An examination of relational dynamics of power in the context of supported (assisted) decision-making with older people and those with disabilities in an acute healthcare setting.

INTRODUCTION: Supported (assisted) healthcare decision-making (ADM) focuses attention on how people with disabilities, including cognitive impairments, can be best supported to make decisions about their health and social care on an equitable basis with others. Meaningful implementation of legal frameworks for ADM challenges long-held presumptions about who has access to valued decision-making resources, influence and power within a particular socio-cultural setting. This study aims to explore the relational power dynamics around ADM with older people in acute care settings. METHODS: This study adopts a critical hermeneutic approach to qualitatively explore the lived experience of ADM from the perspectives of Health and Social Care Professionals (N = 26). This is supported by an exploration of the experiences of older people (N = 4), older people with a diagnosis of dementia (N = 4) and family carers (N = 5). RESULTS: We present three themes of data analysis that represent three spaces where the relational aspects of power in ADM are manifested. The first space, centralising decision-making power within multidisciplinary teams identified the privileging of physicians in traditional hierarchical leadership models that may lead to the implicit exclusion of family carers and some Health and Social Care Professionals in the ADM process. Privileging cognitive and communication competence identified a tendency to attribute decision-making autonomy to those with cognitive and communication competency. The final space, balancing the duty of care and individual autonomy, recognises acute care settings as typically risk-averse cultures that limit autonomy for decisions that carry risk, especially for those with cognitive impairment. CONCLUSION: Findings indicate the need to address cultural sources of power operating through social norms premised on ageist and ableist ideologies. It is necessary to challenge institutional barriers to meaningful ADM including positional power that is associated with hierarchies of influence and protectionism. Finally, meaningful ADM requires resistance to the disempowerment created by structural, economic and social circumstances which limit choices for decision-making. PATIENT OR PUBLIC CONTRIBUTION: A public and patient involvement panel of older people were consulted in the development of the grant application (HRB: APA-2016-1878). Representatives from Alzheimer's Society Ireland and Family Carers Ireland were steering committee members guiding design and strategy.

Assisted decision-making and interprofessional collaboration in the care of older people: a qualitative study exploring perceptions of barriers and facilitators in the acute hospital setting.

In recent years, there has been a move toward a more human rights-based approach to the issue of supported and assisted decision-making (ADM) with legislative changes strengthening the formal right for older people to participate in care planning and decision-making. Ireland's Assisted Decision-Making (Capacity) Act, 2015 breaks from traditional views of capacity to consider the uniqueness of each decision in relation to topic, time and place for those with impaired or fluctuating capacity. This study set out to explore experiences of assisted decision making (ADM) in acute care hospitals in Ireland and to identify the barriers and enablers to ADM for older people and people with dementia from the perspective of different Health and Social Care Professionals (HSCPs) involved in their care. We carried out 26 semi-structured audio-recorded interviews with a convenience sample of HSCPs working in two acute hospitals and subsequently confirmed the results. HSCPs identified several barriers to, and enablers of, ADM in acute hospitals that were categorized into three key themes: Building meaningful engagement with older people and their family carers; barriers and enablers associated with interprofessional collaboration and barriers and enablers associated with the environment. Our findings suggest that despite concrete policy and legislative underpinnings to ADM, this was not always evident in practice and suggests the need for specialized education and training on ADM in practice settings.

The micropolitics of implementation; a qualitative study exploring the impact of power, authority, and influence when implementing change in healthcare teams.

BACKGROUND: Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams. METHODS: The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation). RESULTS: The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants' experiences of the implementation process. CONCLUSION: To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes.

Designing and developing core physiology learning outcomes for pre-registration nursing education curriculum.

