"How do I keep this live in my mind?" Allied Health Professionals' perspectives of barriers and enablers to implementing good clinical practice principles in research: a qualitative exploration.

BACKGROUND: Allied health professionals (AHPs) engaged in research are expected to comply with Good Clinical Practice (GCP) principles to protect participant safety and wellbeing and enhance data integrity. Currently, few studies have explored health professionals' perceptions of implementing and adhering to GCP principles in research with none of these including AHPs. Such knowledge is vital to guide future interventions to increase adherence to GCP principles. This study aimed to identify the barriers and enablers AHPs experience when applying GCP principles to research conduct in a public hospital and health service, as well as their perceived support needs. METHODS: The study used a qualitative descriptive study approach guided by behaviour change theory. AHPs currently undertaking ethically approved research within a public health service in Queensland, Australia were interviewed to explore barriers and enablers to adherence to GCP principles and support needs, with interview questions guided by the Theoretical Domains Framework (TDF). The TDF was chosen as it allows for a systematic understanding of factors influencing implementation of a specific behaviour (i.e., GCP implementation) and can be used to inform tailored interventions. RESULTS: Ten AHPs across six professions were interviewed. Participants identified both enablers and barriers to implementing GCP across nine domains of the TDF and enablers across three additional domains. Examples of enablers included strong beliefs about the importance of GCP in increasing research rigour and participant safety (i.e. from TDF - beliefs about consequences); applying clinical skills and personal attributes when implementing GCP (i.e., skills), available training and support (i.e., environmental context and resources); and alignment with their moral sense to 'do the right thing' (i.e., professional identity). Barriers to GCP implementation were generally less commonly reported but included reduced time to implement GCP and a sense of 'red tape' (i.e., environmental context and resources), a lack of knowledge of GCP principles (i.e., knowledge) and a fear of making mistakes (i.e., emotions), and varying relevance to individual projects (i.e., knowledge). Suggestions for support were identified beyond training, such as physical resources (e.g., prescriptive checklists, templates and scripts), additional time, and regular one-on-one mentoring support. CONCLUSION: Findings suggest that while clinicians recognise the importance of GCP and want to implement it, they report barriers to its practical implementation. GCP training alone is unlikely to address these barriers to implementing GCP in daily practice. Findings suggest that GCP training may be more useful to AHPs when it is tailored to the allied heath context and supplemented with additional supports including check-ups from experienced researchers and access to prescriptive resources. Future research however is needed to investigate the effectiveness of such strategies.

Patient-mediated interventions in hospital: A systematic review.

AIMS: To describe the characteristics of hospital-based, patient-mediated interventions and their impact on patient, clinician and organization outcomes. DESIGN: Systematic review. DATA SOURCES: Health literature databases (MEDLINE, CINAHL and EMBASE) were searched in August 2021. Backward and forward citation searching was conducted. REVIEW METHODS: Studies investigating patient-mediated interventions, targeted at adult hospitalized patients were eligible. Data were extracted related to study and intervention characteristics. Narrative synthesis was used to understand intervention impact on patient, clinician and organization outcomes (as per a framework). Methodological quality was assessed using the Mixed Methods Assessment Tool. RESULTS: Thirty-three studies, reporting 18 interventions, were included. Twelve interventions prompted patients to report health information about their own health/needs/concerns and six interventions encouraged patients to provide feedback about clinical practice. Across all interventions, there was evidence that patients used patient-mediated interventions and that they may improve patient communication. Healthcare professional outcomes were mixed for actual/intended use, acceptability and usefulness of interventions; yet there was some evidence of healthcare professional behaviour change. Interventions that encouraged patients to report health information about their own health/needs/concerns appeared more successful than other types of interventions. CONCLUSIONS: There is some evidence that hospital-based patient-mediated interventions may influence patient communication and healthcare professional behaviour. Patient-mediated interventions that encourage patients to report patient data before a clinical encounter may be more impactful than interventions that encourage patient feedback during or post-encounter. IMPACT: To date, most patient-mediated intervention research has been conducted in primary care settings; we uncovered the types of patient-mediated interventions that have been trialled in hospitals. We found that patient communication and healthcare professional behaviour may be influenced by these patient-mediated interventions. Future researchers could explore the suitability and effectiveness of a wider range of hospital-based patient-mediated interventions. NO PATIENT OR PUBLIC CONTRIBUTION: There was no funding to remunerate a patient/member of the public for this review.

