Time spent on activities that can be delegated and reasons for not delegating among acute care nurses: A mixed-methods study.

AIM: To describe the activities nurses perceived to be delegable to other staff (delegable activities) in order to estimate the time nurses spend on delegable activities and explore nurses' reasons for not delegating these activities. DESIGN: Mixed-methods explanatory sequential. METHODS: In total, 236 nurses from 27 medical and surgical wards of five hospitals in northern Italy completed a web-based survey during a single shift between June and July 2022. Minutes spent on delegable activities, staff member to whom participants could have delegated and reason(s) for not delegating were reported. Chief nurses provided specific wards' characteristics using a paper-and-pencil questionnaire. Twenty semi-structured interviews were conducted to explore delegable activities and reasons for not delegating. Quantitative and qualitative results were merged using joint displays. RESULTS: Participants spent approximately one-quarter of their time performing delegable activities, mainly delegable to nurse aides or nurse clerks, and performed due to a lack/shortage of staff or their concurrent participation in other activities. Participants recognized that activities requiring clinical assessment and decision-making skills cannot be delegated, whereas technical activities and indirect care should be delegated. Organizational, structural and cultural factors, as well as patient characteristics, available staff and experience affected delegation, leading nurses to perform delegable activities to ensure patient care. CONCLUSION: Nurses spend a considerable part of their time on delegable activities due to a lack of staff or support services and suboptimal organization, which could be addressed by optimal staff management, but also to the complexity of the contexts, including individual and cultural factors that should be addressed through policy interventions. IMPACT: This study estimates the time nurses spend on delegable activities in acute care settings. Our findings highlighted the reasons that sustain the decision not to delegate that policymakers, healthcare managers, and nurse educators should consider to promote nurses' delegation skills. REPORTING METHODS: MMR checklist. PATIENT/PUBLIC CONTRIBUTION: None.

Consensus definition of advance care planning in dementia: A 33-country Delphi study.

INTRODUCTION: Existing advance care planning (ACP) definitional frameworks apply to individuals with decision-making capacity. We aimed to conceptualize ACP for dementia in terms of its definition and issues that deserve particular attention. METHODS: Delphi study with phases: (A) adaptation of a generic ACP framework by a task force of the European Association for Palliative Care (EAPC); (B) four online surveys by 107 experts from 33 countries, September 2021 to June 2022; (C) approval by the EAPC board. RESULTS: ACP in dementia was defined as a communication process adapted to the person's capacity, which includes, and is continued with, family if available. We identified pragmatic boundaries regarding participation and time (i.e., current or end-of-life care). Three interrelated issues that deserve particular attention were capacity, family, and engagement and communication. DISCUSSION: A communication and relationship-centered definitional framework of ACP in dementia evolved through international consensus supporting inclusiveness of persons with dementia and their family. HIGHLIGHTS: This article offers a consensus definitional framework of advance care planning in dementia. The definition covers all stages of capacity and includes family caregivers. Particularly important are (1) capacity, (2) family, (3) engagement, and communication. Fluctuating capacity was visualized in relation to roles and engaging stakeholders.

Lived experience of ethical challenges among undergraduate nursing students during their clinical learning.

BACKGROUND: Undergraduate nursing students may experience several ethical challenges during their clinical learning placement that can lead to moral distress and intention to leave the profession. Ethical challenges are complex phenomena and ethical frameworks may help improve their understanding and provide actionable recommendations to enhance students' readiness for practice. AIM: To explore undergraduate nursing students' ethical challenges experienced during their clinical learning and their suggestions for better ethics education; to illuminate students' experience against a foundational ethical framework. RESEARCH DESIGN: Qualitative study based on interpretative phenomenology. Semi-structured, in-person or at distance, one-to-one interviews were performed, audio-recorded, and transcribed verbatim. The 'Dignity-enhancing care framework' was employed to frame the study findings. PARTICIPANTS AND RESEARCH CONTEXT: Nineteen nursing graduands attending seven sites of one Northwestern Italian University were interviewed. ETHICAL CONSIDERATION: The study protocol was approved by the Ethics Committee of the University of Torino (number 0187646/2023). All participants provided written informed consent. FINDINGS: Students experienced several ethical challenges concerning daily practice such as pain control or the decision to restrain patients, and reported deficient professional ethics with healthcare professionals who demonstrated poor caring attitudes and teamwork. Moreover, they perceived professionals poorly committed to their role of educators and complained of poor support in the learning process. When a supportive, dialogical, and relational context lacked, students experienced negative feelings about the profession and the healthcare system and reported the intention to leave the profession. Dialogue with peers, family members or significant others, nursing educators, and clinical nurse supervisors, as well as self-learning activities and discussion-based teaching methods grounded on real scenarios helped to overcome challenging situations. CONCLUSION: While complying with normative standards, nursing education policies should encourage the adoption of dynamic teaching methods and sustain a regular, dialogical approach within and between the clinical and academic contexts to improve readiness for practice.

