The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study).

BACKGROUND: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective.

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

Negotiating pace, focus and identities: Patient/public involvement/engagement in a palliative care study.

Patient and public involvement and engagement (PPIE) is an increasingly important component of research conduct to enhance processes and potential for impact, yet is rarely critically interrogated. This paper draws on Foucauldian analysis to highlight the disciplinary powers and tensions arising in PPIE. The paper draws on a nested evaluation interview study with three PPIE members and eight academics, who had been involved in an implementation science study focused on palliative care. PPIE members were involved in the whole study and are co-authors of this article. Through shared values and commitments to the study, a team culture of equality was developed. Yet while power was dispersed and taken-up by all team members, in so doing a self-governance approach within the team was developed. The pace and focus of discussions was at times more subjugating than co-production. Identities and positions were porous; the simplistic division of 'academic' and 'PPIE' did not stand up to scrutiny, with an increasing blurring of boundaries as people's experiences and insights changed over time. Continual, subtle, negotiations of roles, inputs and identities were manifest throughout the project. PPIE in research involves subtle, complex and ongoing disciplinary practices enacted by all members of the team.

Frailty in community-dwelling older people and nursing home residents: An adaptation and validation study.

AIM: The aim of this was to psychometrically adapt and evaluate the Tilburg Frailty Indicator to assess frailty among older people living in Slovenia's community and nursing home settings. DESIGN: A cross-cultural adaptation and validation of instruments throughout the cross-sectional study. METHODS: Older people living in the community and nursing homes throughout Slovenia were recruited between March and August 2021. Among 831 participants were 330 people living in nursing homes and 501 people living in the community, and all were older than 65 years. RESULTS: All items were translated into the Slovene language, and a slight cultural adjustment was made to improve the clarity of the meaning of all items. The average scale validity index of the scale was rated as good, which indicates satisfactory content validity. Cronbach's α was acceptable for the total items and subitems. CONCLUSIONS: The Slovenian questionnaire version demonstrated adequate internal consistency, reliability, and construct and criterion validity. The questionnaire is suitable for investigating frailty in nursing homes, community dwelling and other settings where older people live. IMPACT: The Slovenian questionnaire version can be used to measure and evaluate frailty among older adults. We have found that careful translation and adaptation processes have maintained the instrument's strong reliability and validity for use in a new cultural context. The instrument can foster international collaboration to identify and manage frailty among older people in nursing homes and community-dwelling homes. REPORTING METHOD: The Strengthening the Reporting of Observational Studies in Epidemiology checklist for reporting cross-sectional studies was used. NO PATIENT OR PUBLIC CONTRIBUTION: No patient or public involvement in the design or conduct of the study. Head nurses from nursing homes and community nurses helped recruit older adults. Older adults only contributed to the data collection and were collected from nursing homes and community dwelling.

Leadership practices that enable healthful cultures in clinical practice: A realist evaluation.

AIM: To generate, test and refine programme theories that emerged from a rapid realist review investigating practising UK Nurses' and Midwives' experiences of effective leadership strategies during the COVID-19 pandemic. BACKGROUND: The realist review of literature generated six tentative theories of healthful leadership practices reflecting, working with people's beliefs and values; being facilitative; multiple means of communication and; practical support. The review yielded little insight into the actual impact of the leadership approaches advocated. METHODS: A realist study, informed by person-centredness using mixed-methods. Online survey (n = 328) and semi-structured interviews (n = 14) of nurses and midwives across the UK in different career positions/specialities. Quantitative data analysed using descriptive statistics and exploratory factor analysis. Framework analysis for qualitative data using context (C), mechanism (M), outcome (O) configurations of the tentative theories. RESULTS: Three refined theories were identified concerning: Visibility and availability; embodying values and; knowing self. Healthful leadership practices are only achievable within organisational cultures that privilege well-being. CONCLUSIONS: Leaders should intentionally adopt practices that promote well-being. 'Knowing self' as a leader, coaching and mentoring practice development is important for leadership development. IMPLICATIONS FOR CLINICAL PRACTICE: Nurses who feel valued, heard, cared for and safe are more likely to remain in clinical practice. Job satisfaction and being motivated to practice with confidence and competence will impact positively on patient outcomes. IMPACT: The study addresses the role of leadership in developing healthful workplace cultures. The main findings were six leadership practices that promote healthful cultures. The research will have an impact on strategic and clinical leaders, nurses and midwives. REPORTING METHOD: This study used EQUATOR checklist, RAMASES II as reporting standards for realist evaluations. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention.

