Facilitators and barriers to implementing a specialized care unit for persons with cognitive impairment in an acute geriatric hospital: a process evaluation.

BACKGROUND: Implementing dementia care interventions in an acute hospital poses multiple challenges. To understand factors influencing the implementation, in-depth knowledge about specific facilitators and barriers is necessary. The aim of this study was to identify facilitators and barriers to implementing an interprofessional, multicomponent intervention of a specialized unit for persons with cognitive impairment in an acute geriatric hospital. METHODS: We conducted a process evaluation as part of a participatory action research study. For data collection, semi-structured individual interviews with fifteen professionals involved in the implementation of the specialized unit. We further conducted two focus groups with twelve professionals working on other units of the geriatric hospital. We performed a qualitative content analysis following Kuckartz's content-structuring analysis scheme. RESULTS: We identified the following barriers to implementing the specialized unit: uncontrollable contextual changes (e.g., COVID-19 pandemic), staff turnover in key functions, high fluctuation in the nursing team, traditional work culture, entrenched structures, inflexible and efficiency-oriented processes, monoprofessional attitude, neglect of project-related communication, and fragmentation of interprofessional cooperation. An established culture of interprofessionalism, an interprofessionally composed project group, cooperation with a research partner, as well as the project groups' motivation and competence of managing change facilitated the implementation. CONCLUSIONS: The implementation faced numerous barriers that can be described using the key constructs of the i-PARIHS framework: context, recipients, innovation, and facilitation. Overcoming these barriers requires an organizational development approach, extended project duration and increased process orientation. Furthermore, strategically planned, precise and ongoing communication towards all persons involved seems crucial. Differences between the work cultures of the professions involved deserve particular attention with regard to project-related roles and processes.

The Nurse-Police Assistance Crisis Team (N-PACT): A new role for nursing.

AIM: This study aimed to gain insights into forensic nurses' perspectives and approaches to behavioural crisis situations, comparing them to disciplines traditionally involved in first-line behavioural crisis response. DESIGN: This study used a descriptive, qualitative exploratory design and was informed by Systems Theory. METHODS: The study was carried in the United States, between 2022 and 2023. Data were gathered through four focus groups: police officers (n = 12), co-response (mental health) clinicians (n = 13), sexual assault nurse examiners (n = 6) and correctional nurses (n = 4). Thematic analysis was performed. REPORTING METHOD: The Standards for Reporting Qualitative Research (SRQR) guidelines were used. RESULTS: Findings revealed temporal themes in crisis response: (1) Searching for Historical Information; (2) Safety and Acting at the Present Scene; and (3) Future Strategies and Interventions. Common priorities (e.g. safety and de-escalation) were identified across groups. Notably, nurses demonstrated a comprehensive approach, addressing physical and mental health assessments, substance involvement, and physical injury evaluation. CONCLUSION: This study proposes the creation of a novel nursing role within first-line multidisciplinary teams (MDTs) for crisis response-the Nurse-Police Assistance Crisis Team (N-PACT). Nurses bring expertise and comprehensive assessment skills to enhance crisis responses, particularly in cases involving mental health emergencies, medical crises, and drug-related incidents. IMPLICATIONS: Forensic nurses, with their diverse competencies and comprehensive training, are highly valuable assets within MDTs. Their expertise extends to proficiently conducting mental and physical assessments, ensuring safety and adeptly navigating situations that intersect with the legal system. IMPACT: The N-PACT concept can improve outcomes and streamline the allocation of resources, particularly considering the number of police calls involving behavioural crises. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Enhancing new graduate nurses and midwives person-centredness through clinical supervision during COVID-19; evaluation of a non-randomized intervention study.

