency staff's lack of ethical perspectives, they also reported the positive impact of an ethically-informed palliative care approach. Lastly, this study illuminates how palliative care professionals' clinical and ethical competence might have assisted a cultural change in caring for dying patients during COVID-19 and future emergencies.

Leadership styles' influence on ICU nurses' quality of professional life: A cross-sectional study.

BACKGROUND: Intensive Care Units are emotionally intense environments where professional autonomy and interprofessional collaboration are essential. Nurses are at high risk of burnout, and the level of compassion satisfaction has a deep impact on the quality of their professional life. Although leadership styles and burnout have been the subject of an extensive body of research, there is an existing gap regarding the relationship between leadership strategies and intensive care nurses' quality of working life and the impact on their compassion satisfaction. Specifically, there is a lack of literature in southern European countries concerning the influence of organizational and cultural contexts. AIM: To evaluate the impact of nurse managers' leadership styles on Intensive Care Unit nurses' job satisfaction and compassion satisfaction. DESIGN: A cross-sectional study. METHODS: An online set of validated tests was sent to a non-probabilistic sample of nurses, recruited via the Italian association of intensive care and emergency nursing website. The set of tests consisted of the Empowering Leadership Questionnaire, Compassion Satisfaction Scale, and McCloskey Mueller Satisfaction Scale. Nurses actively working in intensive care and critical care settings were included in this study. ICU managers and leaders were excluded. RESULTS: 308 nurses (response rate 63,2%) completed the questionnaires. Statistical analysis showed that the Leadership dimension of "Showing concern towards the team" had a significant effect on Compassion Satisfaction. In addition, this dimension had an effect on nurses' overall job satisfaction on five out of eight subscales. CONCLUSIONS: Leaders' authentic listening, communication, and participation capabilities have a positive impact on nurses' job and compassion satisfaction. The interest for team well-being, taking time to discuss team concerns, and working closely with the team affects unpredicted factors like working hours, flexibility in shift scheduling, satisfaction about recognition, and career advancement. RELEVANCE TO CLINICAL PRACTICE: Results suggest that nurse managers can draw on/adopt leadership strategies oriented to authentic listening and interaction with the team in order to manage organizational issues, increase nurses' professional quality of life and prevent burnout.

The prevention of falls in patients with Parkinson's disease with in-home monitoring using a wearable system: a pilot study protocol.

BACKGROUND: Parkinson's disease (PD) is a chronic, progressive neurodegenerative condition that gradually worsens motor function and leads to postural instability and, eventually, falls. Several factors may influence the frequency of future falls, such as slowness, freezing of gait, loss of balance, and mobility problems, cognitive impairments, and the number of previous falls. The TED bracelet is an advanced technological wearable device able to predict falls. AIMS: This principal aim is to investigate the feasibility of a full-scale research project that uses the TED bracelet to identify whether individuals with PD are at risk of falling. METHODS: This study will involve a pilot prospective observational study design; the subjects will include 26 patients suffering from mild PD and 26 others with no PD and no gait problems. Data will be collected from the TED bracelet and then compared to a paper-based fall diary. The enrolled participants will have a scheduled outpatient evaluation to collect both clinical and instrumental data as well as biological samples. DISCUSSION: This pilot study could then be implemented in a larger form to further evaluate the effectiveness of the TED device. Finally, it will help further develop gait monitoring systems for people with Parkinson's disease and other neurodegenerative diseases that can affect physical function and mobility, such as dementia and Alzheimer's. CONCLUSIONS: Preventing falls and their complications could lead to major advancements in the quality of home care for patients with PD, which would significantly impact the quality of life of both these patients and their caregivers.

Gender and sex bias in prevention and clinical treatment of women's chronic pain: hypotheses of a curriculum development.

This discursive paper focuses on undergraduate medical education's role in tackling gender bias in clinical practice, specifically preventing and managing from a non-biomedical perspective chronic pain in women. A preliminary web search of medical schools' curricula was performed to identify programs content related to gender bias in pain management. The web search included 10 universities' websites selected from the top 10 rankings QS Universities Rankings 2022 for medical schools. Additionally, a questionnaire was sent to all deans of the selected academic institutions to explore the curriculum content further. The web search, and the lack of response from the deans, highlighted that relevant curriculum components on gender bias and chronic pain needed to be implemented. Therefore, this paper introduces an innovative curriculum development approach designed by the multi-professional research team to be implemented in medical school programs. This novel educational strategy could also cross-contaminate other healthcare practitioners' university programs and, thus, stimulate an interprofessional debate into fostering inclusiveness and equal opportunities in health.