Lived experiences of end-of-life communication among nursing home staff: An interpretive phenomenological study.

AIMS: To explore and understand lived experiences of end-of-life communication among nursing home staff. DESIGN: Interpretive phenomenological study. METHODS: In-person, semi-structured, in-depth interviews were conducted from May to August 2021 with 21 nursing home staff members involved in end-of-life communication (four managers, four chief nurses, three chief medical officers, three nurses, three psychologists, two occupational therapists, one chief nurse aide and one nurse aide). Data were analysed by van Manen's hermeneutic approach, which uses the lifeworld existentials of spatiality, corporeality, temporality and relationality to guide reflection on the human experience. Data were reported according to the Consolidated Criteria for Reporting Qualitative Research. RESULTS: Thirteen categories were identified and framed within the four existentials. Regarding spatiality, end-of-life communication took place in a physical, mental, socio-cultural and professional competence space. With regard to corporeality, interviewees reported difficulties in managing their own feelings and those of family caregivers. For temporality, interviewees reported delays in end-of-life communication due to staffing issues and an increase in urgent and temporary relief admissions to nursing homes. To compensate, they tried to assure that all interactions that did take place were of high quality. Finally, with regard to relationality, interviewees lived end-of-life communication through their relationships with family caregivers and colleagues. The supportive role of colleagues was expressed as teamwork, which helped promote reflexivity about how to tailor communication, manage challenging emotions and situations, set aside time for communication, and prepare family caregivers for death. CONCLUSION: End-of-life communication was an all-encompassing experience for nursing home staff. The supportive role of colleagues was stressed across all existentials, suggesting that teamwork is essential in delivering effective communication at the end-of-life. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution to this study, which addresses the experiences of nursing home staff only.

Methodological and ethical challenges in designing and conducting research at the end of life: A systematic review of qualitative and textual evidence.

AIM: This systematic review aims to identify methodological and ethical challenges in designing and conducting research at the end of life from the perspective of researchers and provide a set of recommendations. BACKGROUND: Conducting research with patients and family carers facing end-of-life issues is ethically and methodologically complex. DESIGN: A systematic review was conducted. DATA SOURCES: Four databases (MEDLINE, EMBASE, CINAHL, PsycInfo) were searched from inception until the end of 2021 in February 2022. REVIEW METHODS: The Preferred Reporting Items for Systematic Reviews was followed, and the JBI Approach to qualitative synthesis was used for analysis. RESULTS: Seventeen of 1983 studies met inclusion criteria. Data were distilled to six main themes. These included (1) the need for flexibility at all stages of the research process; (2) careful attention to timing; (3) sensitivity in approach; (4) the importance of stakeholder collaboration; (5) the need for unique researcher skills; and (6) the need to deal with the issue of missing data. CONCLUSION: The findings illuminate several considerations that can inform training programmes, ethical review processes and research designs when embarking on research in this field.

Family caregivers' experience of communication with nursing home staff from admission to end of life during the COVID-19 pandemic: A qualitative study employing a transitional perspective.