AIM: To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital. BACKGROUND: Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability. DESIGN: A narrative inquiry. METHODS: Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data. RESULTS: The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation. CONCLUSION: Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly. REPORTING METHOD: The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting. PATIENT OR PUBLIC CONTRIBUTION: The consumer researcher was involved in design, data analysis and publication preparation.

The ecology of human flourishing embodying the changes we want to see in the world.

Flourishing is the highest good of all persons, but hard to achieve in complex societal systems. This challenge is borne out through the lens of the global nursing shortages with its focus on the supply of nurses to meet health system demands. However, nurses and midwives spend a significant part of their lives at work and so the need to pay attention to the conditions that facilitate flourishing at work is important. Drawing on ancient and contemporary philosophies, as well as critical, creative and embodied ways of knowing, enabling a flourishing practice ecosystem will be explored in this paper.

The effects of a salutogenic strength-based intervention on sense of coherence and health outcomes of dementia family carers: A randomized controlled trial.

INTRODUCTION: Dementia caregiving is associated with notable impacts on the health of family carers. Although sense of coherence (SOC), as a core dimension of inner strength, has been found to have health-protecting effects in stressful encounters, few studies have designed a strength-based intervention to optimise SOC and thereby the health of carers. OBJECTIVES: To identify the effects of a strength-based intervention on SOC, coping, health-related quality of life (HRQoL), perceived burden and depression among Chinese family carers of people with dementia and to examine whether the health effects, if any, are mediated through an enhanced SOC and effective coping. DESIGN: A double-blind randomised controlled trial comparing a strengths-based intervention with a general education control. INTERVENTION: A 14-session strengths-based intervention which combined the use of narrative and empowerment strategies to support the carers of people with dementia to optimise the use of their generalised resistance resources in coping with the caregiving situation. SETTING: Older people community centres in Hong Kong. RESULTS: A total of 350 family carers participated in the study (mean age: 65.0 (SD = 12.3); female: 84.6%). Participants who received the strength-based intervention reported significantly greater improvements in their SOC, mental health, perceived burden and depression, than those in the education group, over a 22-week evaluation period. Path analysis models revealed that an SOC wholly mediated the relationship between the strength-based intervention and mental HRQoL (covering energy/vitality and psychosocial functioning) and partially mediated the relationship between the strength-based intervention and depression. We did not identify any harm from the intervention. CONCLUSION: A strength-based intervention is effective in improving the perceived burden and mental health of family caregivers of persons with dementia, and an SOC plays an important role in accounting for the mental health benefits. TRIAL REGISTRATION: The trial was registered in the World Health Organization International Clinical Trials Registry Platform (Main ID: ChiCTR-IIC-17011097).

Stakeholder's experiences of living and caring in technology-rich supported living environments for tenants living with dementia.

BACKGROUND: Technology innovation provides an opportunity to support the rising number of people living with dementia globally. The present study examines experiences of people who have dementia and live in technology enriched supported care models. Additionally, it explores caregiver's attitudes towards technology use with the housing scheme. METHODS: A qualitative research design was adopted, and eight housing schemes consented to take part in the study. A technology audit was undertaken in addition to participant interviews and caregiver survey. Seven peer researchers conducted semi-structured interviews with 22 people living with dementia. Interviews were analysed using thematic analysis. Informal and formal caregivers were invited to complete a survey to capture their attitudes towards technology use. A total of 20 informal and 31 formal caregiver surveys were returned. All surveys were input into Survey Monkey and downloaded into excel for analysis. Closed questions were analysed using descriptive statistics and open-ended questions were organised into themes and described descriptively. RESULTS: The technology audit identified that technologies were in place from as early as 2002. Technology heterogeneity of, both passive and active devices, was found within the housing schemes. Technologies such as wearable devices were reportedly used according to need, and mobile phone use was widely adopted. The themes that developed out of the tenant interviews were: Attitudes and Engagement with Technology; Technology Enhancing Tenants Sense of Security; Seeking Support and Digital Literacy; and Technology Enabled Connection. A lack of awareness about living alongside technology was a major finding. Technologies enabled a sense of reassurance and facilitated connections with the wider community. The interaction with technology presented challenges, for example, remembering passwords, access to Wi-Fi and the identification of its use in an emergency. The caregiver survey reported a range of facilitators and barriers for the use of technology within care. Both types of caregivers held relatively similar views around the benefits of technology, however their views on issues such as privacy and consent varied. Safety was considered more important than right to privacy by family caregivers. CONCLUSIONS: The present study provides new insight into stakeholder's experiences of living, working and caregiving alongside technology in supported living environments. As the generation of people living with dementia become more tech savvy, harnessing everyday technologies to support care could enable holistic care and support the transition through the care continuum. Advance care planning and technology assessments are at the very core of future technology provision. It is evident that a paternalistic attitudes towards technology use could impact the multitude of benefits technology can play in both health and leisure for people living with dementia and their caregivers.

