Barriers and facilitators to implementation of a multifaceted nurse-led intervention in acute care hospitals aimed at reducing indwelling urinary catheter use: A qualitative study.

BACKGROUND: It is essential to evaluate the ways in which practice changes are implemented and received in and across contexts, identifying barriers and enablers, and mechanisms for enhancing success. AIM: To provide insights into the experiences of clinicians in implementing a multifaceted bundled urinary catheter care intervention in four acute care hospitals in New South Wales, Australia. METHODS: The catheter care bundle was implemented using a pre- and postintervention study design. The intervention was implemented in all adult inpatient wards, emergency departments and operating theatres of four hospitals. The bundle consisted of an integrated set of evidence-based practices to assist clinicians in making better informed decisions related to catheter insertion, care and removal practices. Focus groups at each participating hospital evaluated the implementation processes from the clinicians' perspective, identifying barriers and enablers to successful implementation. RESULTS: Eight focus groups were held with 35 participants. Four key inter-related themes were identified: early and sustained engagement with key stakeholders; good planning but remaining flexible; managing the burden of practice change; and adopting and sustaining practice change. These themes capture and highlight the complexity and the challenges associated with implementation of the practice change across contexts and the project timeline. CONCLUSION: It is imperative to understand the challenges associated with complex practice change and ways in which implementation can be optimised. This study identified barriers and enablers experienced by staff implementing the bundled intervention. The themes encapsulate factors central to success of practice change within the complex, multilayered healthcare environment. RELEVANCE TO CLINICAL PRACTICE: Key challenges highlight the need for forward planning, strategic engagement of key players, continuing monitoring and feedback together with adequate resourcing tailored to result in sustainable normalisation of the intervention over time. The COREQ checklist for qualitative studies has been used in reporting this study.

Implementation of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in four Australian hospitals: A pre- and postintervention study.

AIMS AND OBJECTIVES: This study aimed to reduce indwelling urinary catheter (IDC) use and duration through implementation of a multifaceted "bundled" care intervention. BACKGROUND: Indwelling urinary catheters present a risk for patients through the potential development of catheter-associated urinary tract infection (CAUTI), with duration of IDC a key risk factor. Catheter-associated urinary tract infection is considered preventable yet accounts for over a third of all hospital-acquired infections. The most effective CAUTI reduction strategy is to avoid IDC use where ever possible and to remove the IDC as early as appropriate. DESIGN: A cluster-controlled pre- and poststudy at a facility level with a phased intervention implementation approach. METHODS: A multifaceted intervention involving a "No CAUTI" catheter care bundle was implemented, in 4 acute-care hospitals, 2 in metropolitan and 2 in rural locations, in New South Wales, Australia. Indwelling urinary catheter point prevalence and duration data were collected at the bedside on 1,630 adult inpatients at preintervention and 1,677 and 1,551 at 4 and 9 months postintervention. This study is presented in line with the StaRI checklist (see Appendix S1). RESULTS: A nonsignificant trend towards reduction in IDC prevalence was identified, from 12% preintervention to 10% of all inpatients at 4 and 9 months. Variability in preintervention IDC prevalence existed across hospitals (8%-16%). Variability in reduction was evident across hospitals at 4 months (between -2% and 4%) and 9 months (between 0%-8%). Hospitals with higher preintervention prevalence showed larger decreases, up to 50% when preintervention prevalence was 16%. Indwelling urinary catheter duration increased as more of the short-term IDC placements were avoided. CONCLUSIONS: Implementation of a multifaceted intervention resulted in reduced IDC use in four acute-care hospitals in Australia. This result was not statistically significant but did reflect a positive trend of reduction. There was a significant reduction in short-term IDC use at 9 months postintervention. RELEVANCE TO CLINICAL PRACTICE: Clinical nurse leaders can effectively implement change strategies that influence patient outcomes. Implementation of the evidence-based "No CAUTI" bundle increased awareness of appropriate indications and provided nurses with the tools to inform decision-making related to insertion and removal of IDCs in acute inpatient settings. Working in partnership with inpatients and the multidisciplinary team is essential in minimising acute-care IDC use.

Topical Analgesic and Local Anesthetic Agents for Pain Associated with Chronic Leg Ulcers: A Systematic Review.