Physiology is a key element of "bioscience" education within pre-registration nursing programs, but there is a lack of clarity on what is included. Physiology and bioscience content and delivery are highly varied across both higher education institutions and the related programs in the United Kingdom (UK). Despite evidence highlighting concerns over nurses' lack of bioscience knowledge and unsafe practice, there is no universally agreed on curriculum with detailed outcomes of minimum levels of knowledge to support nurses in practice and patient care. This study aimed to inform the construction of discipline-specific physiology learning outcomes to clarify relevant physiological topics required in pre-registration nursing. Initially, 360 learning outcomes were identified from various sources. Using a modified Delphi approach, an expert panel from the Bioscience in Nurse Education group reviewed and modified the list to 195 proposed outcomes. These were circulated to universities in the UK who teach nursing (n = 65). Outcomes that had 80% consensus were automatically included in the next round, with others recommended with modification (response rate 22%). The panel reviewed the modifications, and 182 outcomes were circulated in the second questionnaire (response rate 23%), and further panel review resulting in 177 outcomes agreed. These learning outcomes do not suggest how they should be delivered, but gives the basic level required for qualification as a nurse commensurate with the Nursing and Midwifery Council new standards for the "future nurse."

What are the mechanisms that support healthcare professionals to adopt assisted decision-making practice? A rapid realist review.

BACKGROUND: The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) establishes a right to legal capacity for all people, including those with support needs. People with disabilities have a legal right to be given the appropriate supports to make informed decisions in all aspects of their lives, including health. In Ireland, the Assisted Decision-Making (Capacity) Act (2015) ratifies the Convention and has established a legal framework for Assisted Decision Making (ADM). The main provisions of the Act are not yet implemented. Codes of Practice to guide health and social care professionals are currently being developed. Internationally, concerns are expressed that ADM implementation is poorly understood. Using realist synthesis, this study aims to identify Programme Theory (PT) that will inform ADM implementation in healthcare. METHODS: A Rapid Realist Review using collaborative methods was chosen to appraise relevant literature and engage knowledge users from Irish health and social care. The review was led by an expert panel of relevant stakeholders that developed the research question which asks, 'what mechanisms enable healthcare professionals to adopt ADM into practice?' To ensure the PT was inclusive of local contextual influences, five reference panels were conducted with healthcare professionals, family carers and people with dementia. PT was refined and tested iteratively through knowledge synthesis informed by forty-seven primary studies, reference panel discussions and expert panel refinement and consensus. RESULTS: The review has developed an explanatory PT on ADM implementation in healthcare practice. The review identified four implementation domains as significant. These are Personalisation of Health & ADM Service Provision, Culture & Leadership, Environmental & Social Re-structuring and Education, Training & Enablement. Each domain is presented as an explanatory PT statement using realist convention that identifies context, mechanism and outcome configurations. CONCLUSIONS: This realist review makes a unique contribution to this field. The PT can be applied by policymakers to inform intervention development and implementation strategy. It informs the imminent policy and practice developments in Ireland and has relevance for other worldwide healthcare systems dealing with similar legislative changes in line with UNCRPD.

Optimizing nursing time in a day care unit: Quality improvement using Lean Six Sigma methodology.

OBJECTIVE: This study applies Lean Six Sigma (LSS) to improve the efficiency of a private hospital day care unit and generate a positive impact on optimizing nursing time and improving personalized patient care and staff satisfaction. DESIGN: A prospective interventional study using pre- and post-evaluation. SETTING: A day care unit at a private hospital. PARTICIPANTS: Nurses and patients from the day unit. INTERVENTION(S): Define, Measure, Analyze, Improve and Control was used as an overarching problem-solving framework. All front line staff, clinical leaders and managers were supported as active change agents in the quality improvement (QI) initiative. Multiple interventions were adopted across the service that aimed to de-implement non-value added activities and enhance processes with activities that added value. MAIN OUTCOME MEASURES: Patient turnaround times (PTTs), nursing time, nurse-patient ratio, nurse and patient survey. RESULTS: A post-implementation evaluation highlighted significant improvements in service performance and patient and staff satisfaction. Significant added value includes a reduction in PTTs, an increase in nursing care time and improvement in the nurse-patient ratio. CONCLUSION: This project identified that utilizing LSS that relies on collaborative team effort is effective in creating a positive organizational culture for improvement and change. The Six Sigma tools and techniques provide evidence-based approaches that support QI in practice.