OBJECTIVES: Family caregivers' (FCs) caregiving in nursing home (NH) moves across 3 main phases: transitioning relatives to long-term care, worsening of a relative's conditions, and end of life; each phase brings specific challenges that FCs must confront. Moreover, during the COVID-19 pandemic, strict mandatory visitor restrictions affected communication modalities. This study explored FCs' experience of communication with NH staff during the COVID-19 pandemic from admission to end of life. METHODS: A descriptive qualitative study with inductive content analysis was performed in 7 Italian NHs from May to June 2021. NH managers purposively identified 25 FCs at different phases of their caregiving trajectory: transitional (i.e., admission in the previous 8 weeks, n = 8), deterioration-in-condition (i.e., acknowledged changes in care needs of their relative after trigger events, n = 10), and end-of-life phase (i.e., death expected in the next weeks or a few months, n = 7), who were interviewed. RESULTS: Regardless the phase of caregiving trajectory, what mattered most to FCs was the opportunity to have regular and sensitive discussions with health-care professionals. The need of in-person communication increased nearing death. The COVID-19 pandemic enhanced FCs' need to interact with health-care professionals they trusted. Knowledge of residents' preferences mitigated FCs' turbulent emotions throughout the overall caregiving trajectory. SIGNIFICANCE OF RESULTS: Findings suggest that in-person contacts should be prioritized and facilitated when possible, particularly at the end of life; nonetheless, meaningful communication can occur also through remote modalities. Investments in training health-care professionals about effective long-distance communication and supportive skills can help trusting relationships to be established. Open discussions about residents' care preferences should be encouraged.

Interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes: A mixed-methods systematic review.

BACKGROUND: Most people with dementia transition into nursing homes as their disease progresses. Their family caregivers often continue to be involved in their relative's care and experience high level of strain at the end of life. AIM: To gather and synthesize information on interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes and provide a set of recommendations for practice. DESIGN: Mixed-Methods Systematic Review (PROSPERO no. CRD42020217854) with convergent integrated approach. DATA SOURCES: Five electronic databases were searched from inception in November 2020. Published qualitative, quantitative, and mixed-method studies of interventions to support family caregivers of people with advanced dementia at the end of life in nursing home were included. No language or temporal limits were applied. RESULTS: In all, 11 studies met the inclusion criteria. Data synthesis resulted in three integrated findings: (i) healthcare professionals should engage family caregivers in ongoing dialog and provide adequate time and space for sensitive discussions; (ii) end-of-life discussions should be face-to-face and supported by written information whose timing of supply may vary according to family caregivers' preferences and the organizational policies and cultural context; and (iii) family caregivers should be provided structured psychoeducational programs tailored to their specific needs and/or regular family meetings about dementia care at the end of life. CONCLUSION: The findings provide useful information on which interventions may benefit family caregivers of people with advanced dementia at the end of life and where, when, and how they should be provided.

A family carer decision support intervention for people with advanced dementia residing in a nursing home: a study protocol for an international advance care planning intervention (mySupport study).

BACKGROUND: Where it has been determined that a resident in a nursing home living with dementia loses decisional capacity, nursing home staff must deliver care that is in the person's best interests. Ideally, decisions should be made involving those close to the person, typically a family carer and health and social care providers. The aim of the Family Carer Decisional Support intervention is to inform family carers on end-of-life care options for a person living with advanced dementia and enable them to contribute to advance care planning. This implementation study proposes to; 1) adopt and apply the intervention internationally; and, 2) train nursing home staff to deliver the family carer decision support intervention. METHODS: This study will employ a multiple case study design to allow an understanding of the implementation process and to identify the factors which determine how well the intervention will work as intended. We will enrol nursing homes from each country (Canada n = 2 Republic of Ireland = 2, three regions in the UK n = 2 each, The Netherlands n = 2, Italy n = 2 and the Czech Republic n = 2) to reflect the range of characteristics in each national and local context. The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework will guide the evaluation of implementation of the training and information resources. Our mixed methods study design has three phases to (1) establish knowledge about the context of implementation, (2) participant baseline information and measures and (3) follow up evaluation. DISCUSSION: The use of a multiple case study design will enable evaluation of the intervention in different national, regional, cultural, clinical, social and organisational contexts, and we anticipate collecting rich and in-depth data. While it is hoped that the intervention resources will impact on policy and practice in the nursing homes that are recruited to the study, the development of implementation guidelines will ensure impact on wider national policy and practice. It is our aim that the resources will be sustainable beyond the duration of the study and this will enable the resources to have a longstanding relevance for future advance care planning practice for staff, family carers and residents with advanced dementia.

Multi-level analysis of individual and work environment factors associated with nurses' perceived emotional exhaustion.