GENERAL PURPOSE: To provide information about the effectiveness of topical analgesic and local anesthetic agents for reducing pain associated with chronic leg ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Distinguish adverse reactions to topical analgesics and local anesthetic agents.2. Evaluate the effectiveness of topical analgesics and local anesthetic agents for pain associated with chronic leg ulcers.3. Identify substances used as topical analgesics and local anesthetic agents and the application of those agents. ABSTRACT: To examine the evidence related to the effectiveness of topical analgesic and topical local anesthetic agents for reducing pain associated with chronic leg ulcers.A systematic search and review of the literature were undertaken using key search terms such as leg ulcers, topical anesthetics, topical analgesics, and pain. Six databases were electronically searched for articles published between January 1990 and August 2019.A total of 23 articles were identified that met the inclusion criteria. Data were extracted using content analysis. Most of the included studies were randomized controlled trials; however, the reported methodology for most of studies was poor, so the validity and reliability of the evidence are uncertain. Lidocaine/prilocaine cream, ibuprofen foam, and morphine gel were the most examined topical agents. Lidocaine/prilocaine cream significantly improved wound-related pain compared with all other studied agents. For topical analgesic agents, ibuprofen foam reduced chronic leg ulcer pain significantly, whereas morphine gel was ineffective.Lidocaine/prilocaine cream and ibuprofen foam are effective agents for reducing wound-related pain associated with chronic leg ulcers. Effective use of topical agents could reduce the need for systemic pain relief agents, mitigating potential adverse effects, while giving clinicians another treatment option to manage wound-related pain associated with chronic leg ulcers.

To examine the evidence related to the effectiveness of topical analgesic and topical local anesthetic agents for reducing pain associated with chronic leg ulcers. A systematic search and review of the literature were undertaken using key search terms such as leg ulcers, topical anesthetics, topical analgesics, and pain. Six databases were electronically searched for articles published between January 1990 and August 2019. A total of 23 articles were identified that met the inclusion criteria. Data were extracted using content analysis. Most of the included studies were randomized controlled trials; however, the reported methodology for most of studies was poor, so the validity and reliability of the evidence are uncertain. Lidocaine/prilocaine cream, ibuprofen foam, and morphine gel were the most examined topical agents. Lidocaine/prilocaine cream significantly improved wound-related pain compared with all other studied agents. For topical analgesic agents, ibuprofen foam reduced chronic leg ulcer pain significantly, whereas morphine gel was ineffective. Lidocaine/prilocaine cream and ibuprofen foam are effective agents for reducing wound-related pain associated with chronic leg ulcers. Effective use of topical agents could reduce the need for systemic pain relief agents, mitigating potential adverse effects, while giving clinicians another treatment option to manage wound-related pain associated with chronic leg ulcers.

Variations in indwelling urinary catheter use in four Australian acute care hospitals.

AIMS AND OBJECTIVES: To identify the point prevalence of indwelling urinary catheters (IDCs) in adult inpatients in acute care hospitals, and to describe the indications for IDC insertion based on patient age, gender, specialty and hospital. BACKGROUND: Catheter-associated urinary tract infections (CAUTIs) are preventable healthcare-associated infections. IDC duration is the strongest predictor of CAUTI, and little is known about characteristics of patients who receive an IDC. DESIGN: Two single-day point prevalence surveys collected baseline patient data as part of a larger pre-post control-intervention study. METHODS: Surveys were conducted at four acute care hospitals in NSW, Australia, for all adult patients. Data collection included IDC presence, insertion details and urine culture collection. Point prevalence data were linked with electronically extracted patient demographic data. This study is presented in line with STROBE checklist (See Supplementary File 1). RESULT: Data from 1,630 patients were analysed, with 196 patients (12%) identified as having an IDC on the survey dates. IDC prevalence rates were higher in males (13%) than in females (11%). Critical care had the highest rate of patients with IDCs (42%). Urine cultures were collected in 70 patients with an IDC (43%). CONCLUSIONS: Findings indicated similar rates of IDC use in males and females, and there was no significant difference in age between patients with or without an IDC. However, indication for IDC varied by patient age and gender. High rates of urine culture collection may represent routine collection. RELEVANCE TO CLINICAL PRACTICE: IDC use is found across genders, all age groups and specialties. Nurses should be aware that any of their patients may have an IDC and be particularly aware of certain indications based on patient age and gender. Routine urine culture collection is not advised, and instead, nurses should be guided by clinical decision-making tools.