Transforming Nurse Self-Care Through Integration of Spirituality: Lessons From an International Collaboration in Palliative Care.

INTRODUCTION: With growing evidence of compassion fatigue and burnout in health care, it is time for a deeper look at the vital practice of self-care among professionals providing palliative care. The purpose of this study was to provide insights into ways empowerment, caring for self, environment, and building relationships impact well-being among palliative care professionals. METHODS: Interpretative descriptive methods framed focus group interviews, conducted during a conference on palliative care integrative health practices held in Thailand. An interprofessional research team used inductive reasoning processes to analyze the interviews. RESULTS: Three themes emerged from the four focus groups (N = 22): Buddhist Beliefs and Practices, Community-mindedness, and Empowerment. Aspects of spirituality were consistently woven into self-care practices. DISCUSSION: Findings suggest that self-care can be reimagined to include highly personal and unique expressions of spirituality. Health care communities are called to integrate ritual in culturally congruent ways, thus supporting health care professionals to find new sources of meaning, enrichment, and empowerment.

The Family and Community Nurses Cultural Model in the Times of the COVID Outbreak: A Focused Ethnographic Study.

The ageing population, increasingly frail and chronically ill, and COVID-19 pandemic challenges have highlighted national health systems' vulnerability and, more strongly/to a greater extent, the pivotal role of the family and community nurse (FCN). However, the recent introduction of FCNs in primary care settings has yet to be explored in Italy. This study aimed to identify the FCNs' cultural model and its implementation during the COVID-19 outbreak. A focused ethnographic study was performed in a primary care community service in northern Italy. Participants were FCNs (N = 5), patients and caregivers (N = 12). Qualitative data were collected through semi-structured interviews, field notes, observation of FCNs' activities and access to documents. Qualitative analysis identified themes concerned with crucial aspects of FCNs' activities, role implementation, and their relationship with patients and families. This study illuminated how the FCN strategically takes care of and identifies patients' and community needs. Although the COVID-19 outbreak hindered effective FCN project implementation, this study highlighted that the pandemic provided a chance to better identify cultural, organisational and educational weaknesses that need to be addressed to support the full accomplishment of FCNs' scope of practice.

Managing the end of life in COVID patients. The role of palliative care in emergency departments during the pandemic.

Managing COVID-19 patients has been an extremely difficult and dramatic task, especially for emergency departments during the strongest waves of the pandemic in Italy. Medical staff and health professionals were redeployed from their work setting to COVID units; many were overwhelmed by the deaths of so many patients in a very short time. This work aimed to explore palliative care health professionals' and physicians' perceptions of end-of-life care management in COVID units during the first two waves of the pandemic in Italy. Qualitative data was collected through 24 semi-structured in-depth interviews. The participants were palliative care medical and health professionals redeployed, or in a supporting role, COVID units from the most affected areas of northern and central Italy. The interview questions were focused on four thematic areas concerning different aspects of the role and responsibilities of the palliative care specialist (physician and healthcare professional). A brief presentation of the main sociological literature on end-of-life management in hospital contexts will be firstly presented and discussed to offer a theoretical frame. Subsequently, some of the most significant results that emerged from our research will be illustrated concerning the role played by palliative care professionals during the pandemic and the relevance of the palliative care approach in emergency contexts.

Role of Cyclodextrins and Drug Solid State Properties on Flufenamic Acid Dissolution Performance from Tablets.

Flufenamic acid (FFA) is a non-steroidal anti-inflammatory drug characterised by a low solubility and problems of variable dissolution rate and bio-inequivalence. Different FFA batches, obtained by different suppliers, showed different powder characteristics (particle size, shape and surface properties) that may affect its dissolution behaviour from solid dosage forms. Aim of this work was the improvement of FFA solubility and dissolution rate by the use of cyclodextrins (CDs) and the obtainment of an effective tablet formulation by direct compression. Several CDs have been tested, both in solution and in solid state and several binary systems drug-CDs have been obtained with different techniques, with the scope to select the most effective system. Grinding technique with randomly methylated-ß-cyclodextrin (RAMEB) was the only one that allowed the complete drug amorphization, together with the highest improvement in drug dissolution rate, and was then selected for tablets formulation. Conventional and immediate release tablets were obtained and fully characterised for technological properties. In both cases an improved and well reproducible drug dissolution performance was obtained, independently from the FFA supplier and thus no more affected by the differences observed between the original FFA crystalline samples.

"Permission to Touch": Nurses' Perspectives of Interpersonal Contact during Patient Care.

