Implementation of a Frailty Care Bundle (FCB) Targeting Mobilisation, Nutrition and Cognitive Engagement to Reduce Hospital Associated Decline in Older Orthopaedic Trauma Patients: Pretest-Posttest Intervention Study.

Objective: To implement and evaluate a Frailty Care Bundle (FCB) targeting mobilisation, nutrition, and cognition in older trauma patients to reduce hospital associated decline. Methods: We used a two group, pretest-posttest design. The FCB intervention was delivered on two orthopaedic wards and two rehabilitation wards, guided by behaviour change theory (COM-B) to implement changes in ward routines (patient mobility goals, nurse assisted mobilisation, mealtimes, communication). Primary outcomes were patient participants' return to pre-trauma functional capability (modified Barthel Index - mBI) at 6-8 weeks post-hospital discharge and average hospital daily step-count. Statistical analysis compared pre versus post FCB group differences using ordinal regression and log-linear models. Results: We recruited 120 patients (pre n=60 and post n=60), and 74 (pre n=43, post n=36) were retained at follow-up. Median age was 78 years and 83% were female. There was a non-significant trend for higher mBI scores (improved function) in the post compared to pre FCB group (OR 2.29, 95% CI 0.98-5.36), associated with an average 11% increase in step-count. Conclusion: It was feasible, during the Covid-19 pandemic, for multidisciplinary teams to implement elements of the FCB. Clinical facilitation supported teams to prioritise fundamental care above competing demands, but sustainability requires ongoing attention. ISRCTN registry: ISRCTN15145850 (https://doi.org/10.1186/ISRCTN15145850).

Comprehensive geriatric assessment-where are we now, where do we need to be in the context of global ageing?

Comprehensive geriatric assessment (CGA) is the cornerstone of modern geriatric medicine and the framework around which conventional and new models of care for older people are developed. Whilst there are a substantial number of reviews synthesising the evidence on patient and service outcomes from CGA, as an intervention it remains poorly described. There is a lack of detail on how a CGA plan is coordinated, delivered and followed up, especially outside of acute care. This commentary reflects on the authors' experience of extracting data from 57 published studies on CGA. CGA as an intervention is akin to a 'black box' in terms of describing and measuring participants' interactions with CGA activity in terms of time, frequency and amount (dose) received. There is also a lack of detail on how newly established CGA teams become effective, interdisciplinary, high functioning and sustainable teams. The CGA knowledge-do gap persists with a need to draw from complex system theory and implementation science frameworks to better describe the intervention and understand the influence of the organisation and health service within which CGA is operationalised. Equally, the voice of older people, families and staff is critical in the conduct and evaluation of CGA, and how it evolves as a model to meet the growing needs of ageing populations.

Evaluation of the feasibility of an Education-Career pathway in Healthcare for Older People (ECHO) for early career nurses.

BACKGROUND: Rapid population ageing is driving demand for qualified gerontological nurses. Yet, early career nurse attrition and limited focus on retention in the speciality limits supply. OBJECTIVES: To test the feasibility and acceptability of an Education-Career pathway in Healthcare for Older People (ECHO) intervention for early career nurses to improve retention and capability in gerontological nursing. ECHO is a multicomponent intervention with integrated education, career planning and coaching components, tested over two 6-month cycles. METHODS: A feasibility study with a pre-post design using a multi-methods evaluation. Twenty-nine early career nurse participants were recruited from eight NHS acute and community care Trusts in England. ECHO participants completed online questionnaires at baseline (Time 1), 6-month (T2, end of intervention) and follow-up at 18 months from baseline (T3). Outcome measures were career intention, self-reported knowledge, career planning confidence, and burnout using the Maslach Burnout Inventory. Qualitative interviews were undertaken with participants (n = 23) and organizational stakeholders (n = 16) who facilitated ECHO. Data analysis used descriptive statistics and non-parametric tests for paired data and thematic analysis for qualitative data. RESULTS: Overall, 19 of 29 participants (65%) completed all aspects of the intervention. The evaluation was completed by 23 participants. ECHO was well received by participants and stakeholders. At T3, the 23 participants were working in the speciality, though two had changed organizations. There was a significant improvement in self-reported gerontological knowledge, pre 87 (IQR 81-102), post 107 (IQR 98-112) p = 0.006, but no significant changes in other outcomes. In qualitative data, participants and organizational stakeholders held similar views, presented under four main themes: intended outcomes (personal and professional development, raise gerontological profile, expand horizons); nurse retention-a double-edged sword, ECHO logistics, and sustainability. CONCLUSION: Education-Career pathway in Healthcare for Older People was feasible and may positively impact early career nurse retention, capability and socialization into gerontological nursing. ECHO requires further refinement and piloting, but learning can contribute to retention strategies. IMPLICATIONS FOR PRACTICE: Attracting and retaining early-career nurses to the gerontological speciality requires greater innovation, organizational and senior nurse leadership.

