Patient mortality and the neglect of vital signs' assessment: An audit of a national coronial database.

BACKGROUND: Vital signs assessment is critical for patient surveillance and safety. Research has found, however, that this assessment is often neglected in clinical practice. The reasons for this are unclear as few studies have explored this issue. Those studies that have are small, single site studies and found that culture and poor understanding are contributing factors. AIM: The aim was to explore the link between the clinical neglect of vital signs assessment and patient mortality and provide a better understanding of factors influencing vital signs assessment in the context of acute patient care. Coroners' reports represent an untapped source of information regarding shortfalls in vital signs assessment. Using a framework analysis, an audit was conducted of the Australian National Coronial Information System for cases where vital signs' assessment was mentioned in coronial reports. RESULTS: Fifty-eight cases met the eligibility criteria, with deceased patients aged from 7 days to 93 years. Key themes related to absence of reassessment of vital signs, inappropriate delegation, passing responsibility to another staff member and not following policy. CONCLUSIONS: The findings reflect a combination of individual and institutional failings and suggest that vital signs assessment was not considered a priority aspect of care. RELEVANCE TO CLINICAL PRACTICE: Vital signs assessment must be considered an essential aspect of clinical care in all patients. This important aspect of care should be emphasized across all domains of patient care.

Fundamental drivers of nurses' experiences of ICU surging during the coronavirus disease 2019 (COVID-19) pandemic.

PURPOSE OF REVIEW: Nurses working in intensive care units have been heavily impacted by the coronavirus disease 2019 (COVID-19) pandemic. This review summarizes the current state of the evidence regarding intensive care nurses experience of the pandemic. RECENT FINDINGS: The pandemic has had an impact on: nursing workload, the organization of nurse staffing, experiences of staff redeployed into ICU, nurses' perceptions of the safety and quality of patient care, and staff health. In the few comparative studies, mental health was worse for nurses than other healthcare workers in intensive care. Despite some of this evidence being published early in the pandemic, no studies were found to evaluate interventions to improve nurses' experiences. SUMMARY IMPLICATIONS FOR PRACTICE OR RESEARCH: Many of the adverse impacts of the pandemic are interdependent; for example, reducing nurses' workload is likely to have benefits for mental health indicators.Adverse mental health outcomes are likely to have an impact on future recruitment and retention for intensive care nursing.More studies are needed to understand the longer term impact of the pandemic on intensive care nurses.

What the curtains do not shield: A phenomenological exploration of patient-witnessed resuscitation in hospital. Part 2: Healthcare professionals' experiences.

AIMS: To explore healthcare professionals' experiences of patient-witnessed resuscitation in hospital. DESIGN: Descriptive phenomenology. METHODS: Healthcare professionals involved in hospital resuscitation activities were recruited from medical, intensive care, resuscitation and education departments in a university hospital in England. Data were collected through face-to-face and focus group interviews, between August 2018 and January 2019. Data were analysed using Giorgi's phenomenological approach. RESULTS: Nine registered nurses, four healthcare assistants and seven doctors participated in four individual interviews and three focus groups. Findings were related to three themes: (1) Protecting patients from witnessing resuscitation: healthcare professionals used curtains to shield patients during resuscitation, but this was ineffective. Thus, they experienced challenges in explaining resuscitation events to the other patients and communicating sensitively. (2) Emotional impact of resuscitation: healthcare professionals recognized that witnessing resuscitation impacted patients, but they also felt emotionally affected from performing resuscitation and needed coping strategies and support. (3) Supporting patients who witnessed resuscitation: healthcare professionals recognized the importance of patients' well-being, but they felt unable to provide effective and timely support while providing life-saving care. CONCLUSION: Healthcare professionals involved in hospital resuscitation require specific support, guidance and education to care effectively for patients witnessing resuscitation. Improving communication, implementing regular debriefing for staff, and allocating a dedicated professional to support patients witnessing resuscitation must be addressed to improve clinical practice. IMPACT: The WATCH study uncovers patients' and healthcare professionals' experiences of patient-witnessed resuscitation, a phenomenon still overlooked in nursing research and practice. The main findings highlight that, in common with patients, healthcare professionals are subject to the emotional impact of resuscitation events and encounter challenges in supporting patients who witness resuscitation. Embedding the recommendations from this research into clinical guidelines will impact the clinical practice of healthcare professionals involved in hospital resuscitation and the quality and timeliness of care delivered to patients.