The Effectiveness of EMLA as a Primary Dressing on Painful Chronic Leg Ulcers: A Pilot Randomized Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of the eutectic mixture of local anesthetics (EMLA; Aspen Pharmacare, St. Leonards, New South Wales, Australia) as a primary dressing on painful chronic leg ulcers. DESIGN: A pilot randomized controlled trial. SETTING: The study was conducted across 6 community nursing procedure clinics located in a community nursing service in New South Wales, Australia. PARTICIPANTS: Sixty participants with painful chronic leg ulcers of varied etiology were recruited into the study. INTERVENTION: Participants were randomly assigned to an intervention (daily EMLA use for 4 weeks as a primary dressing) or a standard wound care group. MAIN OUTCOME MEASURE: The effectiveness of EMLA on wound-related pain intensity before, during, and after dressing change. MAIN RESULTS: Mean pain scores were similar between the 2 groups at baseline (P = .84). During dressing change, mean pain scores across the 4-week intervention period were significantly lower in the intervention compared with the control group (intervention group: mean, 3.39 [SD, 2.16]; control group: mean, 4.82 [SD, 2.27]; P = .02). Mean pain scores after dressing change were also significantly lower for the intervention group over the 4-week intervention period (intervention group: mean, 2.71 [SD, 1.94]; control group: mean, 3.92 [SD, 2.03]; P = .03). CONCLUSIONS: Data from this pilot study suggest that EMLA as a primary dressing may be effective in reducing chronic leg ulcer pain during and after dressing change and warrant further evaluation.

Investigating the effect of enhanced cleaning and disinfection of shared medical equipment on health-care-associated infections in Australia (CLEEN): a stepped-wedge, cluster randomised, controlled trial.

BACKGROUND: There is a paucity of high-quality evidence based on clinical endpoints for routine cleaning of shared medical equipment. We assessed the effect of enhanced cleaning and disinfection of shared medical equipment on health-care-associated infections (HAIs) in hospitalised patients. METHODS: We conducted a stepped-wedge, cluster randomised, controlled trial in ten wards of a single hospital located on the central coast of New South Wales, Australia. Hospitals were eligible for inclusion if they were classified as public acute group A according to the Australian Institute of Health and Welfare, were located in New South Wales, had an intensive care unit, had a minimum of ten wards, and provided care for patients aged 18 years or older. Each cluster consisted of two randomly allocated wards (by use of simple randomisation), with a new cluster beginning the intervention every 6 weeks. Wards were informed of their allocation 2 weeks before commencement of intervention exposure, and the researcher collecting primary outcome data and audit data was masked to treatment sequence allocation. In the control phase, there was no change to environmental cleaning practices. In the intervention phase, a multimodal cleaning bundle included an additional 3 h per weekday for the dedicated cleaning and disinfection of shared medical equipment by 21 dedicated cleaning staff, with ongoing education, audit, and feedback. The primary outcome was the number of confirmed cases of HAI, as assessed by a fortnightly point prevalence survey and measured in all patients admitted to the wards during the study period. The completed trial is registered with Australia New Zealand Clinical Trials Registry (ACTRN12622001143718). FINDINGS: The hospital was recruited on July 31, 2022, and the study was conducted between March 20 and Nov 24, 2023. We assessed 220 hospitals for eligibility, of which five were invited to participate, and the first hospital to formally respond was enrolled. 5002 patients were included in the study (2524 [50·5%] women and 2478 [49·5%] men). In unadjusted results, 433 confirmed HAI cases occurred in 2497 patients (17·3%, 95% CI 15·9 to 18·8) in the control phase and 301 confirmed HAI cases occurred in 2508 patients (12·0%, 10·7 to 13·3) in the intervention phase. In adjusted results, there was a relative reduction of -34·5% (-50·3 to -17·5) in HAIs following the intervention (odds ratio 0·62, 95% CI 0·45 to 0·80; p=0·0006), corresponding to an absolute reduction equal to -5·2% (-8·2 to -2·3). No adverse effects were reported. INTERPRETATION: Improving the cleaning and disinfection of shared medical equipment significantly reduced HAIs, underscoring the crucial role of cleaning in improving patient outcomes. Findings emphasise the need for dedicated approaches for cleaning shared equipment. FUNDING: National Health and Medical Research Council.

Effect of buttonhole cannulation with a polycarbonate PEG on in-center hemodialysis fistula outcomes: a randomized controlled trial.