Has bioscience reconciled mind and body?

AIMS AND OBJECTIVES: The aim of this discursive paper is to explore the question 'has biological science reconciled mind and body?'. BACKGROUND: This paper has been inspired by the recognition that bioscience has a historical reputation for privileging the body over the mind. The disregard for the mind (emotions and behaviour) cast bioscience within a 'mind-body problem' paradigm. It has also led to inherent limitations in its capacity to contribute to understanding the complex nature of health. DESIGN: This is a discursive paper. METHODS: Literature from the history and sociology of science and psychoneuroimmunology (1975-2015) inform the arguments in this paper. The historical and sociological literature provides the basis for a socio-cultural debate on mind-body considerations in science since the 1970s. The psychoneuroimmunology literature draws on mind-body bioscientific theory as a way to demonstrate how science is reconciling mind and body and advancing its understanding of the interconnections between emotions, behaviour and health. RESULTS: Using sociological and biological evidence, this paper demonstrates how bioscience is embracing and advancing its understanding of mind-body interconnectedness. It does this by demonstrating the emotional and behavioural alterations that are caused by two common phenomena; prolonged, chronic peripheral inflammation and prolonged psychological stress. The evidence and arguments provided has global currency that advances understanding of the inter-relationship between emotions, behaviour and health. CONCLUSIONS: This paper shows how bioscience has reconciled mind and body. In doing so, it has advanced an understanding of science's contribution to the inter-relationship between emotions, behaviour and health. RELEVANCE TO CLINICAL PRACTICE: The biological evidence supporting mind-body science has relevance to clinical practice for nurses and other healthcare professions. This paper discusses how this evidence can inform and enhance clinical practice directly and through research, education and policy.

Teaching and learning in the Biosciences: the development of an educational programme to assist student nurses in their assessment and management of patients with wounds.

AIMS AND OBJECTIVES: The aim of this project was to develop an educational package for undergraduate student nurses that would provide them with the theoretical knowledge and clinical judgement skills to care for a patient with a wound. BACKGROUND: Internationally there is concern over the adequacy of preparation of undergraduate nurses for the clinical skill of wound care. Deficits have also been identified in the underpinning biological sciences needed for this skill. Expectations associated with wound management have altered significantly in the last two decades with decision making around wound care coming under the scope of practice of nurses. The treatment and care options for patients with wounds must be based on a sound knowledge of how wounds are formed and healed. If nurses do not have the evidence-based knowledge, it can affect wound healing adversely leading to increased patient suffering, pain and delayed healing. From an organisational perspective, delayed healing will increase the cost of care. DESIGN: This project used constructivism learning theory to provide a framework for the development of a wound care educational package for undergraduate Irish nurses in their penultimate year of training. METHODS: Collaboration was formed with key stake holders. Pertinent curriculum content was mapped. Learning strategies to suit the incoming student learning styles were incorporated into newly developed theoretical content and practical skill sessions. CONCLUSION: The developed educational programme will assist student nurses in their care of patients with wounds. RELEVANCE TO CLINICAL PRACTICE: This study provides a model that can be followed to develop small units of the study to keep abreast of changes in health care delivery and the changing scope of practice of nurses. It also contributes to the debate on the teaching and learning of biosciences as it highlights the depth of biological knowledge required as a basis for good evidence-based nursing care.

'Two dead frankfurts and a blob of sauce': the serendipity of receiving nutrition and hydration in Australian residential aged care.