German translation, cultural adaptation and validation of the Person-Centred Practice Inventory-Staff (PCPI-S).

BACKGROUND: The person-centred practice framework represents the cornerstone of a middle-range theory. Internationally, person-centredness has become an increasingly common topic. The measurement of the existence of a person-centred culture is complex and subtle. The Person-Centred Practice Inventory-Staff (PCPI-S) measures clinicians' experience of a person-centred culture in their practice. The PCPI-S was developed in English. Therefore, the aims of this study were (1) to translate the PCPI-S into German and to cross-culturally adapt and test in the acute care setting (PCPI-S aG Swiss) and (2) to investigate the psychometric properties of the PCPI-S aG Swiss. METHODS: The two-phase investigation of this cross-sectional observational study followed the guidelines and principles of good practice for the process of translation and cross-cultural adaptation of self-reporting measures. Phase 1 involved an eight-step translation and cultural adaptation of the PCPI-S testing in an acute care setting. In Phase 2, psychometric retesting and statistical analysis based on a quantitative cross-sectional survey were undertaken. To evaluate the construct validity, a confirmatory factor analysis was implemented. Cronbach's alpha was used to determine the internal consistency. RESULTS: A sample of 711 nurses working in a Swiss acute care setting participated in testing the PCPI-S aG Swiss. Confirmatory factor analysis indicated a good overall model fit, validating the strong theoretical framework, which underpins the PCPI-S aG Swiss. Cronbach's alpha scores demonstrated excellent internal consistency. CONCLUSION: The chosen procedure ensured cultural adaptation to the German-speaking part of Switzerland. The psychometric results were good to excellent and comparable with other translations of the instrument.

The operational experience of private owners of small-sized care homes in China: a qualitative study.

BACKGROUND: Private small-sized care homes (<50 beds)  have proliferated across China, however, until recently little was known about the characteristics of such institutions, and the challenges and the problems faced by their owners. This study aimed to explore the characteristics of small-sized, privately-owned care homes in the People's Republic of China; and to understand the motivation and challenges faced by their owners. METHODS: This study used an interpretative phenomenological analysis approach of qualitative research. Owners of eight small-sized private care homes located in two cities of Henan Province, China, were interviewed using semi-structured interviews. RESULTS: Four themes and eight subthemes were identified: 1. Motivation for establishing a care home business; 2. Certification and establishing a legal footing for the business; 3. Operational challenges; 4. Future business development. The study found that the development of privately owned small-sized care homes faced great challenges and critical survival problems due to policies, staffing, and management issues. There is a lack of regulations about the safety and quality of care provided for older people and a lack of legal protections for the owners of small-sized private care homes. CONCLUSION: The study suggests that formal regulations and provisions are needed to support these smaller-sized private care homes. Monitoring is also needed to ensure the quality of care. It also suggests that there needs more support by policymakers as well as provision monitoring services to improve quality of care in these care homes. Care regulations and standards are not unique to China so findings from this study can be applied to places where there are similar situations or if there are aged care services still developing.

Trust-based service innovation of municipal home care: a longitudinal mixed methods study.