AIM: The aim of the study was to evaluate a person-centred model of clinical supervision to enhance person-centredness. DESIGN: Experimental, quantitative. METHODS: One hundred and three New Graduates were supported to reflect through a person-centred lens (July-December 2020). Evaluation was undertaken at 6 months using: the Manchester Clinical Supervision Scale-26 (effectiveness of supervision) and the Person-centred Practice Inventory (measures attributes of the nurse/midwife, the care environment and person-centred processes). Due to participation difficulties, scores were calculated by attendance rates using descriptive and inferential statistics. RESULTS: Regular attendees scored higher on the supervision's effectiveness; however, this did not reach efficacy. 'Finding time' to attend contributed to low scores. Supervision scored well on its supportive function when attended. Many New Graduates perceived a decline in their care environment. Attendance aside, New Graduates averaged an increased in their person-centred attributes and processes. Greater participation was found in those who scored higher at baseline on their person-centred attributes and processes, and this higher scoring continued at 6 months than those who attended less. CONCLUSION: New Graduates who perceive themselves as person-centred and reflective at baseline are more likely to attend a person-centred clinical supervision and score higher at 6 months than those who attended less often. New Graduates found support within supervision during challenging times. IMPLICATIONS FOR PRACTICE FOR PROFESSIONAL AND/OR PATIENT CARE: For successful implementation of Person-centred Clinical Supervision, New Graduates need support to attend, as attendance supports them to begin seeing value in the process. IMPACT: This intervention kept person-centred practice at the forefront of New Graduates reflection, in a time of extreme change. The research has implications for nursing and midwifery management with the imperative to deliver person-centred care and create the person-centred cultures for staff to feel supported and empowered. REPORTING METHOD: Transparent Evaluation of Non-randomized Designs (TREND). PATIENT OF PUBLIC CONTRIBUTION: No patient or public contribution. CONTRIBUTION TO WIDER COMMUNITY: New Graduates grow their person-centredness over their transitioning year; however, this can be enhanced with regular clinical supervision underpinned by person-centred theory. Clinical supervisors can provide support to New Graduates when the environment is challenged.

Empowering Support for Family Members of Patients With Traumatic Brain Injury During the Acute Care: Insights From Family Members and Nurses.

AIM: To investigate the perceptions of family members (FMs) of patients with traumatic brain injury (TBI) and nurses on empowering support and its implementation during the acute phase within Finnish neurosurgical and neurological care in hospital settings, focusing on identifying similarities and differences in their viewpoints. DESIGN: Participatory qualitative descriptive study. METHODS: Data were collected from seven FMs and 11 nurses using the World Café method in November 2019. An abductive approach was employed for data analysis, combining deductive interpretation within the conceptual framework of empowering support and inductive content analysis. RESULTS: Four main themes were identified: (1) FMs' diverse information and guidance needs of TBI, treatment and its impact on family life, (2) support based on empowering FMs in participation, competence and decision-making, (3) empowering FMs through collaborative nursing practices and interprofessional support, and (4) internal and external hospital support enhancing and promoting the empowerment of FMs. CONCLUSION: The perceptions of FMs and nurses regarding empowering support were largely consistent, yet diverged in its implementation in nursing practice. Nurses play a crucial role in fostering the empowerment of FMs; however, further research is needed to explore the impact of organisational and community factors on the implementation of empowering support. IMPACT: Our study contributes to advancing nursing practices by underscoring the necessity for a paradigm shift towards a family-centred approach. Furthermore, it emphasises the urgency for standardising nursing practices to ensure equitable access to empowering support for FMs, applicable across various care settings for patients with TBI. PUBLIC CONTRIBUTION: This review is part of a larger research project in which FMs of patients with TBI and nurses were involved in designing the project. REPORTING METHOD: This study was reported using the Consolidated Criteria for Reporting Qualitative Checklist for qualitative studies.

Contextual influences on knowledge translation capacity in a nursing home organisation: A phenomenological hermeneutical study.

INTRODUCTION: The demand for advanced clinical care in nursing homes (NHs) is increasing. Evidence-based practices and knowledge translation (KT) initiatives are growing to bridge the gap between what is known and what is done. However, research on contextual influence on KT has primarily focused on hospital settings. AIM: To expand our understanding of contextual influences on KT capacity in a NH organisation. DESIGN AND METHODS: Lindseth and Norberg's phenomenological hermeneutical method was used to explore and describe practice development nurses' experiences, perspectives and practices regarding how contextual factors influence KT capacity in NHs. Focus group interviews, participant observations, in-depth interviews and non-participant observations provided the data. RESULTS: Two main themes and four subthemes were identified. (1) Continuous limited resources are a cultural condition that inhibits KT readiness; prioritising keeping the NH machinery running at all costs and having contrasting care philosophies undermines KT. (2) Organisational prioritisations leave KT as a missing cogwheel in the machinery; retaining a system of fragmented KT strategies and lacking a structure for collective KT effort. CONCLUSION: The study showed that KT held a minor role in the fast-paced NH machinery. Contradicting values characterise the NH organisation, resulting in a lack of a common vision and priorities. Building a sustainable KT capacity and providing evidence-based practice necessitates explicit responsibilities, dedicated resources and robust organisational support. Management has a critical role in strengthening the position of KT. Incorporating KT in daily NH practice can help staff become adaptable and confident, capable of meeting the increasing challenges of advanced care that alleviates suffering and promote the health and well-being of NH patients.