BACKGROUND: Quality improvement strategies to increase and maintain the numbers of arteriovenous fistulas (AVFs) are a critical drive in enhancing the quality of care of patients receiving treatment with hemodialysis. How the AVF is needled is an important consideration in AVF survival; the ideal cannulation technique has not been established to date. STUDY DESIGN: Prospective randomized single-center trial. SETTING & PARTICIPANTS: Patients on maintenance hemodialysis therapy (N = 140). INTERVENTION: A 1-year intervention of buttonhole (constant site) or usual-practice (different site) cannulation. OUTCOMES: Primary study outcome was AVF survival over 1 year, in which AVF failure was defined as an AVF no longer used for hemodialysis (also referred to as assisted patency). Secondary outcomes included primary patency, number of access interventions, bleeding time, infection rate, cannulation time and pain, and aneurysm formation. RESULTS: Demographic data were similar for both groups. The primary outcome measure of AVF survival at 1 year was statistically significantly increased in the buttonhole group (100% vs 86% with usual practice; P = 0.005, log-rank test). In the buttonhole group, there were fewer interventions (19% vs 39% in usual practice) and less existing aneurysm enlargement (23% vs 67% in usual practice). There were no bacteremia events in the buttonhole group and 2 in the usual-practice group (0.09/1,000 AVF days). There were no significant differences in bleeding times and lignocaine use between the 2 groups. LIMITATIONS: A single-center study, lack of blinding. CONCLUSIONS: In this study, AVF survival was significantly greater when using buttonhole cannulation. The buttonhole technique significantly decreased the need for access interventions and reduced existing aneurysm enlargement. Concerns of increased infection rates or prolonged bleeding times with the buttonhole technique were not seen in this study. The buttonhole technique should be considered the cannulation technique of choice for AVFs.

A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study.

BACKGROUND: Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices. METHODS: The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36 weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention. DISCUSSION: Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

Empathy development and volunteering for undergraduate healthcare students: A scoping review.

OBJECTIVES: Empathy in healthcare benefits patients and healthcare providers. However, empathy decline is a recent trend within healthcare education. There is a paucity of literature that investigates the impact of volunteering on the empathy levels of undergraduate healthcare students. This scoping review explores the literature regarding empathy and volunteering for healthcare students. DESIGN: The Joanna Briggs Institute methodology for scoping reviews guided this study. DATA SOURCES: The electronic databases MEDLINE, CINAHL, ProQuest, JBI, Cochrane, PubMed, PsychInfo, and PsychNurses were searched from January 2001 to August 2021. The original search was developed in MEDLINE and then adapted to the other databases. REVIEW METHODS: This scoping review used the Joanna Briggs Institute scoping review methodology. The search retrieved a total of 310 articles. Following deduplication, 271 articles were reviewed by title and abstract. Thirty articles were reviewed in full text with twelve articles meeting the criteria for inclusion. Included studies were assessed using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Five qualitative, four quantitative and three mixed method studies were included. A variety of volunteering interventions for undergraduate healthcare students were identified from countries including the United States of America, Singapore, Australia, and Brazil. Thematic analysis identified that volunteer undergraduate healthcare students practiced and developed empathy, and experienced professional and personal development. CONCLUSIONS: Volunteering interventions were primarily in a service-learning modality within community health and palliative healthcare settings. Inconsistencies exist in empathy definitions and empirical empathy measurement. There is a need for more research that explores empathy development through volunteer activities in acute care settings.

Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER RCT.

BACKGROUND: There is modest evidence that exercise referral schemes increase physical activity in inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of exercise referral schemes on long-term physical activity. OBJECTIVES: To determine if adding the e-coachER intervention to exercise referral schemes is more clinically effective and cost-effective in increasing physical activity after 1 year than usual exercise referral schemes. DESIGN: A pragmatic, multicentre, two-arm randomised controlled trial, with a mixed-methods process evaluation and health economic analysis. Participants were allocated in a 1 : 1 ratio to either exercise referral schemes plus e-coachER (intervention) or exercise referral schemes alone (control). SETTING: Patients were referred to exercise referral schemes in Plymouth, Birmingham and Glasgow. PARTICIPANTS: There were 450 participants aged 16-74 years, with a body mass index of 30-40 kg/m2, with hypertension, prediabetes, type 2 diabetes, lower limb osteoarthritis or a current/recent history of treatment for depression, who were also inactive, contactable via e-mail and internet users. INTERVENTION: e-coachER was designed to augment exercise referral schemes. Participants received a pedometer and fridge magnet with physical activity recording sheets, and a user guide to access the web-based support in the form of seven 'steps to health'. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in the importance of physical activity, competence, autonomy in physical activity choices and relatedness. All participants were referred to a standard exercise referral scheme. PRIMARY OUTCOME MEASURE: Minutes of moderate and vigorous physical activity in ≥ 10-minute bouts measured by an accelerometer over 1 week at 12 months, worn ≥ 16 hours per day for ≥ 4 days including ≥ 1 weekend day. SECONDARY OUTCOMES: Other accelerometer-derived physical activity measures, self-reported physical activity, exercise referral scheme attendance and EuroQol-5 Dimensions, five-level version, and Hospital Anxiety and Depression Scale scores were collected at 4 and 12 months post randomisation. RESULTS: Participants had a mean body mass index of 32.6 (standard deviation) 4.4 kg/m2, were referred primarily for weight loss and were mostly confident self-rated information technology users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (n = 108) compared with the control group (n = 124); 11.8 weekly minutes of moderate and vigorous physical activity (95% confidence interval -2.1 to 26.0 minutes; p = 0.10). Sixty-four per cent of intervention participants logged on at least once; they gave generally positive feedback on the web-based support. The intervention had no effect on other physical activity outcomes, exercise referral scheme attendance (78% in the control group vs. 75% in the intervention group) or EuroQol-5 Dimensions, five-level version, or Hospital Anxiety and Depression Scale scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months, but not at 12 months. At 12 months, the intervention group incurred an additional mean cost of £439 (95% confidence interval -£182 to £1060) compared with the control group, but generated more quality-adjusted life-years (mean 0.026, 95% confidence interval 0.013 to 0.040), with an incremental cost-effectiveness ratio of an additional £16,885 per quality-adjusted life-year. LIMITATIONS: A significant proportion (46%) of participants were not included in the primary analysis because of study withdrawal and insufficient device wear-time, so the results must be interpreted with caution. The regression model fit for the primary outcome was poor because of the considerable proportion of participants [142/243 (58%)] who recorded no instances of ≥ 10-minute bouts of moderate and vigorous physical activity at 12 months post randomisation. FUTURE WORK: The design and rigorous evaluation of cost-effective and scalable ways to increase exercise referral scheme uptake and maintenance of moderate and vigorous physical activity are needed among patients with chronic conditions. CONCLUSIONS: Adding e-coachER to usual exercise referral schemes had only a weak indicative effect on long-term rigorously defined, objectively assessed moderate and vigorous physical activity. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000 per quality-adjusted life-year. The intervention did improve some process outcomes as specified in our logic model. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15644451. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 63. See the NIHR Journals Library website for further project information.