The purpose of this study was to describe nurses' perceptions about the use of interpersonal touch in their clinical practice. A qualitative descriptive approach with content analysis method was used to identify common themes. Registered nurses (N = 22) participated in focus groups and individual interviews. Three themes emerged from the analysis: (a) touch and massage as a resource, (b) individualized boundaries, and (c) professional role conflict. While the approach to touch varied, stories about the positive impacts that touch can have on patient care were consistently evident throughout the data. Implications for practice include incorporating areas from the themes into the development of educational programs focusing on how to integrate touch into practice as a comforting resource, while keeping individual's preferences in mind.

From classroom training to e-learning: a journey through the quality of learning life of nurse students in post-graduate education - A longitudinal qualitative study.

BACKGROUND AND AIM: recent studies regarding COVID-19 experiences of nursing students highlighted the effect of the transition from face-to-face to online education, rather than the complexity of the overall quality of educational life. This study aim investigating of how the students perceive the quality of educational life in the forced online training, searching for any shift of meanings concerning the students learning experience, from the first phase of the sudden transition to online and the online stabilization phase. METHODS: a longitudinal qualitative study, carried during two moments of the online teaching activity forced by COVID-19, the first one in May-June 2020 and the second six months later in January -February 2021. A convenience sample of 24 students attending post-graduate courses for health professions recruited at University of Parma, answered in-depth interviews, videotaped, verbatim transcribed and analyzed using the Braun and Clarke model. RESULTS: five themes emerged from meaning shift of data collection: reactions to change in educational life; factors favoring a new quality of educational life; factors hindering the perception of the quality of educational life; adaptation strategies to the new educational life; tools and strategies to facilitate communication and the absence of the classroom. CONCLUSIONS: participants perceive advantages of online teaching, on quality of their educational life. The issue of how to create opportunities for internship period remains open. Further research to understand online internship and exploring what extent it is essential to propose it in face-to-face modality.

Multidisciplinary team perceptions of the Case/Care Managers' role implementation: a qualitative study.

BACKGROUND AND AIM OF THE WORK: The roles of Case Managers, Care Managers and fledgling Case / Care Managers integrate clinical systems to achieve optimal patient outcomes through the coordinated use of the most appropriate clinical resources. Although the Case and Care Managers roles have been researched, there is still little evidence of the development of the Case / Care Manager in the Italian Healthcare System. Aim of this research is to investigate the perception of healthcare professionals of the implementation of the Case / Care Manager figure and how it operates . RESEARCH DESIGN AND METHODS: The study adopted a qualitative descriptive methodology with a phenomenological approach, using in-depth interviews. Participants (N = 21) were health professionals of multidisciplinary teams from several healthcare contexts in northern and central Italy, in which was activated a Case, Care, or Case / Care Manager role. The study was conducted in December 2020/ January 2021. Results. The themes showed a vision of the Case Manager, even a critical one, as a figure in transformation precisely from Case Management to Case / Care management. The themes underline how the Case / Care Manager represent a facilitator of clinical-therapeutic paths while acting as a reference figure, supporting the patient, his/her family and the multidisciplinary team. CONCLUSIONS: The results of the study confirm the Case / Care Manager as the health professional who deals with care pathways through an integrated, interdisciplinary and personalized approach, placing the person at the centre and thus overcoming a disease-centered approach.

Searching for a professional identity: a qualitative study of the oncology nurses role in a multidisciplinary breast-unit team.

BACKGROUND AND AIMS: Interprofessional collaboration concept in healthcare implies and evoke enhanced nurses' involvement and role consideration. Our research aimed to investigate: 1) the impact of nursing within a multidisciplinary team of breast-unit practice; 2) healthcare team and patients' perceptions of key-features of the interprofessional care pathway. METHODS: A qualitative exploratory approach was adopted. Researchers were involved in the activities of the Breast Unit: department meetings, review of unit guidelines, observation of professional practice and documents. In-depth interviews were conducted with 14 patients and a representative group of 15 healthcare professionals from the unit. Qualitative content analysis was chosen to infer data from interviews' transcripts. RESULTS: The analysis' critical themes showed a very marginal nursing presence and the unfulfilled role of the Case Manager, especially in organizing the patient's journey and facilitating team communication. Furthermore, the lack of shared decision-making, team communication problems and limited inter-professional collaboration indicated the mono-professional management of the breast unit and a devaluation of specialist nurses role in managing patient care. CONCLUSION: The supportive roles of the oncology specialist nurse and case manager are still struggling within the cancer care pathways and multidisciplinary team. Although healthcare organizations attempt to develop and expand these roles, nurses must assess, identify challenges and barriers to navigate through such complex systems. Therefore, the implementation of interprofessional collaboration and a person-centred model of care can also take place through greater socio-cultural awareness and the recognition by health professionals and patients of the specialist nurses role.