How COVID-19 has affected staffing models in intensive care: A qualitative study examining alternative staffing models (SEISMIC).

AIMS: To understand how COVID-19 affected nurse staffing in intensive care units (ICUs) in England, and to identify factors that influenced, and were influenced by, pandemic staffing models. DESIGN: Exploratory qualitative study. METHODS: Semi-structured, online interviews conducted July-September 2020 with regional critical care leaders including policy leads (n = 4) and directors/lead nurses (n = 10) across critical care networks in England. FINDINGS: The six themes emerging from the framework analysis illustrate how the pre-pandemic ICU culture influenced ICU staffing models during the pandemic. Changes in staffing impacted on the workforce and the care delivered, whilst it was necessary to learn from, and adjust to, a rapidly changing situation. Variation across and between networks necessitated variation in responses. The overwhelming outcome was that the pandemic has challenged the central tenets of ICU nurse staffing. CONCLUSIONS: Pandemic nurse staffing models resulted in changes to ICU skill-mix and staffing numbers. Factors such as the impact of nurse staffing on care practices and on the workforce need to be taken into account when developing and testing future nurse staffing models for ICU. The extent to which ICUs will return to former staffing models is not yet known but there seems to be an appetite for change. IMPACT: In common with many countries, nurse staffing in English ICUs was adapted to address surge requirements during the COVID-19 pandemic. Findings highlight the challenge COVID-19 presented to pre-pandemic ICU nurse staffing guidelines, the impact on patient and staff well-being and the potential legacy for future staffing models. Study findings have implications for ICU nurse managers, researchers and policy makers: nurse staffing models need to be adaptable to the local context of care and future research should investigate the impact of different models on patients, staff and health service outcomes.

What the curtains do not shield: A phenomenological exploration of patient-witnessed resuscitation in hospital. Part 1: patients' experiences.

AIMS: The aim of the study was to explore the experiences of hospital patients who witnessed resuscitation of a fellow patient. DESIGN: Descriptive phenomenology. METHODS: Patients who witnessed resuscitation were recruited from nine clinical wards in a university hospital in England. Data were collected through face-to-face individual interviews. Participants were interviewed twice,in 1 week and 4 to 6 weeks after the resuscitation event. Data were collected between August 2018 and March 2019. Interviews were analysed using Giorgi's phenomenological analysis. RESULTS: Sixteen patients participated in the first interview and two patients completed follow-up interviews. Three themes were developed from the patients' interviews. (1) Exposure to witnessing resuscitation: patients who witness resuscitation felt exposed to a distressing event and not shielded by bed-space curtains, but after the resuscitation attempt, they also felt reassured and safe in witnessing staff's response. (2) Perceived emotional impact: patients perceived an emotional impact from witnessing resuscitation and responded with different coping mechanisms. (3) Patients' support needs: patients needed information about the resuscitation event and emotional reassurance from nursing staff to feel supported, but this was not consistently provided. CONCLUSION: The presence of other patients during resuscitation events must be acknowledged by healthcare professionals, and sufficient information and emotional support must be provided to patients witnessing such events. This study generates new evidence to improve patients' experience and healthcare professionals' support practices. IMPACT: The phenomenon of patient-witnessed resuscitation requires the attention of healthcare professionals, resuscitation officers and policymakers. Study findings indicate that witnessing resuscitation has an emotional impact on patients. Strategies to support them must be improved and integrated into the management of in-hospital resuscitation. These should include providing patients with comprehensive information and opportunities to speak about their experience; evacuating mobile patients when possible; and a dedicated nurse to look after patients witnessing resuscitation events.

The organisation of nurse staffing in intensive care units: A qualitative study.

AIMS: To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates. BACKGROUND: Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence. METHODS: Focus groups with intensive care health care professionals (n = 52 participants) and individual interviews with critical care network leads and policy leads (n = 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis. FINDINGS: Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes. CONCLUSIONS: Whilst nurse:patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff well-being, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies. IMPLICATIONS FOR NURSING MANAGEMENT: In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services.

Neurally Adjusted Ventilator Assist in Infants With Acute Respiratory Failure: A Literature Scoping Review.