BACKGROUND: In Scandinavia, various public reforms are initiated to enhance trust in the healthcare services and the public sector in general. This study explores experiences from a two-step service innovation project in municipal home care in Norway, coined as the Trust Model (TM), aiming at developing an alternative to the purchaser-provider split (PPS) and enhancing employee motivation, user satisfaction, and citizen trust. The PPS has been the prevalent model in Norway since the 1990s. There is little empirical research on trust-based alternatives to the PPS in healthcare. The overall objectives of this study were to explore facilitators and barriers to trust-based service innovation of municipal homecare and to develop a framework for how to support the implementation of the TM. METHODS: The TM elements were developed through a comprehensive participatory process, resulting in the decision to organize the home care service in small, self-managed and multidisciplinary teams, and trusting the teams with full responsibility for care decisions and delivery within a limited area. Through a longitudinal mixed methods case study design a) patients' expressed values and b) factors facilitating or preventing the service innovation process were explored through two iterations. The first included three city districts, three teams and 80 patients. The second included four districts, eight teams and 160 patients. RESULTS: The patient survey showed patients valued and trusted the service. The team member survey showed increased motivation for work aligned with TM principles. Both quantitative and qualitative methods revealed a series of facilitators and barriers to the innovation process on different organizational levels (teams, team leaders, system). The key message arising from the two iterations is to keep patients' values in the centre and recognize the multilevelled organizational complexity of successful trust-based innovation in homecare. Synthesizing the results, a framework for how to support trust-based service innovation was constructed. CONCLUSIONS: Trust-based innovation of municipal homecare is feasible. The proposed framework may serve as a tool when planning trust-based innovation, and as a checklist for implementation and improvement strategies. Further research is needed to explore the validity of the framework and its replicability in other areas of healthcare.

Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study.

BACKGROUND: People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life. OBJECTIVE: In this study (CareTrack Aged, CT Aged), we aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes in aged care. METHODS: Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multiround modified Delphi process to develop a consensus on what constitutes appropriate care. RESULTS: From 139 CPGs, 5609 recommendations were used to draft 630 indicators. Clinical experts (n = 41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity and sleep. CONCLUSIONS: The suite of CT Aged clinical indicators can be used for research and assessment of the quality of care in individual facilities and across organizations to guide improvement and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved.

An investigation of the level of burnout and resilience among hospital based nurse managers after COVID 19 - A cross-sectional questionnaire-based study.

AIM: We aim to investigate burnout and resilience among hospital based nurse managers post COVID-19 in order to suggest appropriate person-centred leadership support. BACKGROUND: Nurse leaders are central to establishing safe and caring environments for patients and staff. Therefore, their own wellbeing is crucial, particular in times of crisis where they must provide support and guidance. METHODS: Cross-sectional questionnaire included ward managers. Data collected were burnout inventory, brief resilience score and demographic data. To analyse data, we used descriptive statistics. RESULTS: 51.2% answered the questionnaire. Of those, 32.3% displayed symptoms of high personal burnout and 29% of work-related burnout. 6.5% showed signs of high employee-related burnout. As a group, ward managers showed moderate to high resilience. CONCLUSION: Personal and work-related burnout was highly prevalent among ward managers. Results suggest that the cause of their burnout symptoms cannot be attributed to low individual resilience. We thus suggest a shift in focus from strengthening individual leadership resilience to the establishment of healthful and resilient cultures in accordance with person-centred leadership. IMPLICATIONS FOR NURSING MANAGEMENT: Person-centred leadership has the potential to shift the focus from the resilience of individual leaders to that of collective responsibility for creating a healthful and resilient culture.

UK nurses' and midwives' experiences of healthful leadership practices during the COVID-19 pandemic: A rapid realist review.