BACKGROUND: This paper explores the serendipity of residents accessing adequate food and fluids in aged care facilities. It draws on the findings of two discrete but interrelated research projects conducted in 2009 and 2011 relating to the experience of living in, or having a friend or family member living in, residential aged care. METHODS: Participants were recruited through media outlets. Indepth interviews with participants were audiotaped, transcribed verbatim and thematically analysed. FINDINGS: This paper discusses a theme that was iterated by participants in both projects that is, the difficulty residents in aged care facilities experienced in receiving adequate and acceptable food and fluids. Unacceptable dining room experiences, poor quality food and excessive food hygiene regulations contributed to iatrogenic malnutrition and dehydration. Implications for staffing, clinical supervision, education of carers and the impact of negative attitudes to older people are discussed. CONCLUSION: The inability of dependent residents in aged care facilities to receive adequate nourishment and hydration impacts on their health and their rights as a resident, and is an ongoing issue in Australian residential aged care.

A realist process evaluation of an intervention to promote competencies in interprofessional collaboration among interdisciplinary integrated care teams for older people: Study protocol.

Background: International policy is increasingly committed to placing interdisciplinary team-working at the centre of health and social care integration across the lifespan. The National Clinical Programme for Older People in Ireland has a critical role in the design and implementation of the National Older Person's Service Model, which aims to shift the delivery of care away from acute hospitals towards community-based care. Interdisciplinary Community Specialist Teams for older persons (CST-OPs) play an important role in this service model. To support the development of competencies for interprofessional collaboration and an interdisciplinary team-based approach to care integration, a culture shift will be required within care delivery. Design:This study builds upon a collaborative partnership project which co-designed a framework describing core competencies for interprofessional collaboration in CST-OPs. A realist-informed process evaluation of the framework will be undertaken as the competencies described in the framework are being fostered in newly developed CST-OPs under the national scale-up of the service model. Realist evaluation approaches reveal what worked, why it worked (or did not), for whom and under what circumstances. Three iterative and integrated work packages are proposed which combine multiple methods of data collection, analysis and synthesis. Prospective data collection will be undertaken within four CST-OPs, including qualitative exploration of the care experiences of older people and family carers. Discussion: The realist explanatory theory will provide an understanding of how interprofessional collaboration can be fostered and sustained in various contexts of care integration for older people. It will underpin curriculum development for team-based education and training of health and social care professionals, a key priority area in the national Irish health strategy. It will provide healthcare leaders with knowledge of the resources and supports required to harness the benefits of interprofessional collaboration and to realise the goals of integrated care for older people.

Forced into exile: the traumatising impact of rural aged care service inaccessibility.

INTRODUCTION: The shortage of residential aged care places is especially acute in rural areas and this results in many older people who live in these areas being forced to leave their home communities to access care in distant communities. This article reports on one aspect of a larger study that explored family and caring community members' experiences when someone they cared for needed to access residential aged care away from their rural communities. METHODS: This qualitative research project, informed by phenomenology, was conducted in rural communities of New South Wales (NSW), Australia. Participants were recruited from media coverage of the proposed research. Indepth interviews were conducted, audiotaped and transcribed. Thematic analysis was undertaken by two researchers independently analysing the themes and then cross-checking these to ensure their strength. RESULTS: The 21 interviews conducted revealed that inaccessibility of residential aged care places caused many to experience loss, loneliness and a sense of social disconnectedness. The affected rural older person is exiled from their home community only to return to be buried. There are implications for the family and the rural community who are distanced by kilometres, transport and finances and, more significantly, by the emotional ties that bind families, friends and communities. CONCLUSION: The participants whose experiences were explored in this article described a sense of being in exile when residential aged care services are inaccessible in their local communities. The sense of exile is felt not only by the person moving away but also by their family, friends and neighbours. For this reason, rural residential aged care service delivery should be based on the identified needs of the older person and those who love and care for them.

Context counts: a qualitative study exploring the interplay between context and implementation success.