Self-appropriation in nurse engagement: Facilitating the development of expert nurses using Benner and Lonergan.

Expert nurses, as described by the work of Patricia Benner, are at the peak of clinical nursing practice and vitally important in ensuring the best possible patient care and clinical outcomes. The development of Benner's theory and its relationship with the Dreyfus model of skill acquisition provides context for understanding the progression necessary for expert development. Contemporary healthcare challenges present implications to the development of advancing levels of nursing practice. Engagement has been identified as critical to achieving expert practice. I propose the incorporation of the philosophical framework of self-appropriation from Benard Lonergan as a strategy to develop internal engagement in nurses to facilitate expert practice. I outline the synergy between Benner's theory and the work of Lonergan, which provide overlap and opportunity to overcome barriers to developing expert nursing practice. In the challenging climate of healthcare, there is an obligation to promote engagement and facilitate expert nurse development, necessary for patient outcomes as well as clinical role models, preceptors, and leaders to guide future nurses.

A facilitator's reflection on the democratizing potential of emancipatory practice development.

Emancipatory practice development (ePD) is a practitioner-led research methodology which enables workplace transformation. Underpinned by the critical paradigm, ePD works through facilitation and workplace learning, with people in their local context on practice issues that are significant to them. Its purpose is to embed safe, person-centred learning cultures which transform individuals and workplaces. In this article, we critically reflect on a year-long ePD study in an acute care hospital ward. We explore the challenges of practice change within systems, building collective strength with frontline collaborations and leadership to sustain new learning cultures. Our work advances practice development dialogue through working closely with the underpinning theories. Our critique analyses how ePD can enact and sustain change within a complex system. We argue that ePD works to strengthen safety cultures by challenging antidemocratic practices through communicative action. By opening communicative spaces, ePD enables staff to collectively deliberate and reach consensus. Their raised awareness supports staff to resist ways of working which conspire against safe patient care. Sustainability of practice change is fostered by the co-operative democracies created within the frontline team and meso level enablement. We conclude that the democratising potential of ePDt generates staff agency at the frontline.

Co-creating system-wide improvement for people with traumatic brain injury across one integrated care system in the United Kingdom to initiate a transformation journey through co-production.

BACKGROUND AND OBJECTIVE: There is a need for better integration of services across communities and sectors for people living with traumatic brain injury (TBI) to meet their complex needs. Building on insights gained from earlier pilot work, here we report the outcomes of a participatory workshop that sought to better understand the challenges, barriers and opportunities that currently exist within the care pathway for survivors of TBI. METHODS: A diverse range of stakeholders from the acute and rehabilitation care pathway and the health and social care system were invited to participate in a 3-h workshop. The participants worked in four mixed subgroups using practice development methodology, which promotes person-centred, inclusive and participatory action. RESULTS: Thematic analysis identified shared purposes and values that were used to produce a detailed implementation and impact framework for application at both the level of the care interface and the overarching integrated care system. A variety of enablers were identified that related to collective values and behaviours, case management, team leadership and integrated team working, workforce capability, evidence-based practice and resourcing. The clinical, economic, cultural and social outcomes associated with these enablers were also identified, and included patient safety, independence and well-being, reduced waiting times, re-admission rates, staff retention and professional development. CONCLUSION: The co-produced recommendations made within the implementation and impact framework described here provide a means by which the culture and delivery of health and social care services can be better tailored to meet the needs of people living with TBI. We believe that the recommendations will help shape the formation of new services as well as the development of existing ones. PATIENT OR PUBLIC CONTRIBUTION: Patient and public involvement have been established over a 10-year history of relationship building through a joint forum and events involving three charities representing people with TBI, carers, family members, clinicians, service users, researchers and commissioners, culminating in a politically supported event that identified concerns about the needs of people following TBI. These relationships formed the foundation for the interactive workshop, the focus of this publication.