"Awareness to touch": A qualitative study of nurses' perceptions of interpersonal professional contact after an experiential training.

AIM: This study aimed to explore nurses' perceptions of touch in their professional practice and how these perceptions were articulated in discourse, among participants who attended a specific training on touch and those who did not. BACKGROUND: Touch is an essential part of nursing practice. Research showed that the use of touch influences patients' general well-being, improving a sense of presence and infusing security and encouragement. Nurses' attitude towards touch influence positively their job satisfaction and reduces burnout syndrome risks. Nevertheless, there are very few studies describing specifically nurses' perceptions and opinions about the use of interpersonal physical contact in the clinical setting. Also, an educational perspective focusing on touch seems missing from nursing curricula and research. DESIGN: A qualitative methodology was adopted. Focus groups were organized to explore how nurses define and interpret touch and its relevance in their professional practice. The findings obtained in a previous quantitative step of this research inspired the formulation of the questions posed to nurse participants. METHODS: Six focus groups were conducted in three Italian hospitals, which also hosted a one-day training on touch. For each hospital, a purposive sampling approach was used to organize two focus groups: one was made up of nurses who attended the training, and one was made up of nurses who did not. Qualitative thematic analysis was used to identify recurring patterns of meaning by which touch is discussed and interpreted in the focus groups. RESULTS: Registered nurses (N = 39) from different clinical experiences participated in six focus groups. The analysis identified four themes: 1) Touch preferences, 2) Touch and Contact as a natural dimension, 3) Touch as a "praxis" and 4) Reflexivity on Touch. All six focus groups showed a general awareness of interpersonal touch and discussed it as a highly valorized (personal and professional) dimension. Specifically, the trained nurses showed a greater variety and richness of their lexicon, a semantic and imaginary repository by which they described their experience and competence. CONCLUSIONS: This study highlights that nurses consider touch as an important, essential part of their practice. Moreover, it suggests that specific training on interpersonal touch in nursing care facilitate nurses to shift their perceptions from a generic, abstract and "personal" dimension, into an articulated, disciplined and specialized practice. This has implications for education on touch in nursing.

A Delphi survey of health education system and interprofessional nurse' role.

BACKGROUND: Interprofessional education in healthcare academic and professional training is renowned to improve collaborative culture. International studies showed the existence of obstacles to establishing interprofessional collaboration and the relevance of Nurses' role in the implementation process. AIM: This study was conducted to explore interprofessional collaboration practice and education perceptions, opinions and awareness of healthcare professionals, such as academics, professional bodies representatives and multidisciplinary team managers. METHODS: A multi-method two-stage approach using: 1) explorative survey and 2) Delphi group technique. A survey questionnaire focusing on interprofessionality in practice and education was administered to a convenience group of students and academics from health degree courses of three universities. Delphi group panellists were selected from a list of experts from three areas (n = 169). The iterative Delphi technique implied three-rounds to reach panel consensus (or not) about the main research topics, starting from expert panel opinions about survey results. RESULTS: The study witnessed nurses' overall large participation (60-75%). Survey results (n = 198) showed participants' willingness to implement interprofessional education programs but controversial visions of how to implement interprofessional culture in healthcare settings. The Delphi survey showed experts' (n = 25) convergent opinions about introducing elements of communication skills and interprofessional culture into academic curricula and improving the presence of non-medical professions among the academic body. Nurses showed ambiguous positions towards concepts of autonomy and shared responsibility. CONCLUSIONS: Our study highlighted interprofessional education implementation obstacles and possible enablers. Nurses' controversial positions may reflect the struggle of the nursing profession to reach permanent academic positions and to support the shift from a medical-centric to a person-centred model of care.

The role of solid state properties on the dissolution performance of flufenamic acid.

Flufenamic acid is a nonsteroidal anti-inflammatory drug characterized by a low solubility and a variable oral bioavailability. Flufenamic acid is present in the commercial products in two polymorphic enantiotropic forms (Form I and III). Bioinequivalence was observed for commercial solid dosage forms due to the different dissolution rate of batches. Aim of this work is the full characterization of the solid state properties of flufenamic acid in order to evidence reasons of its variable dissolution properties. Two different batches of pure drug obtained by different suppliers were fully characterized. In order to evaluate the effect of the technological processes used for tablet production, the powders were submitted to grinding, kneading, and compression. Thermal analysis and X-ray diffraction studies proved that the drug was provided by both suppliers as Form I, Form III is obtained by recrystallization from ethanol or ethanol/water of both batches and no changes were observed after the different mechanical treatments. No difference was observed between the two forms in terms of equilibrium solubility values. Dissolution rate studies evidenced a difference between the two batches due to their different particle size, which disappeared after sieving. Interestingly, a significant difference in terms of intrinsic dissolution rate and surface wettability of the two compacted powders was observed, even after sieving, probably related to a different behavior of the two powder samples under compaction. These results should be taken into account, during a tablet formulation, in order to obtain a reproducible dissolution performance of the drug, regardless of its original supplier.