Shared decision-making with adults transitioning to long-term care: A scoping review.

BACKGROUND: Transitions to long-term care are challenging for individuals and often associated with a loss of autonomy. Positive experiences are noted, especially when decisions involve the individual in a person-centred way which are respectful of the person's human rights. One approach which facilitates self-determination during a transitional period is shared decision-making, but there is a lack of clarity on the nature and extent of research evidence in this area. OBJECTIVE: The purpose of this scoping review is to identify and document research related to shared decision-making and transitioning to long-term care. METHODS: A comprehensive search in CINAHL, Medline and Psych-info identified papers which included evidence of shared decision-making during transitions to a long-term care setting. The review following the JBI and PAGER framework for scoping reviews. Data were extracted, charted and analysed according to patterns, advances, gaps, research recommendations and evidence for practice. RESULTS: Eighteen papers met the inclusion criteria. A body of knowledge was identified encompassing the pattern advancements in shared decision-making during transitions to long-term care, representing developments in both the evidence base and methodological approaches. Further patterns offer evidence of the facilitators and barriers experienced by the person, their families and the professional's involved. CONCLUSIONS: The evidence identified the complexity of such decision-making with efforts to engage in shared decision-making often constrained by the availability of resources, the skills of professionals and time. The findings recognise the need for partnership and person-centred approaches to optimise transitions. The review demonstrates evidence of approaches that can inform future practice and research to support all adult populations who may be faced with a transitional decision to actively participate in decision-making.

Developing a competency framework for early career nurses undertaking post-registration education in care for older people.

BACKGROUND: Within gerontological nursing as a postgraduate nursing specialty, there is a lack of consensus regarding the standardised competencies and education development required, particularly in the UK. AIM: To develop and evaluate a competency framework for early career nurses undertaking post-registration education in a UK university in care for older people living with frailty. METHOD: The competency framework was developed as part of a broader gerontological education-career pathway intervention to improve competence and retention among early career nurses. A four-step process was used to develop the framework guided by a consensus building approach. A mixed-methods approach to the evaluation was adopted, with an online survey, one-to-one interviews and focus group interviews with students and organisational stakeholders. FINDINGS: A total of 33 students completed the competency framework as part of an academic module, 30 of whom took part in the evaluation. There was consensus among interviewees that the competencies confirmed 'what they knew already' and identified areas they needed to develop. Survey respondents reported that the competency framework was a useful part of the education-career pathway. CONCLUSION: The competency framework was acceptable to students and feasible to complete. It also enabled students to appreciate the unique knowledge and skills that underpin gerontological nursing and to evidence their expertise using a structured approach.

Transitioning to long-term care for older adults with intellectual disabilities: A concept analysis.

AIM: To undertake a concept analysis of transitioning to long-term care for older adults with intellectual disabilities. BACKGROUND: Individuals with an intellectual disability are experiencing increased longevity which is associated with an increase in transitions in later life to long-term care. Their experience of later life transitions is likely to be different to the general older population. METHODOLOGY: Concept Analysis was undertaken using the Walker and Avant framework. RESULTS: Eight studies met the inclusion criteria. Defining attributes are an older person with intellectual disability; a planned relocation to a long-term care facility; person-centred; and supported decision-making. CONCLUSION: There is a dearth of empirical evidence and theorisation on this concept. Transitions of this nature have been inadequately informed by the perspective of the older person with an intellectual disability, and future research and practice requires greater efforts to include their voice.

Primary healthcare reform for chronic conditions in countries with high or very high human development index: A systematic review.

OBJECTIVE: To address the growing burden of chronic disease globally, many countries have developed a national policy for primary healthcare reform. In some countries with high and very high human development index, evaluations of the implementation of these reforms have been published. To date, there has been no systematic review of these evaluations. The objectives of this review are to identify: (a) the vision for primary healthcare; (b) the features of primary healthcare reforms; and (c) evaluation findings of primary healthcare reforms. METHODS: A systematic literature review was conducted guided by the PRISMA statement. We searched for academic articles and grey literature from 1 March 2008 to 1 September 2020. Screening and data extraction were conducted by two authors. Descriptive analysis and narrative synthesis were applied. RESULTS: A vision for integrated primary healthcare shifting chronic disease management from specialist hospital services to primary care was found to require new organization and funding models such as collaborative primary healthcare networks and commissioning along with shared governance across health sectors. The need for general practitioner leadership and engagement to support primary healthcare reform was identified. Although there was evidence of barriers in progressing primary healthcare reform, evaluation results showed some positive outcomes, most notably shifts in services towards increased primary care access and utilization. DISCUSSION: A challenge in undertaking the review was the heterogeneity of articles with little consistency in how primary healthcare reform was evaluated and reported on across countries. Evaluation of national health reforms involves complex system-wide projects and is an area that needs further exploration and discussion to determine the most appropriate methodologies for collecting and analysing large-scale data with consideration for service and health outcomes.