[Advanced nursing practice model for head and neck cancer: A practice development project]. / Advanced Nursing Practice für Patient_innen mit Kopf-Hals-Tumorerkrankungen und ihre Angehörigen.

Advanced nursing practice model for head and neck cancer: A practice development project Abstract. Background: Head and neck cancer confronts patients and their families with big challenges due to complex treatments as well as changes in vital functions and appearance. They require multifaceted support and benefit from coordinated, interprofessional collaboration and advanced nursing practice. Problem/aim: In a tertiary head and neck cancer center, a coordinating contact person was missing for patients, families and the care team. Therefore, a project was launched to develop an advanced nursing practice program. Methods: Methods included an advanced nursing practice concept, approaches for practice development, and action research. The project consisted of four phases: Stakeholder analysis and literature review were followed by the definition of the advanced nursing practice program, which was then tested during a pilot phase, and evaluated using structural/process data and stakeholder interviews. Results: Evidence-based, continuous, person-centered care was improved across the care continuum for patients/families. The nurses' expertise was supported and the collaboration with internal/external clinicians was facilitated. Patients/families valued the continuity offered by the advanced practice nurse. Discussion: The methodological approaches supported a goal-oriented approach; especially participatory practice development helped to address employees' concerns. Limitations/transfer: To date, a sustainable program cannot yet be warranted. For similar projects, an approach with stakeholder analysis, multidisciplinary focus, and early evaluation planning is recommended.

Resilience amongst Ontario registered practical nurses in long-term care homes during COVID-19: A grounded theory study.

AIMS: This study aimed to understand how the personal and professional resilience of Registered Practical Nurses working in long-term care (LTC) homes in Ontario were impacted during the Coronavirus 2019 pandemic. BACKGROUND: Registered Practical Nurses are primary regulated healthcare providers that have worked in Ontario LTC homes during the COVID-19 pandemic. As frontline workers, they have experienced increased stress secondary to lockdowns, changing Ministry of Health recommendations, social isolation and limited resources. LTC homes experienced almost a third of all COVID-19-related deaths in Ontario. Understanding registered practical nurses' (RPNs) resilience in this context is vital in developing the programs and supports necessary to help nurses become and stay resilient in LTC and across a range of settings. METHODS: Purposive sampling was used to recruit 40 Registered Practical Nurses working in LTC homes across Ontario for interviews. Charmaz's Grounded theory guided in-depth one-on-one interviews and analyses completed between April to September 2021. RESULTS: Registered Practical Nurse participants represented 15 (37.5%) private, and 25 (62.5%) public LTC homes across Ontario Local Health Integration Networks. Findings informed two distinct perspectives on resilience, one where nurses were able to maintain resilience and another where they were not. Sustaining and fraying resilience, presented as bimodal processes, was observed in four themes: 'Dynamic Role of the Nurse', 'Preserving Self', 'Banding Together' and 'Sense of Leadership Support'. CONCLUSION: Resilience was largely drawn from themselves as individuals. Resources to support self-care and work-life balance are needed. Additionally, workplace supports to build capacity for team-based care practices, collegial support in problem-solving and opportunities for 'connecting' with LTC nursing colleagues would be beneficial. Our findings suggest a role for professional development resources in the workplace that could help rebuild this workforce and support RPNs in providing quality care for older adults living in LTC. PATIENT OR PUBLIC CONTRIBUTION: Our research team included two members of the Registered Practical Nurses Association of Ontario, and these team members contributed to the discussion and design of the study methodology, recruitment, analysis and interpretation. Further, RPNs working in long-term care during the COVID-19 pandemic were the participants in this study and, therefore, contributed to the data. They did not contribute to data analysis or interpretation.

How nurses and midwives engage with patient experience data to inform person-centred quality and safety improvements.