When health-care professionals refer patients with chronic conditions to an exercise referral scheme, the effects on long-term increases in physical activity are limited. We therefore developed the e-coachER support package to add to usual exercise referral schemes and to prompt the use of skills such as self-monitoring and goal-setting. This package was also intended to empower patients to increase their levels of physical activity long term. The seven-step programme was delivered online (via an interactive website). As part of the package, we mailed participants a guide for accessing the online programme, a pedometer and a fridge magnet with a notepad to record physical activity. We aimed to determine whether or not adding the e-coachER support to usual exercise referral schemes resulted in lasting changes in moderate and vigorous physical activity and whether or not it offers good value for money compared with exercise referral schemes alone. A total of 450 inactive individuals were recruited across Plymouth, Birmingham and Glasgow and were referred to an exercise referral scheme for the following participant-reported main reasons: weight loss (50%), low mood (19%), osteoarthritis (12%), type 2 diabetes (10%) and high blood pressure (8%). Half of the individuals were given access to the e-coachER support and the other half were not. All individuals were mailed a wrist-worn movement sensor (accelerometer) to wear for 1 week and a survey to assess other outcomes at the start of the study as well as at 4 and 12 months post randomisation. At the start of the study, the participants were inactive and most had multiple health conditions. The participants had an average body mass index of 33 kg/m² and an average age of 50 years. Most (83%) were white. Participants with access to e-coachER support were only slightly more active at 12 months than those who did not have access, but we cannot be confident in the findings because we had data from fewer participants than planned. The lack of a clear effect may have been as a result of around one-third of participants not accessing the website, but otherwise there was reasonable engagement. The provision of the e-coachER support package led to an additional cost of £439 per participant over a 12-month period.

Randomised controlled trial of tailored support to increase physical activity and reduce smoking in smokers not immediately ready to quit: protocol for the Trial of physical Activity-assisted Reduction of Smoking (TARS) Study.

INTRODUCTION: Smoking reduction can lead to increased success in quitting. This study aims to determine if a client-focused motivational support package for smoking reduction (and quitting) and increasing (or otherwise using) physical activity (PA) can help smokers who do not wish to quit immediately to reduce the amount they smoke, and ultimately quit. This paper reports the study design and methods. METHODS AND ANALYSIS: A pragmatic, multicentred, parallel, two group, randomised controlled superiority clinical trial, with embedded process evaluation and economics evaluation. Participants who wished to reduce smoking with no immediate plans to quit were randomised 1:1 to receive either (1) tailored individual health trainer face-to-face and/or telephone support to reduce smoking and increase PA as an aid to smoking reduction (intervention) or (2) brief written/electronic advice to reduce or quit smoking (control). Participants in both arms of the trial were also signposted to usual local support for smoking reduction and quitting. The primary outcome measure is 6-month carbon monoxide-confirmed floating prolonged abstinence following participant self-reported quitting on a mailed questionnaire at 3 and 9 months post-baseline. Participants confirmed as abstinent at 9 months will be followed up at 15 months. ETHICS AND DISSEMINATION: Approved by SW Bristol National Health Service Research Committee (17/SW/0223). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals. Results will be disseminated to trial participants and healthcare providers. TRIAL REGISTRATION NUMBER: ISRCTN47776579; Pre-results.