OBJECTIVES: To map the evidence for neurally adjusted ventilatory assist strategies, outcome measures, and sedation practices in infants less than 12 months with acute respiratory failure using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidance. DATA SOURCES: CINAHL, MEDLINE, COCHRANE, JBI, EMBASE, PsycINFO, Google scholar, BNI, AMED. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. Also included were Ethos, Grey literature, Google, dissertation abstracts, EMBASE conference proceedings. STUDY SELECTION: Abstracts were screened followed by review of full text. Articles incorporating a heterogeneous population of both infants and older children were assessed, and where possible, data for infants were extracted. Fifteen articles were included. Ten articles were primary research: randomized controlled trial (n = 3), cohort studies (n = 4), retrospective data analysis (n = 2), case series (n = 1). Other articles are expert opinion (n = 2), neurally adjusted ventilatory assist updates (n = 1), and a literature review (n = 2). Three studies included exclusively infants. We also included 12 studies reporting jointly on infants and children. DATA EXTRACTION: A standardized data extraction tool was used. DATA SYNTHESIS: Key findings were that evidence related to neurally adjusted ventilatory assist ventilation strategies in infants and related to specific primary conditions is limited. The setting of neurally adjusted ventilatory assist level is not consistent, and how to optimize this mode of ventilation was not documented. Outcome measures varied considerably, most studies focused on improvements in respiratory and physiological variables. Sedation use is variable with regard to medication type and dose. There is an indication that less sedation is required in patients receiving neurally adjusted ventilatory assist, but no conclusive evidence to support this. CONCLUSIONS: This review highlights a lack of standardized strategies for neurally adjusted ventilatory assist ventilation and sedation practices among infants with acute respiratory failure. Studies were limited by small sample sizes and a lack of focus on specific patient groups. Robust studies are needed to provide evidence-based clinical recommendations for the use of neurally adjusted ventilatory assist in infants with acute respiratory failure.

Ventilation bundle compliance in two Australian intensive care units: An observational study.

BACKGROUND: The ventilation bundle has been used in adult intensive care units to decrease harm and improve quality of care for mechanically ventilated patients. The ventilation bundle focuses on prevention of specific complications of mechanical ventilation; ventilator-associated pneumonia, sepsis, barotrauma, pulmonary oedema, pulmonary embolism, and acute respiratory distress syndrome. The Institute for Healthcare Improvement ventilation bundle consists of five structured evidence-based interventions: head of the bed elevation at 30-45°; daily sedation interruptions and assessment of readiness to extubate; peptic ulcer prophylaxis; deep vein thrombosis prophylaxis; and daily oral care with chlorhexidine. OBJECTIVES: The objective of the study was to evaluate the use of the ventilation bundle in two intensive care units in Victoria, Australia. METHODS: This is a 3-month prospective observational study in two intensive care units. Patient medical records were reviewed on days 3, 4, and 5 of mechanical ventilation using a prevalidated ventilation bundle checklist. RESULTS: A total of 96 critically ill patients required mechanical ventilation for more than 2 d. Patients had a mean age of 64.50 y (standard deviation = 14.89), with an Acute Physiology, Age, Chronic Health Evaluation (APACHE) III mean score of 79.27 (standard deviation = 27.11). The mean ventilation bundle compliance rate was 88.3% on the three consecutive mechanical ventilation days (day 3 = 79.4%, day 4 = 91.1%, and day 5 = 96.7%). There was a statistically significant difference in the mean APACHE III score between patients who had head of bed elevation and those without head of bed elevation, on days 3 (p = <0.001) and 4 (p = 0.007). CONCLUSION: The ventilation bundle elements were used in Australian intensive care units. The likelihood of having all ventilation bundle elements on day 3 was low if the patient's APACHE III score was high. However, the ventilation bundle compliance rate increased with mechanical ventilation days.

Investigating the incidence and type of sharps injuries within the nursing student population in the UK.

AIMS: To identify the incidence and type of sharps injuries within a UK nursing student population. BACKGROUND: Evidence suggests that nursing students sustain sharps injuries across the world, but there is a lack of data from the UK. Design: Questionnaire survey. METHODS: A survey was administered to a volunteer sample of nursing students (n=1015) in a university, following which the survey was distributed to nursing students nationwide using snowball sampling via social media. Datasets from 1015 nursing students were available for analysis. RESULTS: Sharps injuries were most likely to occur with glass ampoules, when preparing injections and to occur in the second year of the programme. Contributing factors to sharps injury were identified, with inexperience being the primary cause. Some nursing students reported psychological impacts after sustaining the sharps injury. CONCLUSION: Sharps injuries are common among nursing students, and can have many psychological consequences for an individual.