PURPOSE: Implementing change in healthcare is difficult to accomplish due to the unpredictability associated with challenging the status quo. Adapting the intervention/practice/program being implemented to better fit the complex context is an important aspect of implementation success. Despite the acknowledged influence of context, the concept continues to receive insufficient attention at the team-level within implementation research. Using two heterogeneous multidisciplinary healthcare teams as implementation case studies, this study evaluates the interplay between context and implementation and highlights the ways in which context influences the introduction of a collective leadership intervention in routine practice. DESIGN/METHODOLOGY/APPROACH: The multiple case study design adopted, employed a triangulation of qualitative research methods which involved observation (Case A = 16 h, Case B = 15 h) and interview data (Case A = 13 participants, Case B = 12 participants). Using an inductive approach, an in-depth thematic analysis of the data outlined the relationship between team-level contextual factors and implementation success. FINDINGS: Themes are presented under the headings: (1) adapting to the everyday realities, a key determinant for implementation success and (2) implementation stimulating change in context. The findings demonstrate a dynamic relationship between context and implementation. The challenges of engaging busy healthcare professionals emphasised that mapping the contextual complexity of a site and adapting implementation accordingly is essential to enhance the likelihood of successful implementation. However, implementation also altered the surrounding context, stimulating changes within both teams. ORIGINALITY/VALUE: By exposing the reciprocal relationship between team-level contextual factors and implementation, this research supports the improved design of implementation strategies through better understanding the interplay and mutual evolution of evidence-based healthcare interventions within different contexts.

A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice.

Quality measurement initiatives promote quality improvement in healthcare but can be challenging to implement effectively. This paper presents a Rapid Realist Review (RRR) of published literature on Quality Care-Process Metrics (QCP-M) implementation in nursing and midwifery practice. An RRR informed by RAMESES II standards was conducted as an efficient means to synthesize evidence using an expert panel. The review involved research question development, quality appraisal, data extraction, and evidence synthesis. Six program theories summarised below identify the key characteristics that promote positive outcomes in QCP-M implementation. Program Theory 1: Focuses on the evidence base and accessibility of the QCP-M and their ease of use by nurses and midwives working in busy and complex care environments. Program Theory 2: Examines the influence of external factors on QCP-M implementation. Program Theory 3: Relates to existing cultures and systems within clinical sites. Program Theory 4: Relates to nurses' and midwives' knowledge and beliefs. Program Theory 5: Builds on the staff theme of Programme Theory four, extending the culture of organizational learning, and highlights the meaningful engagement of nurses and midwives in the implementation process as a key characteristic of success. Program Theory 6: Relates to patient needs. The results provide nursing and midwifery policymakers and professionals with evidence-based program theory that can be translated into action-orientated strategies to help guide successful QCP-M implementation.

Children as innovators: harnessing the creative expertise of children to address practical and psychosocial challenges of the coronavirus disease 2019 (COVID-19) pandemic - COVISION study protocol.

Background: We are currently in a period of transition, from the pre-COVID-19 (coronavirus disease 2019) era and the initial reactive lockdowns, to now the ongoing living with and potentially the after COVID-19 period. Each country is at its own individual stage of this transition, but many have gone through a period of feeling adrift; disconnected from normal lives, habits and routines, finding oneself betwixt and between stages, similar to that of liminality. Children and young people have been particularly affected. Aim: To increase the understanding of home and community-based strategies that contribute to children and young people's capacity to adjust to societal changes, both during and after pandemics. Moreover, to identify ways in which children's actions contribute to the capacity of others to adjust to the changes arising from the pandemic. The potential for these activities to influence and contribute to broader social mobilisation will be examined and promoted. Research design: To achieve the aim of this study, a participatory health research approach will be taken. The overarching theoretical framework of the COVISION study is that of liminality. The study design includes four work packages: two syntheses of literature (a rapid realist review and scoping review) to gain an overview of the emerging international context of evidence of psychosocial mitigations and community resilience in pandemics, and more specifically COVID-19; qualitative exploration of children and young people's perspective of COVID-19 via creative outlets and reflections; and participatory learning and action through co-production.

'Mind you, there's no anaesthetist on the road': women's experiences of labouring en route.