Development of the congenital adrenal hyperplasia knowledge assessment questionnaire (CAHKAQ).

AIMS: The purpose of this study was to develop a validated Congenital Adrenal Hyperplasia Knowledge Assessment Questionnaire (CAHKAQ) that can be used to identify deficits in the knowledge of families living with CAH regarding the disease and its management. BACKGROUND: Management of CAH requires good parental and/or patient knowledge and understanding of the disorder, and the action required when clinical problems arise. Effective education initiatives are important in helping families to manage the disorder. However, there are currently no established questionnaires available to assess the knowledge of CAH. METHOD: An extensive survey of the literature was conducted to develop a list of questions about CAH. The Delphi technique was used to develop and determine content validity of the CAHKAQ using a panel of 15 nursing and medical experts in endocrinology. The instrument was piloted to test for item variation, meaning and redundancy, and to determine instrument unidimensionality and internal consistency. The questionnaire was distributed to a convenience sample of family members (n = 98) of 36 children/adults with CAH recorded on the database of a large children's hospital endocrine clinic. RESULTS: Three Delphi rounds were required to achieve final consensus for content validity. The resulting questionnaire contained 22 multiple-choice items and had a Flesch Reading Ease score of 67. Statistical analysis found the instrument to be internally consistent and unidimensional with a reported Cronbach's coefficient alpha of 0.67. CONCLUSION: The CAHKAQ is a valid and reliable questionnaire suitable for use in conjunction with education about CAH. RELEVANCE TO CLINICAL PRACTICE: The CAHKAQ will be invaluable in assessing parental and patient knowledge and understanding of the disorder and identifying deficits that can be addressed through education. Further research is required to determine whether the underlying factors of the instrument are consistent with components of CAH knowledge.

Eutectic mixture of local anaesthetics (EMLA®) as a primary dressing on painful chronic leg ulcers: a pilot randomised controlled trial.

BACKGROUND: The physical, occupational, social and psychological impact of chronic leg ulcers (CLUs) on an individual is considerable. Wound-related pain (WRP), the most common symptom, is frequently reported as moderate to severe and mostly occurs at dressing change. WRP pain may not be alleviated by oral analgesics alone. Persistent poorly controlled leg ulcer pain can negatively impact wound healing and health-related quality of life (HRQoL). METHODS: A pilot, parallel group, non-blinded, randomised controlled trial was conducted in six procedure clinics located in a public community nursing service in New South Wales, Australia to evaluate eutectic mixture of local anaesthetics (EMLA®) on painful CLUs when used as a primary dressing. The primary objective was to assess feasibility by using pre-determined criteria: at least 80% recruitment rate, 80% retention rate and 80% adherence to the study protocol. Key eligibility criteria were that participants had a painful CLU no larger than 100 cm2, a numerical rating scale (NRS) wound-related pain intensity score equal to or greater than 4, low to moderate exudate, no contraindications to EMLA® and capacity to consent. One hundred and seven patients with painful CLUs were screened for eligibility; 56% (n = 60) were eligible and consented to participate in the study. Participants were randomly assigned to the intervention (n = 30) or control (n = 30) groups. The intervention group received a measured dose of the topical anaesthetic EMLA® 5% cream daily as a primary dressing for 4 weeks followed by usual wound management for a further 8 weeks. The control group received usual wound management. Participants and investigators were not blinded to the treatment. WRP was measured at every dressing change. Wound healing and HRQoL were measured at baseline, 4 and 12 weeks. RESULTS: Recruitment rate was lower than expected which likely meant patients were missed. Study retention rate was 90% (n = 54). Intervention fidelity was impacted by availability of resources and patient factors such as increased WRP. CONCLUSION: This study identified that a larger randomised controlled trial investigating EMLA® applied as a primary dressing on painful chronic leg ulcers is feasible with modifications to the study protocol. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Register: Registered 16 December, 2009.

Multicentred randomised controlled trial of an augmented exercise referral scheme using web-based behavioural support in individuals with metabolic, musculoskeletal and mental health conditions: protocol for the e-coachER trial.