The experience and psychological impact of a sharps injury on a nursing student population in the UK.

AIMS: The aims of this study were to explore the experience and psychological impact of sustaining a sharps injury within a nursing student population in the UK. Design: A qualitative approach was taken, using two methods to gather data, namely a Twitter chat and interviews. METHODS: A Twitter chat was orchestrated to investigate the experiences of sharps injury with nursing students and registered nurses nationwide (n=71). Interviews were conducted with nursing students from a university in the UK who had sustained a sharps injury (n=12) to discover their experiences and the impact of the injury. Findings were then synthesised and examined. RESULTS: Some nursing students reported psychological impacts after sustaining the sharps injury, which affected both their professional and personal life. The qualitative findings were synthesised into eight themes. CONCLUSION: Sharps injuries can have many psychological impacts on the individual nursing student and necessary support should be available.

Practice priorities for acute care nursing: A Delphi study.

AIMS AND OBJECTIVES: To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus. BACKGROUND: Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care. DESIGN: Delphi Method. METHOD: A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist. RESULTS: High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care. CONCLUSION: The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise. RELEVANCE TO CLINICAL PRACTICE: This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care.

Public involvement in designing a study on patient-witnessed cardiopulmonary resuscitation in hospital.

The aim of this paper is to report the findings of the consultation rounds with former patients and health care professionals to inform the design of a qualitative study. We aimed to understand stakeholders' views regarding the relevance of a proposed study looking at the impact of patients witnessing cardiopulmonary resuscitation on other patients in hospital, the appropriateness of the proposed methodology and ethical aspects. We conducted an online survey (n = 22) and telephone interviews (n = 4) with former patients linked to the British Heart Foundation charity and a focus group (n = 15) with hospital health care professionals involved in cardiopulmonary resuscitation activities. Data were analysed using thematic analysis. The consultation rounds provided valuable advice on three major themes: conceptual aspects, methodological aspects and practical suggestions. The conceptual aspects were related to the relevance of the proposed study, the emotional impact for participating patients and how the social interaction among patients could influence the witnessing experience. Methodological advice included recruitment strategies and data collection methods such as the use of individual and focus group interviews, the timeframe of interviews with patients and the topics of the interview guides. In the third theme, practical suggestions were provided, such as strategies to advertise the study, improving the public's and participants' engagement throughout the study process and disseminating the findings. Overall, the study proposed in this consultation was considered relevant and worthy by patients and health care professionals to raise awareness and generate new evidence on an unconsidered aspect of cardiopulmonary resuscitation and of patients' hospital experience. These stakeholders' consultation rounds constituted a valuable exercise to design high-quality research based on a shared vision among researchers, service users and clinicians. They also provided pragmatic advice to inform critical care practice to support patients witnessing cardiopulmonary resuscitation in hospital.

Patient diaries: Survey of paediatric intensive care units in the United Kingdom and Ireland.

AIM: The aim of the study was to explore the incidence, use, and scope of patient diaries in paediatric intensive care units (PICUs) in the United Kingdom and Ireland. DESIGN: This was an electronic survey sent to 30 PICUs in the United Kingdom and Ireland. RESULTS: All PICUs (n = 30) responded, and 43% (n = 13) offered diaries. For those units that did not supply diaries, the reasons given were concerns around the legal and professional implication of using diaries. Parental/carer consent to use a diary was obtained informally (79%, n = 11), and once there was agreement to provide a diary to parents, diaries were usually started immediately (72%, n = 12). Parents were the main contributors to the diaries (94%, n = 17), and the diaries were populated with photographs (94%, n = 15), drawings (100%, n = 16), and stickers (94%, n = 15). The reasons for offering diaries were to fill gaps in memories, to engage with families, and to explain what has happened in lay language. The owner of the diary was reported to be the family (82%, n = 14) and the child (12%, n = 2). CONCLUSIONS: The use of patient diaries is an evolving intervention in paediatric intensive care settings in the United Kingdom and Ireland. This national survey has provided a clearer picture of how this intervention is used in the United Kingdom and Ireland. PICU patient diaries are used in a significant number of units, and how these are used is relatively standardized, although in some different ways from general ICUs. RELEVANCE TO CLINICAL PRACTICE: This survey provides a baseline for future exploration, understanding, and promotion of patient diaries, as a well evaluated tool for the critically ill child and his or her family.

What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study.

BACKGROUND: In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres? METHODS: Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach. RESULTS: Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable. CONCLUSIONS: Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.