Nurse-delivered patient education on postoperative wound care: a prospective study.

OBJECTIVE: It is estimated that one in four postoperative wound complications occur within 14 days of hospital discharge. Some estimate that up to 50% of readmissions are preventable with effective postoperative education and closer follow-up. Providing patients with information enables them to detect when medical intervention may be required. The aim of this study was to describe the content of postoperative wound care education given to patients, and to identify demographic and clinical factors that predict receipt of surgical wound care education across two tertiary hospitals in Queensland, Australia. METHOD: A prospective correlational design using structured observations, field notes and an electronic chart audit was used. A consecutive sample of surgical patients and a convenience sample of nurses were observed during episodes of postoperative wound care. Field notes were documented to gain a nuanced understanding of the wound care education delivered by nurses. Descriptive statistics were used to describe the samples. A multivariate logistic regression model was developed to describe associations between seven predictors: sex; age; case complexity; type of wound; dietetic consult; the number of postoperative days; and receipt of postoperative wound care education. RESULTS: In total, 154 nurses delivering surgical wound care and 257 patients receiving wound care were observed. Across the combined number of patients across the two hospitals, 71/257 (27.6%) wound care episodes included postoperative wound education. The content of the wound care education mainly focused on keeping the wound dressing dry and intact, while the secondary focus was on showing patients how to remove and replace the dressing. In this study, three of the seven predictors were significant: sex (ß=-0.776, p=0.013); hospital site (ß=-0.702, p=0.025); and number of postoperative days (ß=-0.043, p=0.039). Of these, sex was the strongest, with females twice as likely to receive some form of wound care education during the postoperative period. These predictors explained 7.6-10.3% of variance in the postoperative wound care education patients received. CONCLUSION: Further research to develop strategies designed to improve the consistency and comprehensiveness of the postoperative wound care education delivered to patients is needed.

Surgical wound care preferences and priorities from the perspectives of patients: a qualitative analysis.

OBJECTIVE: To explore patients' priorities and preferences for optimal care of their acute or hard-to-heal surgical wound(s). METHOD: This qualitative study involved semi-structured individual interviews with patients receiving wound care in Queensland, Australia. Convenience and snowball sampling were used to recruit patients from inpatient and outpatient settings between November 2019 and January 2020. Interviews were audio recorded, transcribed verbatim and analysed using thematic analysis. Emergent themes were discussed by all investigators to ensure consensus. RESULTS: A total of eight patients were interviewed, five of whom were male (average median age: 70.5 years; interquartile range (IQR): 45-80 years). Four interrelated themes emerged from the data that describe the patients' surgical wound journey: experiencing psychological and psychosocial challenges; taking back control by actively engaging in care; seeking out essential clinician attributes; and collaborating with clinicians to enable an individualised approach to their wound care. CONCLUSION: Findings from this study indicate that patients want to actively collaborate with clinicians who have caring qualities, professional skills and knowledge, and be involved in decision-making to ensure care meets their individual needs.

A randomised controlled trial of a nutrition and a decision support intervention to enable partnerships with families of critically ill patients.

AIMS AND OBJECTIVES: The aim of the study was to investigate the effect of supporting family members to partner with health professionals on nutrition intakes and decision-making and to evaluate intervention and study feasibility. BACKGROUND: Family partnerships can improve outcomes for critically ill patients and family members. Interventions that support families to engage with health professionals require evaluation. DESIGN: A multi-centre, randomised, parallel group superiority Phase II randomised controlled trial. METHODS: In nine intensive care units (ICUs) across three countries, critically ill patients ≥60 years, or those 55-59 years with advanced chronic diseases and expected ICU length of stay >72 h and their family member were enrolled between 9 May 2017 and 31 March 2020. Participants were randomised (1:1:1) to either a decision support or nutrition optimisation family-centred intervention, or usual care. Primary outcomes included protein and energy intake during ICU and hospital stay (nutrition intervention) and family satisfaction (decision support). Study feasibility was assessed as a composite of consent rate, intervention adherence, contamination and physician awareness of intervention assignment. RESULTS: We randomised 135 patients/family members (consent rate 51.7%). The average rate of randomisation was 0.5 (0.13-1.53) per month. Unavailability (staff/family) was the major contributor to families not being approached for consent. Declined consent was attributed to families feeling overwhelmed (58/126, 46%). Pandemic visitor restrictions contributed to early study cessation. Intervention adherence for the decision support intervention was 76.9%-100.0% and for the nutrition intervention was 44.8%-100.0%. Nutritional adequacy, decisional conflict, satisfaction with decision-making and overall family satisfaction with ICU were similar for all groups. CONCLUSIONS: Active partnerships between family members and health professionals are important but can be challenging to achieve in critical care contexts. We were unable to demonstrate the efficacy of either intervention. Feasibility outcomes suggest further refinement of interventions and study protocol may be warranted. RELEVANCE TO CLINICAL PRACTICE: Interventions to promote family partnerships in critical illness are needed but require a greater understanding of the extent to which families want and are able to engage and the activities in which they have most impact. REPORTING METHOD: This study has been reported following the Consolidated Standards of Reporting Trials (CONSORT) and the Template for Intervention Description and Replication (TIDieR) guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers were engaged in and contributed to the development and subsequent iterations of the two family-centred interventions use in this study. CLINICAL TRIAL REGISTRATION NUMBER: Trial registration. CLINICALTRIALS: gov, ID: NCT02920086. Registered on 30 September 2016. First patient enrolled on 9 May 2017 https://clinicaltrials.gov/ct2/results?cond=&term=NCT02920086&cntry=&state=&city=&dist=.