AIMS AND OBJECTIVES: To explore how nurses and midwives engage with patient experience data collected via a mobile health app to inform person-centred practice improvements. BACKGROUND: A large amount of data is collected in healthcare, yet there is limited evidence outlining how nursing and midwifery staff utilise patient experience data to inform person-centred quality and safety improvements. METHODS: This study utilised action research, underpinned by Practice Development methodology and has been reported using the SQUIRE 2.0 checklist. Six clinical units (medical short stay, acute medical, surgical, oncology/haematology, day surgery and maternity) in a large health district in Australia engaged in three cycles of data collection using a mobile health app. The app captured patient experience data relating to the person-centred KPIs developed and tested by McCance et al. (2012). Staff used the data to develop and evaluate person-centred practice. RESULTS: A number of improvements in scores and practice occurred through engaging with the data in a cyclical way. All six clinical units saw an improvement in four or more of the KPIs in the patient survey results from cycle one to cycle three, with two clinical units improving in all eight. On average across the six units, there was also an increase in time nurses/midwives were visible to their patients, an increase in clinical documentation reflecting the patients' needs and what was important to them, an increase in positive comments and a decrease in negative comments in patient stories. CONCLUSION: This study shows that collecting and utilising data from the person-centred KPIs in a collaborative and cyclical way lead to enhanced patient experience and the development and implementation of person-centred quality and safety improvements. RELEVANCE TO CLINICAL PRACTICE: Capturing and utilising data that are meaningful to nursing/midwifery teams in a cyclical, action-orientated approach result in person-centred practice improvements that enhance the experience of those that are receiving and delivering patient care.

Building safety cultures at the frontline: An emancipatory Practice Development approach for strengthening nursing surveillance on an acute care ward.

AIM: To evaluate an emancipatory Practice Development approach for strengthening nursing surveillance on a single medical-surgical ward. BACKGROUND: Registered nurses keep patients safe in acute care settings through the complex process of nursing surveillance. Our interest was understanding how frontline teams can build safety cultures that enable proactive nursing surveillance in acute care wards. DESIGN: A year-long emancipatory Practice Development project. METHODS: A collaborative relationship was established around a shared interest of nursing surveillance capacity and researcher embedded on a medical-surgical ward. Critical analysis of workplace observations and reflection with staff generated key sites for collective action. Ward engagement was supported by creative Practice Development methods including holistic facilitation, critical reflection and action learning. An action learning set was established with a group of clinical nurses, facilitating practitioner-led change initiatives which strengthened nursing surveillance and workplace learning. Evaluation supported an iterative approach, building on what worked in an acute care context. Immersive researcher evaluation, drawing on multiple data sources, generated an analysis of how ward nursing surveillance capacity can be strengthened. COREQ criteria guided reporting. RESULTS: The ward moved through a turbulent and transformative process of resistance and retreat towards a new learning culture where nursing surveillance was visible and valued. Staff developed and sustained innovations including the 'My MET Call series', a 'Shared GCS initiative', an enhanced 'Team Safety Huddle', and staff-led Practice Development workshops. These new practices affirmed nurses' agency, asserted nurses' clinical knowledge, positioned nurses to participate in team decision-making and humanised care. CONCLUSION: Working collaboratively with frontline staff enabled bottom-up sustainable innovation to strengthen nursing surveillance capacity where it mattered most, at the point of care. RELEVANCE TO CLINICAL PRACTICE: Emancipatory Practice Development enables the profound impact of small-scale, microsystem level practice transformation. It is an accessible methodology for clinical teams to develop effective workplace cultures.

First steps to integrate general palliative care into a cardiac hospital setting - using dialogue-based workshops.