INTRODUCTION: The aim of this article was to learn from women in rural New South Wales (NSW) Australia, their experiences of labouring en route to birth in a centralised maternity unit. METHODS: This qualitative study was exploratory and descriptive. It was part of a larger project that explored women's experiences when they birthed away from their rural communities. Participants were recruited from communities all over rural NSW where a maternity unit had closed. Forty-two female participants and three of their male partners shared their stories of 73 labours and births. This article draws on data collected during in-depth interviews with 12 participants and one partner who shared their experiences of labouring en route to a centralised maternity service. Interviews were audiotaped and transcribed verbatim for the purpose of thematic analysis. Exemplars, using the participants' own words and highlighting story are identified as a tool used for data synthesis and presentation. RESULTS: Two themes were identified. These relate to the way the risk of dangerous road travel is ignored in obstetric risk discourse, and the deprivations experienced when women labour en route. An unexpected finding was the positive nature of one woman's experience of birthing by the side of the road. CONCLUSIONS: Many participants questioned why they needed to risk unsafe road travel when their preference was to labour and birth in their local communities with a midwife.

Animal assisted interventions in the children's hospital: protocol for a scoping review.

The introduction of animal interventions in healthcare are relatively common; however, their actual effectiveness and longer term findings are not so well known or published, especially in relation to the children's hospital setting.  It is important to plot where and why animal interventions take place but also to focus on how the human animal bond impacts on children, their parents and staff in a children's hospital setting.  Family members, including companion animals, are important supports which help children to relax and give them a sense of familiarity to navigate the busy and stressful hospital environment.  The scoping review of the literature proposed will explore the scientific evidence for animal assisted activities (AAA) in children's hospitals and will map results prior to undertaking a full scale research project.   Arksey and O'Malley's framework guided by the Joanna Briggs Institute will frame this review protocol.  Appendices are used to ensure transparency of methods. The protocol is presented in narrative style to demonstrate flow and fluency and appeal to wider readership.

"What Bothers Me Most Is the Disparity between the Choices that People Have or Don't Have": A Qualitative Study on the Health Systems Responsiveness to Implementing the Assisted Decision-Making (Capacity) Act in Ireland.

OBJECTIVE: The Assisted Decision-Making (ADM) (Capacity) Act was enacted in 2015 in Ireland and will be commenced in 2021. This paper is focused on this pre-implementation stage within the acute setting and uses a health systems responsiveness framework. METHODS: We conducted face-to-face interviews using a critical incident technique. We interviewed older people including those with a diagnosis of dementia (n = 8), family carers (n = 5) and health and social care professionals (HSCPs) working in the acute setting (n = 26). RESULTS: The interviewees reflected upon a healthcare system that is currently under significant pressures. HSCPs are doing their best, but they are often halted from delivering on the will and preference of their patients. Many older people and family carers feel that they must be very assertive to have their preferences considered. All expressed concern about the strain on the healthcare system. There are significant environmental barriers that are hindering ADM practice. CONCLUSIONS: The commencement of ADM provides an opportunity to redefine the provision, practices, and priorities of healthcare in Ireland to enable improved patient-centred care. To facilitate implementation of ADM, it is therefore critical to identify and provide adequate resources and work towards solutions to ensure a seamless commencement of the legislation.

Increasing competence in wound care: A cross-sectional study to evaluate use of a virtual patient by undergraduate student nurses.

Concerns have arisen internationally over the competency of student nurses to perform wound care. A global shortage of nursing faculty and clinical practice opportunities is regarded as a contributing factor. Virtual simulation offers a possible solution. The aim of this study was to describe the development and educational evaluation of a virtual patient to supplement undergraduate learning of wound care. The National League for Nursing Jeffries model informed the design of the media. Evaluation of the virtual patient by penultimate year nursing students (n = 148) was conducted using a survey design. Findings are presented from statistical and directed content analyses. Most students rated the educational value of the virtual patient and its support of learning highly. They reported a perceived increase in confidence and ability to meet wound care competency outcomes. The virtual patient also provided students with opportunities to develop their clinical reasoning skills. This study provides evidence that virtual patient simulation is an effective pedagogy to increase clinical competence in wound care. It allows nursing students the opportunity to practice skills and utilise theory repetitively in a safe environment, unhampered by a lack of resources such as clinical placement availability and a declining faculty.