A group program for overweight and obese women with urinary incontinence (ATHENA): an implementation-effectiveness hybrid type 3 study.

INTRODUCTION AND HYPOTHESIS: Supervised pelvic floor muscle training (PFMT), weight loss and exercise are recommended for overweight/obese women with urinary incontinence (UI). This study aimed to implement and evaluate the feasibility, acceptability and effectiveness of a 12-week group exercise and healthy eating program (ATHENA) for overweight/obese women with UI. METHODS: This study, using an implementation-effectiveness hybrid type 3 design, was conducted within a Women's Health Physiotherapy outpatient service at an Australian tertiary public hospital. Intervention feasibility and acceptability were assessed through process evaluation of implementation, while clinical effectiveness was assessed via pre-/post-clinical and quality of life surveys. Process data were analyzed using descriptive statistics and effectiveness data were compared pre-/post-intervention using inferential statistics. RESULTS: Of 156 eligible patients, 37 (24%) agreed to participate; 29 (78%) completed the ATHENA program. Median (IQR) age and body mass index were 53 (47-65) years and 30.8 (29.1-34.8) kg/m2 respectively. ATHENA was feasible to implement, with all components delivered as intended and high participant satisfaction. Ninety-seven percent of participants reported improved UI symptoms (global rating of change) and significant improvements in overall pelvic floor dysfunction and quality of life utility scores (p = 0.001). While weight did not change, significant improvements were found in body-food choice congruence (intuitive eating scale-2; p < 0.01). CONCLUSIONS: The ATHENA intervention was feasible, acceptable and clinically effective for overweight and obese women with urinary incontinence at a tertiary public hospital in Australia. Further research into longer term outcomes and the cost effectiveness of this group intervention is recommended. TRIAL REGISTRATION: N/A. Ethics approval, HREC/2018/QGC/46582, date of registration 14/11/2018.

Improving Accuracy of Texture-Modified Diets and Thickened Fluids Provision in the Hospital: Evidence in Action.

Ensuring inpatients with dysphagia receive and consume the correct texture-modified diet and thickened fluid prescriptions is challenging, and errors can result in significant complications for patients and increased costs to hospitals. The aim of this study was to investigate underlying factors that help or hinder receipt and consumption of correct dietary prescriptions for people with dysphagia in the hospital setting then implement and evaluate a range of strategies to address identified issues. A mixed-methods study design, using an integrated knowledge translation approach, was conducted in three phases. In Phase 1, clinical incident data (i.e., documented incidents of diet/fluid errors, with errors defined as the provision or consumption of any food/fluid not appropriate for a patient's dietary prescription) were analyzed, and staff, patients, and family members were interviewed using the Theoretical Domains Framework to identify factors contributing to errors. In Phase 2, health professionals assisted with the development and implementation of interventions targeted at micro (patient/family), meso (staff), and macro (organizational) levels to address factors identified in Phase 1. In Phase 3, outcomes including the change in number of dietary clinical incidents pre- to post-intervention, meal accuracy error rates from mealtime audits post-intervention, and follow-up interviews were evaluated using quantitative and qualitative measures. Post-intervention, there was a 50% reduction in clinical incidents, and a 2.3% meal accuracy error rate was observed. Staff reported most interventions were acceptable and feasible within their workload, although some interventions were not well embedded in everyday practice. This study highlights the value in using an integrated knowledge translation approach to inform tailored interventions targeting improved dietary accuracy in the hospital setting.