BACKGROUND: Heart failure is a chronic, life-threatening illness with multiple acute events. Palliative care alongside standard treatment is recommended for these patients. There is a lack of knowledge and research literature on how to integrate palliative care interventions for heart failure patients in a general hospital setting. AIM: The aim of this study was to produce new insight for developing and integrating general palliative care into heart failure treatment. METHODS: Guided by action research, we conducted an interdisciplinary workshop inspired by Tsoukas dialogue theory, where tension between perspectives is used as a facilitator of dialogue and the generation of new insights. Perspectives were incorporated through selected patient narratives and professionals' experiences. Data from the workshop were analysed using a thematic analysis. The findings are interpreted with Kleinman's theory on illness and disease and discussed using Tsoukas theory and additional research. RESULTS: General palliative care must be initiated from the patient's perspective and wishes. Doing so requires understanding and uniting the different perspectives and objectives of heart failure treatment and palliative care. One way of doing this is through a narrative approach with interdisciplinary teams. However, this requires organisational efforts and adaptation to the specific cardiac setting. CONCLUSION: Integrating palliative care principles into cardiology is a complex issue. Developing palliative care for heart failure patients requires more than simply designing a set of guidelines. Rather, a wider outlook involving perspectives, competences and organisation is necessary. Acknowledging such considerations, we designed an intervention centred on three elements: standard heart failure treatment, integrated sessions applying a narrative approach and monthly interdisciplinary conferences. RELEVANCE: This article adds to the current research literature on changing palliative care practice for heart failure patients and the value of integrating different perspectives.

Assessing sense of coherence as an element of primary-focused health services in schools for children and adolescents with complex health care needs.

AIM: This study aimed to clarify if sense of coherence (SOC) could be used as an element of primary-focused health services in schools. BACKGROUND: The United Arab Emirates (UAE) is striving to develop a high-quality, primary-focused health care system. School health care services are well established in the UAE but have not yet been fully used to play a key role in this development. METHODS: This is a cross-sectional survey study to explore adolescents' SOC and their behavioural, psychosocial and clinical outcomes. RESULTS: A total of 408 adolescents participated in this study. Compared with others, adolescents with higher SOC had better adherence to treatment, fewer visits to the school nurse, better self-efficacy, fewer hyperactivity problems, fewer emotional problems, more prosocial behaviours and fewer conduct problems. CONCLUSION: Implementing interventions that improve SOC may support improved well-being among adolescents. The findings also support the use of SOC and salutogenesis as a framework to reinforce primary health care services for this population. IMPLICATIONS FOR NURSING MANAGEMENT: Health service managers can utilize SOC as a framework to focus service on illness prevention and health promotion, they should collaborate with education authorities to include more health-related topics as part of school curricula to promote students' SOC and, finally, they should assess and build awareness of SOC and associated tools among school nurses and primary health care providers.

[Journal clubs in nursing practice: An online survey of German university hospitals]. / Journal Clubs in der Pflegepraxis.

Journal clubs in nursing practice: An online survey of German university hospitals Abstract. Background: Journal clubs (JCs) are an evidence-based method for enabling nursing professionals to develop a scientifically based practice. Research results can be made available to nurses to directly influence their nursing practice. The level of implementation in German university hospitals is currently unknown. Aim: This study surveyed the current state of JCs at German university hospitals. The aim is to develop recommendations for the implementation of JCs for nursing practice. Methods: The online survey of all 27 representatives of the "Network of Nursing Science and Practice Development" of the VPU e.V. was conducted from October to November 2020. The questionnaire was developed based on literature. The data analysis was descriptive. Results: 15 of the 19 clinics surveyed currently implement, or have previously implemented, a JC (response rate 70,4%). In approximately half of the clinics, JC is an established structure that is also offered as part of advanced training and continuing education (46,6%) and is used to develop and expand methodological, scientific competencies (86,6%). Positive experiences, but also structural problems in the implementation of a JC were reported. Approximately one quarter of the clinics evaluate their JC regularly (26,7%). Conclusions: JCs at German university hospitals are currently being established. In order to establish JCs on a permanent basis, EBN knowledge must be continuously imparted in further education and training; in addition, JCs should be an essential component of academic role profiles.

Integrated knowledge translation in nursing homes: exploring the experiences of practice development nurses.