INTRODUCTION: Physical activity is recommended for improving health among people with common chronic conditions such as obesity, diabetes, hypertension, osteoarthritis and low mood. One approach to promote physical activity is via primary care exercise referral schemes (ERS). However, there is limited support for the effectiveness of ERS for increasing long-term physical activity and additional interventions are needed to help patients overcome barriers to ERS uptake and adherence.This study aims to determine whether augmenting usual ERS with web-based behavioural support, based on the LifeGuide platform, will increase long-term physical activity for patients with chronic physical and mental health conditions, and is cost-effective. METHODS AND ANALYSIS: A multicentre parallel two-group randomised controlled trial with 1:1 individual allocation to usual ERS alone (control) or usual ERS plus web-based behavioural support (intervention) with parallel economic and mixed methods process evaluations. Participants are low active adults with obesity, diabetes, hypertension, osteoarthritis or a history of depression, referred to an ERS from primary care in the UK.The primary outcome measure is the number of minutes of moderate-to-vigorous physical activity (MVPA) in ≥10 min bouts measured by accelerometer over 1 week at 12 months.We plan to recruit 413 participants, with 88% power at a two-sided alpha of 5%, assuming 20% attrition, to demonstrate a between-group difference of 36-39 min of MVPA per week at 12 months. An improvement of this magnitude represents an important change in physical activity, particularly for inactive participants with chronic conditions. ETHICS AND DISSEMINATION: Approved by North West Preston NHS Research Ethics Committee (15/NW/0347). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals.Results will be disseminated to ERS services, primary healthcare providers and trial participants. TRIAL REGISTRATION NUMBER: ISRCTN15644451; Pre-results.

The perceptions of high school careers advisers regarding nursing: an Australian study.

Effective promotion of nursing as a career to high school students can potentially have a positive impact on the shortage of nurses. This study identified the perceptions of high school careers advisers of the Bachelor of Nursing program as a career choice, their perceptions of the attributes and characteristics necessary for nurses, and their perceptions of nurses' roles and responsibilities. These perceptions have not been previously identified in Australia and may not have been adequately considered in the planning of recruitment and retention strategies for nursing. The study findings suggest that careers advisers recognise the complexity of nursing practice in providing direct patient care and the range of attributes required for the registered nurse who provides this care. Careers advisers recognised that nursing had changed over the past ten years, although few perceived the roles and responsibilities of nurses to extend beyond activities related to patient care. There were few requests for information about nursing as a career from careers advisers and the findings indicates that they do not actively promote nursing as a career. This suggests that despite a range of initiatives to promote registered nursing as a career choice, careers advisers are not influencing significant numbers of school students to consider registered nursing as career.

The Effectiveness of EMLA as a Primary Dressing on Painful Chronic Leg Ulcers: Effects on Wound Healing and Health-Related Quality of Life.

This study aimed to evaluate the effect of EMLA 5% cream applied to painful chronic leg ulcers (CLUs) as a primary dressing on wound healing and health-related quality of life (HRQoL). A pilot, parallel-group, nonblinded, randomized controlled trial was conducted in 6 community nursing procedure clinics in New South Wales, Australia. A total of 60 participants with painful CLUs of varied etiology were randomly assigned to the intervention (EMLA daily for 4 weeks as a primary dressing, followed by usual care) or usual care only. Wound size and HRQoL were measured at baseline, end of the intervention period (week 4), and week 12. At baseline, wound sizes were similar for both the intervention and control groups. During the intervention period, there was no significant difference in wound sizes between groups (intervention group: median (cm2) = 2.4, IQR = 1.3-12.7; control group: median (cm2) = 5.0, IQR = 2.5-9.9; P = .05). Mean HRQoL scores for all subscales at baseline and weeks 4 and 12 were similar between groups except for Wellbeing, which was significantly higher in the intervention group at the end of the 4-week intervention period (intervention group: mean = 52.41, SD = 24.50; control group: mean = 38.15, SD = 21.25; P = .03; d = 0.62). The trial findings suggest that daily applications of EMLA as a primary dressing do not inhibit wound healing and may improve patient well-being. Studies with larger samples are required to more comprehensively evaluate the impact of this treatment on wound healing and HRQoL.

Group debriefing: an approach to psychosocial support for New Graduate Registered Nurses and Trainee Enrolled Nurses.

The transition from student to an accountable health professional is a difficult time for the novice nurse and can result in significant anxiety, stress and poor socialisation into the nursing profession. A strategy applied at a major tertiary teaching hospital to address transitional issues for novice nurses is that of group debriefing sessions. This qualitative study used focus groups to explore the effectiveness of these debriefing sessions for new graduate nurses and trainee enrolled nurses. The results demonstrated that the sessions provided nurses with a supportive environment, access to peer support and a sense of belonging. This provided an opportunity to develop confidence in their nursing competence and improvement in interpersonal communication skills. Debriefing sessions are an effective psychosocial support mechanism that can ameliorate the 'reality shock' experienced by nurses in their first year of practice. Group debriefing is an important component in the transitional support process and should be used to complement other strategies to enhance the psychosocial experiences of novice nurses.