Promoting Confident Body, Confident Child in community child health: A mixed-methods implementation study.

OBJECTIVE: To evaluate population-level implementation of Confident Body, Confident Child (CBCC); an evidence-based program providing parenting strategies to promote healthy eating, physical activity and body satisfaction in children aged 2-6 years; with community child health nurses (CHNs). METHODS: This study utilised an implementation-effectiveness hybrid design, with dual focus on assessing: (a) CBCC implementation into Child Health Centres at a regional health service in Queensland, Australia (process evaluation); and (b) CBCC's effect on CHNs' knowledge and attitudes (outcomes evaluation). Process (CBCC reach, dose, fidelity) and outcome data (CHN knowledge of child body image; and attitudes towards higher body weights) were collected during implementation, and pre- and post-intervention delivery to CHNs, respectively. RESULTS: Twenty-six CHNs (all female; mean age 52.7 ± 9.5 years) participated in the study by attending a 1-day CBCC training workshop and completing demographic and outcome surveys. Process evaluation found that CBCC was implemented as planned and reached 56% of CHNs across the health service. Outcome evaluation showed small but non-significant improvements in CHN knowledge (P = .077) and attitudes towards overweight (using Anti-Fat Attitudes scale; significant improvements on willpower sub-scale only (P < .05)). DISCUSSION: This is the first study to evaluate population-wide CBCC implementation in a real-world health service setting with CHNs. Findings highlight the potential for using pragmatic, implementation-focused methodologies to translate preventive eating disorder programs into community child health services.

Assessment of an integrated knowledge translation intervention to improve nutrition intakes among patients undergoing elective bowel surgery: a mixed-method process evaluation.

BACKGROUND: A large evidence-practice gap exists regarding provision of nutrition to patients following surgery. The aim of this study was to evaluate the processes supporting the implementation of an intervention designed to improve the timing and adequacy of nutrition following bowel surgery. METHODS: A mixed-method pilot study, using an integrated knowledge translation (iKT) approach, was undertaken at a tertiary teaching hospital in Australia. A tailored, multifaceted intervention including ten strategies targeted at staff or patients were co-developed with knowledge users at the hospital and implemented in practice. Process evaluation outcomes included reach, intervention delivery and staffs' responses to the intervention. Quantitative data, including patient demographics and surgical characteristics, intervention reach, and intervention delivery were collected via chart review and direct observation. Qualitative data (responses to the intervention) were sequentially collected from staff during one-on-one, semi-structured interviews. Quantitative data were summarized using median (IQR), mean (SD) or frequency(%), while qualitative data were analysed using content analysis. RESULTS: The intervention reached 34 patients. Eighty-four percent of nursing staff received an awareness and education session, while 0% of medical staff received a formal orientation or awareness and education session, despite the original intention to deliver these sessions. Several strategies targeted at patients had high fidelity, including delivery of nutrition education (92%); and prescription of oral nutrition supplements (100%) and free fluids immediately post-surgery (79%). Prescription of a high energy high protein diet on postoperative day one (0%) and oral nutrition supplements on postoperative day zero (62%); and delivery of preoperative nutrition handout (74%) and meal ordering education (50%) were not as well implemented. Interview data indicated that staff regard nutrition-related messages as important, however, their acceptance, awareness and perceptions of the intervention were mixed. CONCLUSIONS: Approximately half the patient-related strategies were implemented well, which is likely attributed to the medical and nursing staff involved in intervention design championing these strategies. However, some strategies had low delivery, which was likely due to the varied awareness and acceptance of the intervention among staff on the ward. These findings suggest the importance of having buy-in from all staff when using an iKT approach to design and implement interventions.

Engaging hospitalised patients in their nutrition care using technology: development of the NUTRI-TEC intervention.