BACKGROUND: Practice Development Nurses (PDNs) in Norwegian nursing homes (NHs) hold a specific responsibility for knowledge translation in this increasingly complex healthcare setting. They were involved as end users in an integrated knowledge translation (IKT) study, developing, testing and evaluating the IMPAKT (IMPlementation of Action to Knowledge Translation) intervention. PDNs participated in an educational programme tailored to their own defined needs. In a second intervention component, the PDNs applied their new skills with facilitation, in implementing the National Early Warning Score (NEWS2) in their respective NHs. The aim of this study was to explore 1) the PDNs' experiences of participating in an IKT educational intervention, and 2) how they applied the learning in planning, tailoring and initial implementation of the NEWS2. METHODS: This is a qualitative exploratory study based on a phenomenological hermeneutical method. Study participants were PDNs working in the nine NHs in the intervention group of the IMPAKT trial. We conducted nine in-depth interviews and eight non-participatory observational sessions of the intervention delivery. RESULTS: The PDNs expressed that the educational programme met their needs and enhanced their understanding about leading knowledge translation (KT). They reported a move from operating in a "big black box of implementation" to a professional and structured mode of KT. The gamechanger was a shift from KT as the PDNs' individual responsibility to KT as an organizational matter. The PDNs reported enhanced competencies in KT and in their ability to involve and collaborate with others in their facility. Organizational contextual factors challenged their KT efforts and implementation of the NEWS2. CONCLUSIONS: This study demonstrates that an IKT approach has the potential to advance and improve staff competencies and NH readiness for KT. However, individual motivations and competencies were challenged within an organizational culture which was less receptive to this new leadership role and level of KT activity.

Staff experiences of implementing Dementia Care Mapping to improve the quality of dementia care in care homes: a qualitative process evaluation.

BACKGROUND: Dementia Care Mapping™ (DCM) is a widely used, staff-led, psychosocial intervention to support the implementation of person-centred care. Efficacy evaluations in care homes have produced mixed outcomes, with implementation problems identified. Understanding the experiences of staff trained to lead DCM implementation is crucial to understanding implementation challenges, yet this has rarely been formally explored. This study aimed to examine the experiences of care home staff trained to lead DCM implementation, within a large cluster randomised controlled trial. METHODS: Process evaluation including, semi-structured interviews with 27 trained mappers from 16 intervention allocated care homes. Data were analysed using template variant of thematic analysis. RESULTS: Three main themes were identified 1) Preparedness to lead - While mappers overwhelmingly enjoyed DCM training, many did not have the personal attributes required to lead practice change and felt DCM training did not adequately equip them to implement it in practice. For many their expectations of the mapper role at recruitment contrasted with the reality once they began to attempt implementation; 2) Transferring knowledge into practice - Due to the complex nature of DCM, developing mastery required regular practice of DCM skills, which was difficult to achieve within available time and resources. Gaining engagement of and transferring learning to the wider staff team was challenging, with benefits of DCM largely limited to the mappers themselves, rather than realised at a care home level; and 3) Sustaining DCM - This required a perception of DCM as beneficial, allocation of adequate resources and support for the process which was often not able to be provided, for the mapper role to fit with the staff member's usual duties and for DCM to fit with the home's ethos and future plans for care. CONCLUSIONS: Many care homes may not have staff with the requisite skills to lead practice change using DCM, or the requisite staffing, resources or leadership support required for sustainable implementation. Adaptations to the DCM tool, process and training may be required to reduce its complexity and burden and increase chances of implementation success. Alternatively, models of implementation not reliant on care home staff may be required.

Effectiveness of Dementia Care Mapping™ to reduce agitation in care home residents with dementia: an open-cohort cluster randomised controlled trial.

OBJECTIVES: Agitation is common and problematic in care home residents with dementia. This study investigated the (cost)effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation in this population. METHOD: Pragmatic, cluster randomised controlled trial with cost-effectiveness analysis in 50 care homes, follow-up at 6 and 16 months and stratified randomisation to intervention (n = 31) and control (n = 19). Residents with dementia were recruited at baseline (n = 726) and 16 months (n = 261). Clusters were not blinded to allocation. Three DCM cycles were scheduled, delivered by two trained staff per home. Cycle one was supported by an external DCM expert. Agitation (Cohen-Mansfield Agitation Inventory (CMAI)) at 16 months was the primary outcome. RESULTS: DCM was not superior to control on any outcomes (cross-sectional sample n = 675: 287 control, 388 intervention). The adjusted mean CMAI score difference was -2.11 points (95% CI -4.66 to 0.44, p = 0.104, adjusted ICC control = 0, intervention 0.001). Sensitivity analyses supported the primary analysis. Incremental cost per unit improvement in CMAI and QALYs (intervention vs control) on closed-cohort baseline recruited sample (n = 726, 418 intervention, 308 control) was £289 and £60,627 respectively. Loss to follow-up at 16 months in the original cohort was 312/726 (43·0%) mainly (87·2%) due to deaths. Intervention dose was low with only a quarter of homes completing more than one DCM cycle. CONCLUSION: No benefits of DCM were evidenced. Low intervention dose indicates standard care homes may be insufficiently resourced to implement DCM. Alternative models of implementation, or other approaches to reducing agitation should be considered.