BACKGROUND: Several factors at the individual- and work environment-level were suggested to correlate with emotional exhaustion development in nurses. AIM: To explore nurses' perceived emotional exhaustion and associated factors by employing hierarchical modelling techniques. METHODS: 1539 nurses completed the cross-sectional survey. Generalized Linear Mixed Model was performed to identify predictors of emotional exhaustion. RESULTS: At the individual level, female gender, high workload and emotional job demands increased the risk of emotional exhaustion; instead, higher education, satisfaction with the role of follower, perceiving nursing profession as meaningful, feeling independent at work, and group closeness were protective factors. At the work environment level, hospital ward type did not affect emotional exhaustion. CONCLUSIONS: Emotional exhaustion is largely influenced by ward culture and organizational policies, and to a lower extent by socio-demographic variables. Moreover, it emerges as an intrinsic risk of the nursing profession rather than being associated with the clinical area profile.

Peripherally or centrally inserted central catheters: what is the best vascular access device for cancer patients?

Choosing the appropriate vascular access device is a pivotal step to guarantee vessel health and preservation in cancer patients. The first turning point is the determination of the need for central venous catheters (CVCs) followed by the selection of the CVC that will complete the prescribed treatment while minimizing complications and satisfying patients' needs and expectations. Peripherally inserted central catheters (PICCs) have steadily grown over the years as an alternative to centrally inserted central catheters and totally implantable catheters based on several advantages including avoidance of placement-associated mechanical complications, easier transitions from hospital to intermediate care settings and home, but also increase in healthcare expenditure, supportive reimbursement policies, and ability to train existing staff. Notwithstanding PICCs have been perceived for a long time as associated with fewer complications, reduced costs, and higher patients' satisfaction compared to other CVCs, recent evidence has raised concerns about their safety profile without any benefits for longer-term costs neither for patients' satisfaction. This commentary offers a comprehensive overview on PICC-related (1) complications, (2) costs, and (3) patients' satisfaction to help healthcare professionals in the choice of the vascular device during their clinical practice. Based on the most recent literature, we finally suggested that the choice of the CVC should depend on the clinical situation with totally implantable catheters being the preferred device for patients who need intermittent long-term and high-dose chemotherapy, while PICCs may be a better choice for patients who need short-term chemotherapy or continuous short-term supportive therapy.

A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home.

BACKGROUND: With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident's wishes for care at the end-of-life and organise the care plan accordingly. AIM: To explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents. DESIGN: A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted. RESULTS: Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences. CONCLUSION: This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.

Assessing pain in children with autism spectrum disorders: findings from a preliminary validation study.

AIMS: Assessing pain in children with autism spectrum disorders (ASDs) can be extremely challenging, since many cannot self-report pain. This study aims to test the validity of the Non-Communicating Children's Pain Checklist - Revised (NCCPC-R) in identifying pain in children and adolescents affected by ASDs. MATERIALS AND METHODS: A two-phase validation study based on (a) the translation and cultural adaptation of the NCCPC-R to Italian and to ASD-specific needs and context; and (b) the validation of a modified, 32-item version of the NCCPC-R. In all, 141 carers of children aged 6-16 years with ASDs were asked to recall an in-pain episode and a not-in-pain episode of their child and to rate on a 3-point scale (0 = not at all, 3 = very often) each behaviour included in the tool. Internal consistency (Cronbach's α), explorative and confirmative factorial structure, as well as concurrent and discriminant validity, were all assessed. RESULTS: Confirmatory factor analysis established the revised version of the NCCPC-R for children with ASDs (named = NCCPC-RASD ), formed from 10 of the original 30 items categorised into three factors ('Changing in mood', 'Increasing in tension' and 'Alerting reaction') to have an acceptable level of reliability. The tool was internally consistent (α = 0.741 during in-pain episodes, α = 0.790 during not-in-pain episodes) and was able to discriminate between in-pain episodes (13.36 out of 40; CI 95% 12.34-14.39) and not-in-pain episodes (7.84 out of 40; CI 95% 6.86-8.82, p < 0.001). CONCLUSIONS: These results provide preliminary evidence that the 10-item version of the NCCPC-RASD is a reliable and valid tool for assessing pain in children with ASD.