BACKGROUND: Nutrition is vital for health and recovery during hospitalisation, however most patients fail to meet minimum dietary requirements and up to 50% of patients are malnourished in hospital. When patients participate in nutrition care, their dietary intakes are improved. Advances in health information technology (HIT) have broadened the ways by which patients can participate in care. Our team has developed an innovative, HIT-based intervention (called NUTRI-TEC; engaging patients in their nutrition care using technology), facilitating patient participation in their nutrition care in hospital. This paper aims to describe the systematic and iterative process by which the intervention was developed. METHODS: NUTRI-TEC development was informed by the Medical Research Council guidance for developing complex interventions and underpinned by theoretical frameworks and concepts (i.e. integrated knowledge translation and patient participation in care), existing evidence and a rigorous program of research. The intervention was co-developed by the multidisciplinary research team and stakeholders, including health consumers (patients), health professionals and industry partners. We used an iterative development and evaluation cycle and regularly tested the intervention with hospital patients and clinicians. RESULTS: The NUTRI-TEC intervention involves active patient participation in their nutrition care during hospitalisation. It has two components: 1) Patient education and training; and 2) Guided nutrition goal setting and patient-generated dietary intake tracking. The first component includes brief education on the importance of meeting energy/protein requirements in hospital; and training on how to use the hospital's electronic foodservice system, accessed via bedside computer screens. The second component involves patients recording their food intake after each meal on their bedside computer and tracking their intakes relative to their goals. This is supported with brief, daily goal-setting sessions with a health care professional. CONCLUSIONS: NUTRI-TEC is a HIT intervention designed to enable patient participation in their nutrition care in hospital. As research on HIT interventions to engage patients in health care in the hospital setting is in its infancy, and as gaps and inconsistencies in the development of such interventions exist, this paper will inform future development of HIT-based interventions in the hospital setting.

Wound care practices across two acute care settings: A comparative study.

AIMS AND OBJECTIVES: Describe and compare current surgical wound care practices across two hospitals in two health services districts, Australia. BACKGROUND: Surgical site infections (SSI) are a complication of surgery and occur in up to 9.5% of surgical procedures, yet they are preventable. Despite the existence of clinical guidelines for SSI prevention, there remains high variation in wound care practice. DESIGN: Prospective comparative design using structured observations and chart audit. METHODS: A specifically developed audit tool was used to collect data on observed wound care practices, documentation of wound assessment and practice, and patients' clinical characteristics from patients' electronic medical records. Structured observations of a consecutive sample of surgical patients receiving wound care with a convenience sample of nurses were undertaken. The manuscript adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. RESULTS: In total, 154 nurses undertaking acute wound care and 257 surgical patients who received wound care were observed. Across hospitals, hand hygiene adherence after dressing change was lowest (Hospital A: 8/113, 7%; Hospital B: 16/144, 11%; χ2 : 8.93, p = .347). Most wound dressing practices were similar across sites, except hand hygiene prior to dressing change (Hospital A: 107/113, 95%; Hospital B: 131/144, 91%; (χ2 : 7.736, p = .021) and use of clean gloves using nontouch technique (Hospital A: 88/113, 78%; Hospital B: 90/144, 63%; χ2 : 8.313, p = .016). The most commonly documented wound characteristic was wound type (Hospital A: 43/113, 38%; Hospital B: 70/144, 49%). What nurses documented differed significantly across sites (p < .05). CONCLUSIONS: Clinical variations in wound care practice are likely influenced by clinical context. RELEVANCE TO CLINICAL PRACTICE: Using an evidence-based approach to surgical wound management will help reduce patients' risk of wound-related complications.

Child health nurse perceptions of using confident body, confident child in community health: a qualitative descriptive study.

BACKGROUND: Confident Body, Confident Child (CBCC) is an innovative, evidence-based program providing parenting strategies to promote healthy eating, physical activity and body satisfaction in children aged 2-6 years. This study aimed to explore Child Health Nurse (CHN) experiences with using CBCC in their community health clinics with parents of young children. This work is part of a larger study involving tailoring, implementing and evaluating CBCC in a community child health setting. METHODS: This qualitative descriptive study was conducted within community child health centres at a public health service in Queensland, Australia. Participants included CHNs who had recently attended a tailored CBCC training workshop providing training/education, group activities/discussions and CBCC resources for CHN use in clinical practice. Semi-structured interviews were conducted to explore CHN perceptions of CBCC training, content and resources; and how CBCC was used in practice. Interviews were recorded and transcribed verbatim and analysed thematically. RESULTS: Eleven CHNs participated in interviews, with three themes emerging from the data. In Theme 1, High CHN satisfaction with CBCC messages, resources and utility, nurses expressed CBCC was highly valuable, useful and easy to enact in their practice. In Theme 2, Effects of CBCC on CHN knowledge, behaviour and practice, CHNs said they experienced increased awareness around body image, improved confidence in addressing issues with clients, and positive changes in their own behaviour and practice after attending CBCC training. In Theme 3, CHNs discussed Ideas for future implementation of CBCC, including challenges and considerations for practice, ongoing education/training for CHNs and broadening the target audience for wider CBCC dissemination. CONCLUSIONS: This study found CHNs were highly accepting of CBCC as it was useful and valuable in practice, increased their awareness and confidence around body image issues, and positively affected their attitudes and behaviours. CHNs' suggestions for making CBCC delivery more efficient and broadening its reach in the community were valuable and will likely inform local policy and future research. Further research is required on the wider dissemination of CBCC to parents of young children for promoting positive body image and healthy eating, ultimately for the long-term prevention of eating disorders.