Exploring patients' and healthcare professionals' experiences of patient-witnessed resuscitation: A qualitative study protocol.

AIM: The aim of this study was to explore the experiences of patients and healthcare professionals regarding patients witnessing resuscitation on another patient in hospital clinical wards. DESIGN: Phenomenological qualitative study. METHODS: Participants will be recruited from nine wards in a university hospital in England. Data collection will include two in-depth interviews with patients who witnessed resuscitation: the first interview one week after witnessing resuscitation and the second interview after one month. Individual and focus group interviews with healthcare professionals will be also conducted. Data will be transcribed, managed in NVivo 11 and analysed using phenomenological analysis. The National Health Service, Health Research Authority and University Ethics Committee approved the study (May 2018). The study is funded by Resuscitation Council UK (December 2017) and will be conducted between May 2018-March 2019. CONCLUSION: While witnessed resuscitation is a major topic of interest in nursing, specific research on the impact of patients who witness resuscitation on fellow patients is limited. This study will use qualitative methodology to inform the evidence base of a clinical problem with limited understanding. The findings of this study will contribute to the framework of witnessed resuscitation and to identifying the barriers and enablers towards a greater support of patients who witness resuscitation in hospital. This new acquired knowledge will be beneficial to the improvement of future nursing care. IMPACT: The evidence gained from this study can support the development and implementation of guidelines and inform hospital policies to support patients witnessing resuscitation to optimize the quality of nursing care provided.

'They do not care how much you know until they know how much you care': a qualitative meta-synthesis of patient experience in the emergency department.

BACKGROUND: Patient experience is positively associated with both clinical effectiveness and patient safety and should be a priority for emergency care providers. While both quantitative and qualitative approaches can be used to evaluate patient experience in the emergency department (ED), the latter is well aligned to develop a detailed understanding of features influencing the lived experience of ED patients. This study aimed to systematically review the literature of qualitative studies to identify determinants of adult patient experience in the ED. METHODS: A Preferred Reporting Items for Systematic review and Meta-Analysis compliant systematic review was conducted using PubMed, CINAHL, EMBASE, BNI and bibliography searches to identify qualitative studies exploring patient experiences in ED published in English between 1997 and 2018. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist. Descriptive text and quotations relating to patient experience were extracted from included studies and a meta-synthesis conducted using thematic analysis. RESULTS: A total of 625 records were screened from which 40 studies underwent full review and 22 were included. Results were coded by two researchers (BG and JML). Meta-synthesis identified 198 discrete units of analysis which were clustered around five analytical themes. These were based on the perceived 'needs' of patients visiting the ED and were defined as communication, emotional, competent care, physical/environmental and waiting needs. Findings were translated into a conceptual model for optimising patient experience in the ED. CONCLUSION: This meta-synthesis provides a framework for understanding the determinants of patient experience in the ED. The resulting conceptual model and recommendations may have the potential to directly inform practice and improve the patient experience.

Are physiotherapists employing person-centred care for people with dementia? An exploratory qualitative study examining the experiences of people with dementia and their carers.

BACKGROUND: People with dementia may receive physiotherapy for a variety of reasons. This may be for musculoskeletal conditions or as a result of falls, fractures or mobility difficulties. While previous studies have sought to determine the effectiveness of physiotherapy interventions for people with dementia, little research has focused on the experiences of people receiving such treatment. The aim of this study was to gain an in-depth understanding of people's experiences of receiving physiotherapy and to explore these experiences in the context of principles of person-centred care. METHODS: Semi-structured interviews were undertaken with people with dementia or their carers between September 2016 and January 2017. A purposive sampling strategy recruited participants with dementia from the South West of England who had recently received physiotherapy. We also recruited carers to explore their involvement in the intervention. Thematic analysis was used to analyse the data. RESULTS: A total of eleven participants were recruited to the study. Six people with dementia were interviewed and five interviews undertaken separately with carers of people with dementia. Three themes were identified. The first explores the factors that enable exercises to be undertaken successfully, the second deals with perceived resource pressures, and the final theme "the physiotherapy just vanished" explores the feeling of abandonment felt when goals and expectations of physiotherapy were not discussed. When mapped against the principles of person-centred care, our participants did not describe physiotherapy adopting such an approach. CONCLUSION: Lack of a person-centred care approach was evident by ineffective communication, thus failing to develop a shared understanding of the role and aims of physiotherapy. The incorporation of person-centred care may help reduce the frustration and feelings of dissatisfaction that some of our participants reported.