What contributes to family carers' decision to transition towards palliative-oriented care for their relatives in nursing homes? Qualitative findings from bereaved family carers' experiences.

OBJECTIVES: Family carers (FCs) of nursing home (NH) residents are best placed to notice deteriorations that signal impending death in their relative, which can open a conversation with healthcare professionals (HCPs) about adjusting the care plan. We explored contributors to bereaved FCs' decision to transition towards palliative-oriented care for their relatives in NHs. METHODS: This qualitative descriptive study used a phenomenological design. Thirty-two bereaved FCs across 13 Italian NHs completed semi-structured interviews. Additional data were collected on NH referrals to palliative care services (PCS) in the 6 months before study start and treatments provided in the last week of life. Content analysis with a combined inductive and deductive approach was applied to identify codes and fit them into an a priori framework. When codes did not fit, they were grouped into new categories, which were finally gathered into themes. RESULTS: FCs reported four types of "trigger events" that made them doubt that their relative would recover: (1) physical deterioration (e.g., stopping eating/walking or swallowing problems); (2) social confirmation (e.g., confirming their relative's condition with friends); (3) multiple hospitalizations; and (4) external indicators (e.g., medical examinations by external consultants). A "resident-centered environment" helped FCs recognize trigger events and "raise awareness of the possibility of death"; however, the "need for reassurance" was pivotal to a "gradual transition towards palliative-oriented care". When participants did not recognize the trigger event, their relative continued to receive curative-oriented care. NHs that referred residents to PCS discussed palliative-oriented care more frequently with FCs, had a lower nurse-to-resident and nurse aide-to-resident ratio, and administered more palliative-oriented care. SIGNIFICANCE OF RESULTS: Trigger events represent an opportunity to discuss residents' prognosis and are the starting point for a gradual transition towards palliative-oriented care. Adequate staffing, teamwork, and communication between FCs and healthcare professionals contribute to a sensitive, timely shift in care goals.

Avoidable and Unavoidable Pressure Injuries Among Residents Living in Nursing Homes: A Retrospective Study.

PURPOSE: The aim of this study was to describe the prevalence of unavoidable pressure injuries (UPIs) in residents of nursing homes (NHs) and characteristics associated with UPIs. DESIGN: A retrospective study. SUBJECTS AND SETTING: Residents 65 years or older residing in any of 105 NHs in the Friuli Venezia Giulia region of Italy between January and December 2013. METHODS: Database search comprised of a multidimensional assessment of NH residents. RESULTS: Data from 7950 residents were reviewed, 925 (11.6%) of whom had 1 or more documented pressure injuries (PIs). Among these, 221 (23.9%) residents met criteria for avoidable PIs (APIs) and 704 (76.1%) for UPIs. Residents with UPIs were more frequently hemodynamically unstable, terminally ill, and had medical devices (all Ps < .001) than residents with APIs. Moreover, residents with UPIs showed higher functional, cognitive, and mood impairments compared to residents with APIs (all Ps < .001). CONCLUSIONS: Our findings suggest a high prevalence of UPIs compared to APIs among residents residing in NHs in one region of Italy. Additional research is needed to establish the prevalence of UPIs among NH residents country-wide, as well as determine specific criteria that identify UPIs in long-term care settings and increase consistency in prevalence and incidence measurement models.

What nursing home environment can maximise eating independence among residents with cognitive impairment? Findings from a secondary analysis.

To explore the influence of the Nursing Home (NH) environment on eating independence while taking into account individual and nursing care factors, was the aim of the study. A secondary analysis was performed based on data collected in a multicentre prospective observational study involving 13 NHs. Residents aged >65 were included (n = 1,027). Dependence in eating was measured using the Edinburgh Feeding Evaluation in Dementia scale (EdFED, range 0-20). In addition to individual and nursing care variables, the NHs environments were assessed with the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH, range 0-149). The mean EdFED score was 2.48 (95% Confidence Interval [CI]=2.22-2.73) and the TESS-NH score was 122.19 (95% CI=115.89-128.49). A linear regression analysis explained 30.8% of the total variance in eating dependence. Alongside individual and nursing care factors, in poor NH unit environments, residents with severe cognitive impairment showed increased eating dependence; in contrast, in better environments, similar residents showed maximal eating performance.