A qualitative exploration of factors influencing medical staffs' decision-making around nutrition prescription after colorectal surgery.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) guidelines recommend early oral feeding with nutritionally adequate diets after surgery. However, studies have demonstrated variations in practice and poor adherence to these recommendations among patients who have undergone colorectal surgery. Given doctors are responsible for prescribing patients' diets after surgery, this study explored factors which influenced medical staffs' decision-making regarding postoperative nutrition prescription to identify potential behaviour change interventions. METHODS: This qualitative study involved one-on-one, semi-structured interviews with medical staff involved in prescribing nutrition for patients following colorectal surgery across two tertiary teaching hospitals. Purposive sampling was used to recruit participants with varying years of clinical experience. The Theoretical Domains Framework (TDF) underpinned the development of a semi-structured interview guide. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and sub-themes were discussed by all investigators to ensure consensus of interpretation. RESULTS: Twenty-one medical staff were interviewed, including nine consultants, three fellows, four surgical trainees and five junior medical doctors. Three overarching themes emerged from the data: (i) Prescription preferences are influenced by perceptions, experience and training; (ii) Modifying prescription practices to align with patient-related factors; and (iii) Peers influence prescription behaviours and attitudes towards nutrition. CONCLUSIONS: Individual beliefs, patient-related factors and the social influence of peers (particularly seniors) appeared to strongly influence medical staffs' decision-making regarding postoperative nutrition prescription. As such, a multi-faceted approach to behaviour change is required to target individual and organisational barriers to enacting evidence-based feeding recommendations.

Partnering with families to promote nutrition in cancer care: feasibility and acceptability of the PIcNIC intervention.

BACKGROUND: Malnutrition is frequent in patients with cancer, particularly those in advanced stages of the disease. The aim of the present study was to test the feasibility of a family-centred nutritional intervention, based on the Family Systems theory and past research. METHODS: This was a single-arm trial assessing feasibility (eligibility, recruitment and retention rates); acceptability by patients, family caregivers and health professionals; intervention fidelity, and energy/protein intake (in one site only). Two sites were involved; one each in Australia (AUS) and Hong Kong (HK), with one site delivering the intervention to oncology patients receiving curative treatments in the hospital, and the other to advanced cancer patients in the home. RESULTS: The sample included 53 patients (23 from AUS and 30 from HK), 22 caregivers (3 from AUS and 19 from HK) and 30 health professionals (20 from AUS and 10 from HK). Recruitment was difficult in the acute inpatient oncology care setting (AUS) and feasibility criteria were not met. Sufficient recruitment took place in the home care setting with advanced cancer patients in HK. Patients, family members and health professionals found the intervention helpful and acceptable, and patients and families indicated they would take part in the future in a similar study. Energy and protein intake improved from baseline to end of intervention (mean 22 kcal/kg/day to 26 and 0.9 g/kg/day to 1.0 respectively). CONCLUSION: The new intervention is feasible in a home setting when delivered to patients with advanced cancer, acceptable to patients and families, and has the potential to improve nutritional status in patients. A large randomised trial is warranted in the future.

Using technology to engage hospitalised patients in their care: a realist review.