Perceived language proficiency and pain assessment by registered and student nurses in native English-speaking and EAL children aged 4-7 years.

AIMS AND OBJECTIVES: To identify the factors that influence decisions made by health professionals when assessing the pain of native English speaking and children whose English is an additional language. BACKGROUND: Pain assessment in children is often poorly executed following acute injury. Whilst a range of pain assessment tools have been developed, little guidance is provided for assessing pain in children with English as an additional language. DESIGN: Factorial survey design. METHODS: Twenty minor injuries unit nurses and 20 children's nursing students participated in an electronic survey to make judgements on 12 scenarios describing a child attending a minor injuries unit following an incident, accompanied by a parent. Respondents had to decide the most important form of pain assessment, and whether they would ask a parent or an interpreter to assess the pain of the child. An open-ended question asked about the difficulties found in making a judgement. RESULTS: Observation of the child's behaviour was the most common pain assessment reported. The visual analogue scale was significantly associated with children with proficient English. Respondents were significantly more likely to involve parents in the assessment if they could speak English well compared to parents with poor English skills. Moreover, nursing students were significantly more likely than registered nurses to call for support from an interpreter. Thematic analysis identified three themes related to difficulties with pain assessment: contrasting approaches, differing perceptions of pain and overcoming challenges. CONCLUSIONS: The reduced ability to communicate between child, parent and healthcare professional highlights the need to identify forms of assessment based on individual cases. RELEVANCE TO CLINICAL PRACTICE: The number of children with English as an additional language has seen a marked rise over the last decade. In situations where communication ability is reduced, assessment of pain should be tailored to meet the needs of the child. This may require timely access to interpreter services.

Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses.

AIMS AND OBJECTIVES: To determine, from the perspectives of enrolled nurses and registered nurses, the current scope of enrolled nurse practice and to identify the activities that most enrolled nurses frequently performed in their workplace. BACKGROUND: Enrolled nurse scope of practice in Australia has evolved and expanded over the past decade. However, the unclear role, function and competency differentiation between enrolled nurse and registered nurse leads to role confusion and ongoing professional debate. DESIGN: Exploratory Descriptive Study. METHODS: A cross-sectional online survey of enrolled nurses and registered nurses across Australia was conducted examining their levels of agreement on statements related to the scope of practice and the clinical and nonclinical activities that enrolled nurses were required to perform in their workplace. RESULTS: Valid responses were received from 892 enrolled nurses and 1,198 registered nurses. Enrolled nurses mostly agreed that they understood their scope of practice; did not undertake roles for which they were unprepared; sometimes undertook activities other than direct patient care; and believed that they operated equally to many registered nurses. The majority of enrolled nurses reported that they performed tasks mostly related to basic patient care in their workplace. There were a number of significant differences between perspectives of registered nurses and enrolled nurses. CONCLUSIONS: Clarifying the roles and scope of practice between the registered nurse and the enrolled nurse is important, and explicit differences in responsibility and accountability between their roles must be clearly articulated to harmonise perceptions about role and capability. Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned. RELEVANCE TO CLINICAL PRACTICE: Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned.

Health professional perspectives of patient safety issues in intensive care units in Saudi Arabia.

AIM: To examine attitudes to patient safety in two intensive care units from the perspective of health care professionals in Saudi Arabia. BACKGROUND: Despite adverse errors leading to poor patient outcomes, there is a paucity of literature, including staff perceptions, on adverse errors in Saudi Arabian intensive care units. METHODS: A descriptive cross-sectional design was used. Health professionals (n = 144) completed the safety attitude questionnaire-intensive care unit. RESULTS: The scores from the six safety domains of the safety attitude questionnaire-intensive care unit showed all respondents had a negative attitude towards patient safety, with participants in one intensive care unit scoring lower in all domains. The mean scores across all domains ranged from 47.1 to 70.3 on a 100-point scale, with the lowest score reported in the "perceptions of management" domain. Respiratory therapists reported a significantly higher job satisfaction score than nurses, and physicians rated communication amongst themselves and nurses as high. CONCLUSION: There are significant challenges for safety culture in this study, with negative attitudes across all domains. IMPLICATION FOR NURSING MANAGEMENT: Managers may need to review and consider policies relating to safety culture including workforce planning, leadership and patient centred care. Further research into this global health priority is required to contribute to improving patient safety in intensive care units.