Systematic review of interventions targeting fundamental care to reduce hospital-associated decline in older patients.

AIMS: To examine the effectiveness of targeted nursing interventions on mobilization, nutrition and cognitive engagement to reduce functional and hospital-associated decline (HAD) in older patients. DESIGN: Systematic review of experimental studies using randomized and quasi-experimental designs. DATA SOURCES: We searched electronic databases CINAHL, MEDLINE, EMBASE, Cochrane library, google scholar and BMJ quality reports from January 2009 to February 2020. REVIEW METHODS: We reviewed intervention studies that targeted ward nursing teams to increase mobilization, nutrition or cognitive engagement of older adults. Inclusion criteria included older patients, acute care (medical, surgical and older adult wards) and reporting patient level outcomes. Quality appraisal included the Joanna Briggs Critical Appraisal Checklist for Quasi-Experimental Studies. RESULTS: From 1729 papers, 18 studies using quasi-experimental and pre-post designs were selected. Study heterogeneity necessitated a narrative synthesis. The quality of evidence was low to moderate. All studies used multicomponent strategies, and 10 studies used evidence translation frameworks to align interventions to local barriers. Overall, 74% (n = 14) of studies reported a significant improvement in the stated primary outcome. Eight studies reported a significant increase in mobilization (e.g., sitting in a chair or walking), and four reported improved functional outcomes. Five studies improved nutrition outcomes (e.g., protein or energy intake), and three studies reported a significant reduction in delirium. CONCLUSION: Acknowledging methodological limitations, the evidence indicates that nursing teams using evidence-translation frameworks can improve mobilization, nutrition and cognitive engagement in acute care settings. Future research requires higher-quality pragmatic trial designs, standardized outcomes, staff co-designed interventions, evidence-translation frameworks and patient engagement to make more confident inference about effectiveness. IMPACT: Nursing teams with the support of hospital management have to address ward and system barriers to prioritize fundamental care to improve patient outcomes. There is sufficient evidence on multicomponent interventions and implementation strategies to inform nurse-led quality improvement.

Mealtime and patient factors associated with meal completion in hospitalised older patients: An exploratory observation study.

AIMS AND OBJECTIVES: To examine mealtime and patient factors associated with meal completion among hospitalised older patients. We also considered contextual factors such as staffing levels and ward communication. BACKGROUND: Sub-optimum nutrition is a modifiable risk factor for hospital associated decline (HAD) in older patients. Yet, the quality of mealtime experiences can be overlooked within ward routinised practice. DESIGN: Cross sectional, descriptive observation study. METHODS: We undertook structured observation of mealtimes examining patient positioning, mealtime set-up and feeding assistance. The outcome was meal completion categorised as 0, 25%, 50%, 75% or 100%. Data were collected on patient characteristics and ward context. We used mixed-effects ordinal regression models to examine patient and mealtime factors associated with higher meal completion producing odds ratios (OR) and 95% confidence intervals (CI). The study was reported as per STROBE guidelines. RESULTS: We included 60 patients with a median age of 82 years (IQR 76-87) and clinical frailty score of 5 IQR (4-6). Of the 279 meals, 51% were eaten completely, 6% three quarters, 15% half, 18% a quarter and 10% were not eaten at all. Mealtime predictors with a weak association with less-meal completion were requiring assistance, special diets, lying in bed, and red tray (indicator of nutrition risk), but were not statistically significant. Significant patient-level factors were higher values for frailty (OR 0.34 [0.11-1.04]) and Malnutrition Universal Screening Tool (OR 0.22 [0.08-0.62]). The average nurse-to-patient ratio was 1:5.5. CONCLUSION: Patient factors were the strongest predictors for meal completion, but mealtime factors had a subtle influence. The nursing teams' capacity to prioritise mealtimes above competing demands is important as part of a comprehensive nutrition strategy. RELEVANCE TO CLINICAL PRACTISE: Nurses are central to optimising nutrition for frail older patients. It requires ward leadership to instil a culture of prioritising assisted mealtimes, improved communication, greater autonomy to tailor nutrition strategies and safe staffing levels.

Evaluating a specialist education programme for nurses and allied health professionals working in older people care: A qualitative analysis of motivations and impact.