BACKGROUND: Patient participation in health care is associated with improved outcomes for patients and hospitals. New technologies are creating vast potential for patients to participate in care at the bedside. Several studies have explored patient use, satisfaction and perceptions of health information technology (HIT) interventions in hospital. Understanding what works for whom, under what conditions, is important when considering interventions successfully engaging patients in care. This realist review aimed to determine key features of interventions using bedside technology to engage hospital patients in their care and analyse these in terms of context, mechanisms and outcomes. METHODS: A realist review was chosen to explain how and why complex HIT interventions work or fail within certain contexts. The review was guided by Pawson's realist review methodology, involving: clarifying review scope; searching for evidence; data extraction and evidence appraisal; synthesising evidence and drawing conclusions. Author experience and an initial literature scope provided insight and review questions and theories (propositions) around why interventions worked were developed and iteratively refined. A purposive search was conducted to find evidence to support, refute or identify further propositions, which formed an explanatory model. Each study was 'mined' for evidence to further develop the propositions and model. RESULTS: Interactive learning was the overarching theme of studies using technology to engage patients in their care. Several propositions underpinned this, which were labelled: information sharing; self-assessment and feedback; tailored education; user-centred design; and support in use of HIT. As studies were mostly feasibility or usability studies, they reported patient-centred outcomes including patient acceptability, satisfaction and actual use of HIT interventions. For each proposition, outcomes were proposed to come about by mechanisms including improved communication, shared decision-making, empowerment and self-efficacy; which acted as facilitators to patient participation in care. Overall, there was a stronger representation of health than IT disciplines in studies reviewed, with a lack of IT input in terms of theoretical underpinning, methodological design and reporting of outcomes. CONCLUSION: HIT interventions have great potential for engaging hospitalised patients in their care. However, stronger interdisciplinary collaboration between health and IT researchers is needed for effective design and evaluation of HIT interventions.

Hospital staffs' perceptions of an electronic program to engage patients in nutrition care at the bedside: a qualitative study.

BACKGROUND: Advancements in technology are enabling patients to participate in their health care through self-monitoring and self-management of diet, exercise and chronic disease. Technologies allowing patients to participate in hospital care are still emerging but show promise. Our team is developing a program by which hospitalised patients can participate in their nutrition care. This study explores hospital staffs' perceptions of using this technology to engage patients in their care. METHODS: This qualitative study involved semi-structured interviews with hospital staff providing routine nutrition care to patients (i.e. dietitians, nutrition assistants, nurses, doctors and foodservice staff) from five wards at a tertiary metropolitan teaching hospital in Australia. The hospital currently uses an electronic foodservice system (EFS) for patient meal ordering, accessed through personal screens at the bedside. Participants were shown the EFS program on an iPad and asked about their perceptions of the program, with questions from a semi-structured interview guide. Staff were interviewed individually or in small focus groups. Interviews lasted 15-30 min and were audio recorded and later transcribed. Data were analysed using thematic analysis. RESULTS: Nineteen staff participated in interviews. Overall, they expressed positive views of the EFS program and wanted it to be implemented in practice. Their responses formed three themes, each with a number of subthemes: 1) Enacting patient participation in practice; 2) Optimising nutrition care; and 3) Considerations for implementing an EFS program in practice. Staff thought the program would improve various aspects of nutrition care and enable patient participation in care. Whilst they raised some concerns, they focused on overcoming barriers and facilitating implementation if the program were to be adopted into practice. CONCLUSIONS: Staff found an EFS program designed to engage patients in their nutrition care acceptable, as they saw benefits to using it for both patients and staff. Staff recognised characteristics of the program itself, as well as allocation of roles and responsibilities in operationalising it, were pivotal for successful implementation in practice. Their perspectives will inform program and intervention design, and implementation and evaluation strategies.

Patients' Perceptions of a Pressure Ulcer Prevention Care Bundle in Hospital: A Qualitative Descriptive Study to Guide Evidence-Based Practice.

BACKGROUND: Pressure ulcers place a significant burden on patients and hospitals. Our team developed and tested a pressure ulcer prevention care bundle (PUPCB) in a cluster randomized trial. As part of the process evaluation conducted alongside the trial, we explored patients' perceptions of the intervention. AIMS: To identify patients' perceptions and experiences of a PUPCB in hospital. METHODS: This qualitative descriptive study explored the perceptions of a subset of patients who participated in a trial testing the PUPCB across four intervention hospitals. A trained interviewer conducted semistructured interviews, which were digitally recorded, transcribed, and analyzed using thematic analysis. FINDINGS: Nineteen patients were interviewed across the four hospitals. Three main themes emerged: (a) importance of personal contact in PUPCB delivery; (b) understanding pressure ulcer prevention (PUP) enhances participation; and (c) individual factors impact patients' engagement in PUP. DISCUSSION: The extent to which patients adopted the intervention appeared to be influenced by the complexity of education materials, compatibility with patients' existing knowledge and beliefs, and perceived advantage of the intervention; ability for human interaction; and patient-related facilitators and barriers to participating in PUP care. LINKING EVIDENCE TO ACTION: This study found patients accepted a PUPCB that encouraged participation in care, particularly as it involved personal and positive interactions with nurses and provision of information that was easy to understand and resonated with patients.