Minding the gap: identifying values to enable public and patient involvement at the pre-commencement stage of research projects.

BACKGROUND: The University College Dublin (UCD) Public and Patient Invovlement (PPI) ignite program is focused on embedding PPI in health and social care related research, education and training, professional practice and administration. During a PPI knowledge sharing event challenges were noted during the pre-commencement stage of research projects. This stage includes the time before a research projects/partnership starts or when funding is being applied for. As a response, we agreed there was a need to spend time developing a values-based approach to be used from the pre-commencement of PPI projects and partnerships. Values are deeply held ideals that people consider to be important. They are vital in shaping our attitudes and motivating our choices and behaviours. METHODS: Using independent facilitators, we invited a diverse group of participants to a full-day workshop in February. During the workshop, the concept of a values statement and values-based approaches was introduced. The group via a majority consensus, agreed on a core set of values and a shared understanding of them. After the workshop, a draft was shared with participants for further comment and final agreement. RESULTS: The workshop had 22 people representing experts by experience, PPI charity partners, funders, academics and national PPI Ignite partners. The group via consensus identified four values of respect, openness, reciprocity and flexibility for the pre-commencement stage. A frequently reported experience of PPI partners was that some felt that the pre-commencement activities appeared at times like a performance; an act that had to be completed in order to move to the next stage rather than a genuine interest in a mutually beneficial partnership. Being open and transparent with all invovled that the funding application may not be successful was stressed. Another important feature related to 'openness' was the 'spaces' and 'places' in which meetings between partners could occur in an accessible and equitable way. The issue of 'space' is particularly critical for the involvement of seldom heard groups. The benefits of the research are often clear for academics, but for PPI partners, these are often less certain. To achieve reciprocity, academic and PPI partners need to engage in a timely, repeated and transparent dialogue to achieve beneficial outcomes for all stakeholders. Being open to new inputs and differing modes of knowledge and ideas was also stressed. For some, this will require a change in attitudes and behaviours and should result in more collective decision making. Several areas were identified using the four values. CONCLUSIONS: This work via majority consensus identified four values of respect, openness, reciprocity, and flexibility for the pre-commencement stage. These values should be used to support inclusive, effective and collective PPI across all stages of involvement. We hope this work will stimulate further action in this area. In particular, we would welcome the evaluation of these values involving diverse PPI groups.

Quality care process metrics (QCP-Ms) in nursing and midwifery care processes: a rapid realist review (RRR) protocol.

Background: In 2018, the Office of the Nursing and Midwifery Services Director (ONMSD) completed phase one of work which culminated in the development and launch of seven research reports with defined suites of quality care process metrics (QC-Ms) and respective indicators for the practice areas - acute care, midwifery, children's, public health nursing, older persons, mental health and intellectual disability nursing in Ireland. This paper presents a rapid realist review protocol that will systematically review the literature that examines QC-M in practice; what worked, or did not work for whom, in what contexts, to what extent, how and why? Methods : The review will explore if there are benefits of using the QC-Ms and what are the contexts in which these mechanisms are triggered. The essence of this rapid realist review is to ascertain how a change in context generates a particular mechanism that produces specific outcomes. A number of steps will occur including locating existing theories on implementation of quality care metrics, searching the evidence, selecting relevant documents, data extraction, validation of findings, synthesising and refining programme theory. This strategy may help to describe potential consequences resulting from changes in context and their interactions with mechanisms. Initial theories will be refined throughout the process by the local reference panel, comprised of eight key intervention stakeholders, knowledge users such as healthcare professionals and an expert panel. Ethical approval is not required for this rapid realist review. Conclusion: It is anticipated that the final programme theory will help to explain how QC-Ms work in practice; for whom, why and in what circumstances. Findings of this review could help to give insights into realism as a framework and how nursing and midwifery QC-Ms have been implemented previously.