Buttonhole Tunnel Tract Creation with the BioHole® Buttonhole Device.

BACKGROUND: Cannulation, and in particular, skilled cannulation is the cornerstone to preserving the arteriovenous fistula, the lifeline for a patient receiving long-term hemodialysis therapy. The buttonhole cannulation method has seen a huge revival in the 2000s, but it can sometimes prove challenging to implement successfully. This chapter discusses and describes the method of creating a buttonhole tract using the BioHole® device (a sterile polycarbonate peg), and describes the associated advantages and disadvantages. In a busy hemodialysis unit, use of the thumbtack-shaped 5-mm peg allows a fixed puncture route to be created quickly in just 7-14 days. The peg is placed at the site where the sharp puncture needle has just been removed by the designated primary cannulator. The peg remains in place until the next dialysis session when it is removed, the dialysis therapy completed as usual, and a new peg is inserted after hemostasis has been achieved. These steps are repeated for 1-2 weeks. Once the tunnel is formed, use of the peg is no longer needed and a blunt-ended puncture needle is inserted along the track each time. Buttonhole cannulation using the BioHole peg device offers advantages including reduced risk of needling complications and arteriovenous fistula failure, speedy transition to blunt needles, the tunnel track remaining narrow thus reducing the risk of developing an exit site infection, and suitability in difficult sites. Possible disadvantages are increased cost for purchase of the pegs during the track break-in period and potential complications such as discomfort, bleeding, and risk of infection. These risks/disadvantages minimize after the transition to blunt needles which in itself is a safer option than using sharp needles. As supported by KDOQI (2006) and the UK Renal Association (2011), adoption of the buttonhole method as the cannulation technique of choice is recommended in the majority of patients undergoing hemodialysis who have a native fistula.

Severe Hypoglycemia and the Role of the Significant Other: Expert, Sentry, and Protector.

PURPOSE: The purpose of the study was to gain a better understanding of what severe hypoglycemia means to significant others. METHODS: Narrative inquiry methodology was utilized. In-depth interviews were conducted with 7 significant others of adults with type 1 diabetes about their experience with severe hypoglycemia. Interviews were recorded, transcribed verbatim, and then developed into narrated core stories through a process of selecting and organizing events and by describing the relationship among these events. This was followed by thematic analysis to reveal the shared narrative of significant others. RESULTS: Episodes of severe hypoglycemia were found to turn the participants' lives upside down. The inability of the individual with diabetes to manage severe hypoglycemia required the significant other to detect and treat these episodes. The theme "managing disruption" captured how the significant others' role shifted from one of background support to an active, primary role in severe hypoglycemia management. They became (1) the expert by arming themselves with knowledge and skills to assist with the severe hypoglycemia episodes, (2) the sentry by becoming more vigilant and prepared for these episodes, and (3) the protector of the person with diabetes by shielding him or her from the vulnerable position that the severe hypoglycemia episodes placed one in. CONCLUSIONS: This study highlights the important role that significant others play in the management of severe hypoglycemia. It also emphasizes the need for health care professionals to provide appropriate education and support.

The Self-Directed Learning Readiness Scale for nursing education revisited: a confirmatory factor analysis.

The Self-Directed Learning Readiness Scale for Nursing Education (SDLRSNE) was initially developed as an alternative to Guglielmino's [Guglielmino, L.M. 1977. Development of the Self-Directed Learning Readiness Scale. Unpublished Doctoral Dissertation, University of Georgia. Dissertation Abstracts International, vol. 38 (11a), p. 6467] Self-Directed Learning Readiness Scale. The aim of this study was to re-examine the factor structure of the subscales of the SDLRSNE and provide evidence of its validity. Data was collected using a cross-sectional survey of 227 first year undergraduate nursing students. To examine the factor structure of the SDLRSNE three one-factor congeneric models, each representing a different subscale, were tested with maximum likelihood confirmatory factor analysis. The model fit indices of the three one-factor congeneric models indicate that the resultant models fit the data well, providing support for the factorial validity of the SDLRSNE. Of the 40 items, 11 items had to be removed from the analyses as they failed to provide good fit with their subscales. Further research investigating the factor validity of the SDLRSNE is encouraged, specifically to examine the stability of the items across factors using multi-factor models.