Niosomal Formulation of a Lipoyl-Carnosine Derivative Targeting TRPA1 Channels in Brain.

The transient receptor potential akyrin type-1 (TRPA1) is a non-selective cation channel playing a pivotal role in pain sensation and neurogenic inflammation. TRPA1 channels expressed in the central nervous system (CNS) have a critical role in the modulation of cortical spreading depression (CSD), which is a key pathophysiological basis of migraine pain. ADM_09 is a recently developed lipoic acid-based TRPA1 antagonist that is able to revert oxaliplatin-induced neuropathic pain and inflammatory trigeminal allodynia. In this context, aiming at developing drugs that are able to target TRPA1 channels in the CNS and promote an antioxidant effect, permeability across the blood-brain barrier (BBB) represents a central issue. Niosomes are nanovesicles that can be functionalized with specific ligands selectively recognized by transporters expressed on the BBB. In this work, the activity of ADM_09 on neocortex cultures was studied, and an efficient formulation to cross the BBB was developed with the aim of increasing the concentration of ADM_09 into the brain and selectively delivering it to the CNS rapidly after parenteral administration.

Prevalence, clinical consequences and management of acute faecal incontinence with diarrhoea in the ICU: The FIRST™ Observational Study.

There are limited data on the incidence and management of acute faecal incontinence with diarrhoea in the ICU. The FIRST™ Observational Study was undertaken to obtain data on clinical practices used in the ICU for the management of acute faecal incontinence with diarrhoea in Germany, UK, Spain and Italy. ICU-hospitalised patients ≥18 years of age experiencing a second episode of acute faecal incontinence with diarrhoea in 24 h were recruited, and management practices of acute faecal incontinence with diarrhoea were recorded for up to 15 days. A total of 372 patients had complete data sets; the mean duration of study was 6.8 days. At baseline, 40% of patients experienced mild or moderate-to-severe skin excoriation, which increased to 63% in patients with acute faecal incontinence with diarrhoea lasting >15 days. At baseline, 27% of patients presented with a pressure ulcer, which increased to 37%, 45% and 49% at days 5, 10 and 15, respectively. Traditional methods (pads, sheets and tubes) were more commonly used compared to faecal management systems during days 1-4 (76% vs. 47% faecal management system), while the use of a faecal management system increased to 56% at days 5-9 and 61% at days 10-15. At baseline, only 26% of nurses were satisfied with traditional management methods compared to 69% with faecal management systems. For patients still experiencing acute faecal incontinence with diarrhoea after 15 days, 82% of nurses using a faecal management systems to manage acute faecal incontinence with diarrhoea were satisfied or very satisfied, compared to 37% using traditional methods. These results highlight that acute faecal incontinence with diarrhoea remains an important healthcare challenge in ICUs in Europe; skin breakdown and pressure ulcers remain common complications in patients with acute faecal incontinence with diarrhoea in the ICU.

Prevalence, management and clinical challenges associated with acute faecal incontinence in the ICU and critical care settings: the FIRST cross-sectional descriptive survey.

OBJECTIVE: To evaluate the prevalence, awareness and management of acute faecal incontinence with diarrhoea (AFId) in the Intensive Care Unit. DESIGN: Cross-sectional descriptive survey design of intensive care units across Germany, Italy, Spain and the United Kingdom. RESULTS: 962 questionnaires were completed by nurses (60%), physicians (29%) and pharmacists or purchasing personnel (11%). The estimated prevalence of AFId ranged from 9 to 37% of patients on the day of the survey. The majority of respondents reported a low-moderate awareness of the clinical challenges associated with AFId. Patients with AFId commonly had compromised skin integrity, which included perineal dermatitis, moisture lesions or sacral pressure ulcers. Reducing the risk of cross-infection and protecting skin integrity were rated as the most important clinical challenges. 49% had no hospital protocol or guideline for AFId management. There was also a low awareness of nursing time spent managing AFId; 60% of respondents estimated that 10-20 minutes are required for managing an AFId episode by 2-3 healthcare staff. CONCLUSIONS: AFId in the critical care setting may be an underestimated problem which is associated with a high use of nursing time.