AIM: We aim to explore healthful leadership practices in nursing and midwifery evident within the COVID-19 pandemic in the United Kingdom, the contextual facilitators, barriers and outcomes. BACKGROUND: Globally, the health and care sectors are under pressure and despite nurses and other professionals, demonstrating resilience and resourcefulness in the COVID-19 pandemic; this has negatively impacted on their health and wellbeing and on patient care. EVALUATION: Two searches were conducted in July 2021 and December 2021. Inclusion/exclusion criteria were identified to refine the search, including papers written since the beginning of the pandemic in 2020. A total of 38 papers were included principally from the United States and United Kingdom. Ten were research papers; the others were commentaries, opinion pieces and editorials. MS Teams literature repository was created. A unique critical appraisal tool was devised to capture contexts, mechanisms and outcomes whilst reflecting more standardized tools, that is, the Critical Appraisal Skills Programme and the Authority, Accuracy, Coverage, Objectivity and Date tool for reviewing grey literature to refine the search further. KEY ISSUES: Six tentative theories of healthful leadership emerged from the literature around leadership strategies, which are relational, being visible and present; being open and engaging; caring for self and others; embodying values; being prepared and preparing others; and using available information and support. Contextual factors that enable healthful leadership practices are in the main, created by leaders' values, attributes and style. The literature suggests that leaders who embody values of compassion, empathy, courage and authenticity create conditions for positive and healthful relations between leaders and others. Nurse and midwives' voices are however absent from the literature in this review. CONCLUSION: Current available literature would suggest healthful leadership practices are not prioritized by nurse leaders. Perspectives of nurses' and midwives' about the impact of such practices on their wellbeing is also missing. Tentative theories are offered as a means of identifying healthful leadership strategies, the context that enable these and potential outcomes for nurses and midwives. These will be explored in phase two of this study. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders must be adequately prepared to create working environments that support nurses' and midwives' wellbeing, so that they may be able to provide high-quality care. Ensuring a supportive organizational culture, which embodies the values of healthfulness, may help to mitigate the impact of the COVID-19 pandemic on nurses' and midwives' wellbeing in the immediate aftermath and going forward.

Partnering with older people as peer researchers.

BACKGROUND: The term peer researcher describes the role of a person who has similar characteristics and can identify with the participant group in a research study. This paper describes the methodological approach and experiences of older people who were peer researchers on a study that explored the lived experience of people with dementia who lived in technology-enriched housing. METHODS: Nine people responded to a public recruitment campaign through nongovernment organisations using multiple methods such as seniors' forums, development officers and social media. Mandatory training across 2 days was provided and seven peer researchers successfully completed the training. A total of 22 interviews were undertaken by the seven peer researchers. The data collected from the training feedback proforma (N = 7), interview debrief forms (N = 22) and final evaluation forms (N = 5) were analysed using content analysis and triangulated. RESULTS: Five core themes emerged from the data using a content analysis approach to examine the peer researchers' experience: (1) skill development; (2) recognition of competencies; (3) connection; (4) supplementary information; and (5) the triad dynamic. CONCLUSIONS: Considerations to enhance the peer researcher experience emerged including enhanced communication training, consideration of the optimum number of peer researchers to balance workload and identification of the characteristics that enable people to connect as peer researchers. Future research should consider the impact that experiential skill development has on the data collected. PUBLIC CONTRIBUTION: Older people conducted qualitative interviews as peer researchers with people living with dementia to cocreate knowledge.

Engaging family caregivers and health system partners in exploring how multi-level contexts in primary care practices affect case management functions and outcomes of patients and family caregivers at end of life: a realist synthesis.

BACKGROUND: An upstream approach to palliative care in the last 12 months of life delivered by primary care practices is often referred to as Primary Palliative Care (PPC). Implementing case management functions can support delivery of PPC and help patients and their families navigate health, social and fiscal environments that become more complex at end-of-life. A realist synthesis was conducted to understand how multi-level contexts affect case management functions related to initiating end-of-life conversations, assessing patient and caregiver needs, and patient/family centred planning in primary care practices to improve outcomes. The synthesis also explored how these functions aligned with critical community resources identified by patients/families dealing with end-of-life. METHODS: A realist synthesis is theory driven and iterative, involving the investigation of proposed program theories of how particular contexts catalyze mechanisms (program resources and individual reactions to resources) to generate improved outcomes. To assess whether program theories were supported and plausible, two librarian-assisted and several researcher-initiated purposive searches of the literature were conducted, then extracted data were analyzed and synthesized. To assess relevancy, health system partners and family advisors informed the review process. RESULTS: Twenty-eight articles were identified as being relevant and evidence was consolidated into two final program theories: 1) Making end-of-life discussions comfortable, and 2) Creating plans that reflect needs and values. Theories were explored in depth to assess the effect of multi-level contexts on primary care practices implementing tools or frameworks, strategies for improving end-of-life communications, or facilitators that could improve advance care planning by primary care practitioners. CONCLUSIONS: Primary care practitioners' use of tools to assess patients/families' needs facilitated discussions and planning for end-of-life issues without specifically discussing death. Also, receiving training on how to better communicate increased practitioner confidence for initiating end-of-life discussions. Practitioner attitudes toward death and prior education or training in end-of-life care affected their ability to initiate end-of-life conversations and plan with patients/families. Recognizing and seizing opportunities when patients are aware of the need to plan for their end-of-life care, such as in contexts when patients experience transitions can increase readiness for end-of-life discussions and planning. Ultimately conversations and planning can improve patients/families' outcomes.