Can Peripherally Inserted Central Catheters Be Safely Placed in Patients with Cancer Receiving Chemotherapy? A Retrospective Study of Almost 400,000 Catheter-Days.

BACKGROUND: Peripherally inserted central catheters (PICCs) are central venous catheters (CVCs) that are commonly used in onco-hematologic settings for chemotherapy administration. As there is insufficient evidence to recommend a specific CVC for chemotherapy administration, we aimed to ascertain PICC-related adverse events (AEs) and identify independent predictors of PICC removal in patients with cancer receiving chemotherapy. MATERIALS AND METHODS: Information on adult patients with cancer with a PICC inserted for chemotherapy administration between September 2007 and December 2014 was extracted from six hospital databases. The primary outcome was PICC removal due to PICC-related AEs (occlusion, infection, or symptomatic thrombosis). Independent predictors of PICC removal were identified using a multivariate Cox regression model. RESULTS: Among the 2,477 included patients, 419 PICC-related AEs (16.9%; 1.09 AEs per 1,000 PICC-days) were reported. AEs increased when PICC was inserted at the brachial site (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.02-1.84) and with open systems (HR, 1.89; 95% CI, 1.24-2.88) and decreased in older men (HR, 0.63; 95% CI, 0.49-0.81). CONCLUSION: Use of PICC for chemotherapy administration was associated with a low all-AEs rate. The basilic vein was the safer site, and valved systems had fewer AEs than open systems. More research is needed to explore the interaction between AEs, sex, and age. IMPLICATIONS FOR PRACTICE: These findings provide clinicians with evidence that peripherally inserted central catheters (PICCs) are safe for chemotherapy administration. They also suggest that clinicians should limit the use of open systems when long chemotherapy regimens are scheduled. Moreover, alternatives to PICCs should be considered when administering chemotherapy to young men.

Good end-of-life care in nursing home according to the family carers' perspective: A systematic review of qualitative findings.

BACKGROUND: Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative phase. AIM: To identify the elements that nursing home residents' family carers perceive as good end-of-life care and develop a conceptual model of good end-of-life care according to the family perspective. DESIGN: Systematic review (PROSPERO no. 95581) with meta-aggregation method. DATA SOURCES: Five electronic databases were searched from inception between April and May 2018. Published qualitative studies (and mixed-method designs) of end-of-life care experience of nursing home family carers whose relative was dead or at the end-of-life were included. No language or temporal limits were applied. RESULTS: In all, 18 studies met inclusion criteria. A 'life crisis' often resulted in a changed need of care, and the transition towards palliative care was sustained by a 'patient-centered environment'. Family carers described good end-of-life care as providing resident basic care and spiritual support; recognizing and treating symptoms; assuring continuity in care; respecting resident's end-of-life wishes; offering environmental, emotional and psychosocial support; keeping family informed; promoting family understanding; and establishing a partnership with family carers by involving and guiding them in a shared decision-making. These elements improved the quality of end-of-life of both residents and their family, thus suggesting a common ground between good end-of-life care and palliative care. CONCLUSION: The findings provide a family-driven framework to guide a sensitive and compassionate transition towards palliative care in nursing home.

A retrospective study of the safety of over 100,000 peripherally-inserted central catheters days for parenteral supportive treatments.

The type of central vascular access device providers chosen for providing parenteral supportive treatments has evolved over the past years, going from routinely used centrally inserted catheters to a more recent trend of peripherally-inserted central catheters (PICCs) when expected treatment duration is less than 6 months. This multicenter retrospective study aimed to provide a comprehensive assessment of the safety of PICCs in administering parenteral supportive treatments. All adult inpatients and outpatients who had a PICC inserted for the administration of parenteral supportive treatments (i.e., parenteral nutrition, intravenous fluids, blood products, or antibiotics) between September 2007 and December 2014 in four public Italian hospitals were included. The primary outcome was PICC removal because of an adverse event (AE, defined as occlusion, exit-site infection, or symptomatic thrombosis). Among the 1,250 included patients, 178 PICC-related removals because of AEs (14.2%; 1.62 AEs per 1,000 PICC days) were reported. Rates of PICC removal because of occlusion, exit-site infection, and symptomatic thrombosis were 1.08, 0.32, and 0.23 per 1,000 PICC days, respectively. The median dwell-time between PICC insertion and its removal because of an AE was 67 days (interquartile range 28-180 days). Risk of PICC removal due to AE was higher with open-system PICCs [hazard ratio = 2.75, 95% confidence interval 1.52-4.96]. In this study, we found preliminary evidence that PICCs can be safely used to administer parenteral supportive treatments lasting up to 6 months. PICCs may be a relevant alternative to centrally inserted catheters for medium-term parenteral supportive treatments.