Newly graduated registered nurses' evaluation of their preparedness, confidence and attitudes towards clinical assessments.

BACKGROUND: Historically, it has been reported that new graduates make limited use of their clinical assessment skills, yet these form the basis for making nursing decisions and selecting all nursing interventions. AIMS AND OBJECTIVES: To explore new graduates' preparedness for, and confidence with, clinical assessment and their reliance on electronic monitoring. To identify barriers that hinder, and strategies that enable, clinical assessment. DESIGN: A mixed-method study comprising a cross-sectional, quantitative survey and qualitative data, gathered using the World Café method. METHODS: Data were collected from volunteers (n = 137) of all new graduates (n = 160) working in adult settings for a New Zealand district health board over a 1-year period. A paper-based survey explored use of clinical assessment, using a five-point Likert scale. Qualitative data comprised written records of group discussions and individual responses to four questions with thematic analysis of results. A STROBE checklist was used. RESULTS: Most (n = 128) new graduates agreed/strongly agreed that clinical assessment was part of their role. Most (n = 119) agreed/strongly agreed that assessing patients by technology alone was inadequate. Thirty-six did not agree/strongly agree that they were well-prepared to perform clinical assessment. Forty-one did not agree/strongly agree that they were confident to perform clinical assessment, particularly those aged ≥30 years. Factors limiting use of clinical assessment were lack of time, knowledge, skill, confidence, reliance on doctors and an unsupportive work environment. Factors that would enhance clinical assessment involved increased supervision by experienced staff, provision of short courses and more in-service education on clinical assessment. CONCLUSIONS: New graduates acknowledged that clinical assessment was part of their role and involved more than electronic monitoring. However, many lacked confidence and preparedness for clinical assessment in their work area, particularly those aged ≥30 years, potentially limiting clinical assessment use. Supportive changes, including short courses to revise clinical assessment skills and supervision of workplace-specific clinical assessments, could help new graduates more confidently and efficiently assimilate clinical assessment into their practice. RELEVANCE TO CLINICAL PRACTICE: This research identified reasons that caused a cohort of new graduates to make limited use of their clinical assessment skills. It also reports the practical solutions they considered would help them increase their use of clinical assessment and thus support their decision-making in nursing practice.

Communities of Practice in Acute and Forensic Psychiatry: Lessons Learned and Perceived Effects.

In the Netherlands, two new approaches have been developed for acute and forensic psychiatry, called High and Intensive Care (HIC) and Forensic High and Intensive Care (FHIC). The models provide standards for temporary high-quality clinical care for patients in crisis and combine practices to reduce seclusion. To support the implementation of these approaches, Communities of Practice (CoPs) were created, including peer providers, mental health nurses, psychiatrists and managers. CoPs are increasingly used in healthcare. However, CoPs vary greatly in form and objective, and more insight is needed in the organisation and facilitation of CoPs. Therefore, the aim of this study is to gain insight into the lessons learned and perceived effects of the CoPs. A qualitative approach was used. Data were collected through focus groups (n = 3) with participants in the CoPs, feedback meetings with teams implementing HIC (n = 78) or FHIC (n = 23), and observations by the researchers. Data were analysed thematically. Lessons learned are: 1) create an ambassador role for CoP participants, 2) organize concrete activities, 3) take care of a multidisciplinary composition, and 4) foster shared responsibility and work on sustainability. Perceived effects of the CoPs were: 1) support of HIC and FHIC implementation, 2) creation of a national movement, and 3) further development of the HIC and FHIC approaches. The audits served as an important vehicle to activate the CoPs, and stimulated the implementation of HIC and FHIC. The findings may help others in creating a CoP when it comes to the implementation of best practices and improving healthcare.