Challenging and redesigning a new model to explain intention to leave nursing.

BACKGROUND: It is important to have a full and detailed understanding of the factors that influence intention to leave nursing. It has been shown to be the best predictor of actual turnover, and turnover has a significant financial impact and also on the provision of care. AIMS: The aim is to examine the impact of predictive work environment factors on nurses' intention to leave their position and to explore contributing factors. METHODS: Cross-sectional survey using a convenience sample (n = 605) of Finnish nurses drawn from five clinical settings. The Nursing Context Index, an internationally used and psychometrically validated tool, was used to measure workplace practice environment, work stress, job satisfaction and intention to leave. A response rate of 29.4% was achieved, exceeding power calculation estimates. RESULTS: Personal satisfaction and satisfaction with profession and resources, and organisational commitment were significantly related to intention to leave. Younger nurses reported higher levels of intention to leave and there was variability among clinical specialties. Measures of stress and practice environment had no significant relationship with intention to leave. DISCUSSION: This study provides a new theoretical model for understanding intention to leave. Having a better understanding of the factors that may help reduce intention to leave allows for targeted interventions to be developed and implemented. This would help reduce the personal and financial implications associated with turnover. IMPLICATIONS FOR PRACTICE, POLICY, MANAGEMENT AND EDUCATION: The findings have significant implications for all aspects of nursing. Educators need to prepare new nursing staff for the working environment; policymakers must ensure that nursing satisfaction is promoted to strengthen organisational commitment and nurse managers and leaders respond accordingly in implementing effective interventions.

Nursing students' experience with clinical placement in nursing homes: a focus group study.

BACKGROUND: A renewed interest in nursing homes as clinical placement settings for nursing students has been prompted by the growing healthcare needs of an ageing population. However, if future nurses are to be enthusiastic about working in this healthcare context, it is essential that higher education institutions that educate nurses and nursing homes that provide placement experiences to students do so with a supportive, positive, and enriched approach. METHODS: To explore first-year nursing students' placement experience in nursing homes, we conducted an exploratory qualitative study in three city-based nursing homes in western Norway. Thirteen first-year nursing students participated in the study. Three focus group interviews were conducted to explore the students' placement experiences. Data were analysed using thematic analysis. The findings were reported using the Standards for Reporting Qualitative Research (SRQR). RESULTS: The analysis describes five themes relating to first-year students' placement experience in nursing homes; (1) variations in utility of pre-placement orientation and welcome at placement site; (2) a challenging learning environment; (3) spending considerable placement time with non-registered nurses; (4) considerable variability in supervision practices; and (5) a vulnerable and demanding student role. CONCLUSIONS: The research provides insight into the contextual characteristics encountered by first-year students that influence the quality of their placement experiences. Consequently, these characteristics impede access to important role models who lend support to a student's growth and professional development, preventing full utilisation of the learning potential offered in nursing homes. Hence, we propose that targeted efforts are warranted to foster positive placement experiences and enhance students' clinical education in nursing homes.

Impact of Person-Centered Interventions on Patient Outcomes in Acute Care Settings: A Systematic Review.

BACKGROUND: Preventing adverse events is one of the most important issues in health care. PURPOSE: The purpose of this systematic review was to determine the impact of person-centered interventions on patient outcomes in an acute care setting. METHODS: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eligible interventions included person-centered interventions that address at least one of these outcomes: pressure ulcer, accidental falls, medication errors, and/or cross infection. RESULTS: The review showed that there is a paucity of evidence supporting the use of person-centered interventions in reducing patient falls. For the other outcomes, existing research provides an insufficient evidence base on which to draw conclusions. CONCLUSIONS: Theory of person-centeredness is still in its ascendency. Poor evidence may also be the result of quantitative research designs that are insufficient in studying the impact of a person-centered approach. We postulate that use of mixed-methods designs is beneficial and would give a clearer picture of the impact of person-centered interventions.