Negative prompts aimed at maintaining eating independence.

BACKGROUND: Psychological abuse of older people is difficult to recognise; specifically, nursing home residents have been documented to be at higher risk of psychological abuse during daily care, such as during feeding. Healthcare professionals adopt positive and negative verbal prompts to maintain residents' eating independence; however, negative prompts' purposes and implications have never been discussed to date. RESEARCH AIMS: To critically analyse negative verbal prompts given during mealtimes as forms of abuse of older individuals and violation of ethical principles. RESEARCH DESIGN: This is a secondary analysis of three cases of negative prompts that emerged in a large descriptive study based upon focus group methodology and involving 13 nursing homes and 54 healthcare professionals. PARTICIPANTS AND RESEARCH CONTEXT: This study included 3 out of 13 nursing homes caring for residents with moderate/severe functional dependence in self-feeding mainly due to dementia; in these nursing homes, we conducted three focus groups and 13 healthcare professionals participated. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after being approved by the Review Board of the Trust. FINDINGS: With the intent of maintaining self-feeding independence, negative verbal prompts have been reported as being used by nursing home teams. By critically analysing these negative prompts, it turned out they could trigger intimidation, depression and anxiety and thus could be considered as forms of abuse; moreover, negative prompts can threaten the ethical principles of (1) autonomy using a paternalist approach, (2) beneficence and non-maleficence as with the intent to act in the best interests of residents (to maintain self-feeding independence) they are harmed in their dignity and (3) justice, given that residents who received negative prompts are treated differently from those who received positive prompts. DISCUSSION: Eating should be a pleasant experience with a positive impact on physiological, psychological and social well-being. However, negative prompting can lead to abuse and violation of basic ethical principles, destroying the healthcare professional resident and relative relationships strongly dependent on trust. CONCLUSION: Negative verbal prompting must be avoided.

Opportunity to discuss ethical issues during clinical learning experience.

BACKGROUND: Undergraduate nursing students have been documented to experience ethical distress during their clinical training and felt poorly supported in discussing the ethical issues they encountered. RESEARCH AIMS: This study was aimed at exploring nursing students' perceived opportunity to discuss ethical issues that emerged during their clinical learning experience and associated factors. RESEARCH DESIGN: An Italian national cross-sectional study design was performed in 2015-2016. Participants were invited to answer a questionnaire composed of four sections regarding: (1) socio-demographic data, (2) previous clinical learning experiences, (3) current clinical learning experience quality and outcomes, and (4) the opportunity to discuss ethical issues with nurses in the last clinical learning experience (from 0 - 'never' to 3 - 'very much'). PARTICIPANTS AND RESEARCH CONTEXT: Participants were 9607 undergraduate nursing students who were attending 95 different three-year Italian baccalaureate nursing programmes, located at 27 universities in 15 Italian regions. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after the research protocol was approved by an ethics committee. FINDINGS: Overall, 4707 (49%) perceived to have discussed ethical issues 'much' or 'very much'; among the remaining, 3683 (38.3%) and 1217 (12.7%) students reported the perception of having discussed, respectively, 'enough' or 'never' ethical issues emerged in the clinical practice. At the multivariate logistic regression analysis explaining 38.1% of the overall variance, the factors promoting ethical discussion were mainly set at the clinical learning environment levels (i.e. increased learning opportunities, self-directed learning, safety and nursing care quality, quality of the tutorial strategies, competences learned and supervision by a clinical nurse). In contrast, being male was associated with a perception of less opportunity to discuss ethical issues. CONCLUSION: Nursing faculties should assess the clinical environment prerequisites of the settings as a context of student experience before deciding on their accreditation. Moreover, the nursing faculty and nurse managers should also enhance competence with regard to discussing ethical issues with students among clinical nurses by identifying factors that hinder this learning opportunity in daily practice.