Feasibility of a patient-centred nutrition intervention to improve oral intakes of patients at risk of pressure ulcer: a pilot randomised control trial.

AIM: Nutrition is important for pressure ulcer prevention. This randomised control pilot study assessed the feasibility of conducting a larger trial to test the effectiveness of a patient-centred intervention for improving the dietary intakes of patients at risk of pressure ulcer in hospital. METHODS: A 3-day intervention targeting patients at risk of pressure ulcer was developed, based on three main foundations: patient education, patient participation and guided goal setting. The intervention was piloted in three wards in a metropolitan hospital in Queensland, Australia. Participants were randomised into control or intervention groups and had their oral intakes monitored. A subset of intervention patients was interviewed on their perceptions of the intervention. Feasibility was tested against three criteria: ≥75% recruitment; ≥80% retention; and ≥80% intervention fidelity. Secondary outcomes related to effects on energy and protein intakes. RESULTS: Eighty patients participated in the study and 66 were included in final analysis. The recruitment rate was 82%, retention rate was 88%, and 100% of intervention patients received the intervention. Patients viewed the intervention as motivating and met significantly more of their estimated energy and protein requirements over time. CONCLUSION: This pilot study indicates that the intervention is feasible and acceptable by patients at risk of pressure ulcer. A larger trial is needed to confirm the effectiveness of the intervention in the clinical setting.

Patient engagement in clinical communication: an exploratory study.

AIM: Existing practice strategies for actively involving patients in care during hospitalisation are poorly understood. The aim of this study was to explore how healthcare professionals engaged patients in communication associated with care transitions. METHOD: An instrumental, collective case study approach was used to generate empirical data about patient transitions in care. A purposive sample of key stakeholders representing (i) patients and their families; (ii) hospital discharge planning team members; and (iii) healthcare professionals was recruited in five Australian health services. Individual and group semi-structured interviews were conducted to elicit detailed explanations of patient engagement in transition planning. Interviews lasted between 30 and 60 minutes and were digitally recorded and transcribed verbatim. Data collection and analysis were conducted simultaneously and continued until saturation was achieved. Thematic analysis was undertaken. RESULTS: Five themes emerged as follows: (i) organisational commitment to patient engagement; (ii) the influence of hierarchical culture and professional norms on patient engagement; (iii) condoning individual healthcare professionals' orientations and actions; (iv) understanding and negotiating patient preferences; and (v) enacting information sharing and communication strategies. Most themes illustrated how patient engagement was enabled; however, barriers also existed. CONCLUSION: Our findings show that strong organisational and professional commitment to patient-centred care throughout the organisation was a consistent feature of health services that actively engaged patients in clinical communication. Understanding patients' needs and preferences and having both formal and informal strategies to engage patients in clinical communication were important in how this involvement occurred.

Nurses' perceptions of a pressure ulcer prevention care bundle: a qualitative descriptive study.

BACKGROUND: Pressure ulcer prevention is a critical patient safety indicator for acute care hospitals. An innovative pressure ulcer prevention care bundle targeting patient participation in their care was recently tested in a cluster randomised trial in eight Australian hospitals. Understanding nurses' perspectives of such an intervention is imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the main trial, this study assessed nurses' perceptions of the usefulness and impact of a pressure ulcer prevention care bundle intervention on clinical practice. METHODS: This qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention care bundle. Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured interview guide to question participants about their perceptions of the care bundle. Interviews were digitally recorded, transcribed and analysed using thematic analysis. RESULTS: Eighteen nurses from four hospitals participated in the study. Nurses' perceptions of the intervention are described in five themes: 1) Awareness of the pressure ulcer prevention care bundle and its similarity to current practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention care bundle; 3) Appreciating the positive aspects of patient participation in care; 4) Perceived barriers to engaging patients in the pressure ulcer prevention care bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer prevention care bundle implementation. CONCLUSIONS: Overall, nurses found the care bundle feasible and acceptable. They identified a number of benefits from the bundle, including improved communication, awareness and participation in pressure ulcer prevention care among patients and staff. However, nurses thought the care bundle was not appropriate or effective for all patients, such as those who were cognitively impaired. Perceived enablers to implementation of the bundle included facilitation through effective communication and dissemination of evidence about the care bundle; strong leadership and ability to influence staff behaviour; and simplicity of the care bundle.