BACKGROUND: Developing clinical leaders is essential for high-quality, safe care for older people. Fundamental to achieving this is specialist continuing professional development for nurses and allied health professionals. OBJECTIVES: To investigate the motivations of nurses and allied health professionals to undertake a national specialist gerontological programme, the Older Persons Fellowship, and its impacts on their development and on older people care. DESIGN: A qualitative descriptive design. METHODS: Participants were nurses and allied health professionals undertaking a national specialist gerontological programme in England. A purposive sample of 63 participants was recruited. Twelve focus groups and four individual interviews were conducted between February 2015 and February 2019. Data were analysed using thematic analysis. RESULTS: Three themes were identified: credible gerontological experts; challenging ageism and suboptimal services; and legitimising gerontological practice as a speciality. CONCLUSIONS: Understanding the motivations to undertake a specialist gerontological programme and the impacts on practitioners and older people care and services will help inform the continuing professional development agenda for nurses and allied health professionals working in this field of practice. Policy makers, commissioners, managers, and educators can use the findings to inform continuing professional development priorities and provision for the gerontological workforce.

An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review.

OBJECTIVES: Patients are unintentionally, yet frequently, harmed in situations that are deemed preventable. Incident reporting systems help prevent harm, yet there is considerable variability in how patient safety incidents are reported. This may lead to inconsistent or unnecessary patterns of incident reporting and failures to identify serious patient safety incidents. This systematic review aims to describe international approaches in relation to defining serious reportable patient safety incidents. METHODS: Multiple electronic and gray literature databases were searched for articles published between 2009 and 2019. Empirical studies, reviews, national reports, and policies were included. A narrative synthesis was conducted because of study heterogeneity. RESULTS: A total of 50 articles were included. There was wide variation in the terminology used to represent serious reportable patient safety incidents. Several countries defined a specific subset of incidents, which are considered sufficiently serious, yet preventable if appropriate safety measures are taken. Terms such as "never events," "serious reportable events," or "always review and report" were used. The following dimensions were identified to define a serious reportable patient safety incident: (1) incidents being largely preventable; (2) having the potential for significant learning; (3) causing serious harm or have the potential to cause serious harm; (4) being identifiable, measurable, and feasible for inclusion in an incident reporting system; and (5) running the risk of recurrence. CONCLUSIONS: Variations in terminology and reporting systems between countries might contribute to missed opportunities for learning. International standardized definitions and blame-free reporting systems would enable comparison and international learning to enhance patient safety.

Ethical frameworks for quality improvement activities: an analysis of international practice.

PURPOSE: To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems. DATA SOURCES: We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries. STUDY SELECTION: National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada. DATA EXTRACTION: Data were extracted from 19 documents using an a priori framework developed from the published literature. RESULTS: We organized data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review but requires proportionate review or organizational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement. CONCLUSION: Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organizations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics.

Evaluation of an emergency department falls pathway for older people: A patient chart review.

The number of older adults presenting to EDs following a fall continues to rise, yet falls management often ignores opportunities for secondary falls risk reduction. Advanced Nurse Practitioners (ANPs) in EDs have an important clinical leadership role in improving outcomes for this group of patients. AIM: This study describes the development of an ANP led falls pathway in an ED to improve safe discharge. It evaluates compliance with the pathway and referrals to community falls prevention services. It also draws comparison with baseline practice as recorded in 2014. METHODS: The Falls Pathway involves four steps: 1) screening at triage (3 questions), 2) risk stratification (low, medium, high), 3) risk assessment (lying and standing blood pressure (B/P), timed-up and go (TUG), 4-AT for delirium screening, polypharmacy), and 4) referral to community falls services. We undertook a 12-month chart review of all patients aged 65 years or older presenting following a fall to the ANP service in 2018. We compared data to a baseline audit in 2014; descriptive and Chi squared statistics were used to examine the data. RESULTS: The 2018 audit involved 77 patients representing 27% of ANP caseload. A repeat fall occurred in 42% (32/77) of cases and 35% (22/77) reported a fear of falling. The Falls Pathway was initiated in nearly 80% (62/77) of patients and compliance with falls risk assessment ranged from 42% for lying and standing B/P to 75% for TUG. In 2014, a review of 59 patient charts showed 27% (16/59) experienced a repeat fall, but other risk factors such as fear of falling were not recorded. In 2018, the majority of patients (88%) discharged home were referred to community falls prevention services compared to 22% in 2014. CONCLUSION: The Falls Pathway improved falls risk assessment in the ED, identified opportunities for risk reduction and optimised referral to community falls services. The pathway continues to be a valuable tool but requires resources for ongoing implementation among the wider ED team.

Constraints and ethical tensions in the area of young-onset dementia.

BACKGROUND: young-onset dementia (under age 65) varies in many respects to typical aged dementia. Health professionals are centrally involved in supporting individuals and families to cope with the unique challenges that young-onset dementia (YOD) brings. AIMS: this study aimed to explore professionals' perceptions of the key challenges faced by people living with YOD and their families, and how they provide support to this group. METHODS: qualitative interviews were conducted with nine health professionals from a range of health and social care contexts. Data were analysed using interpretative phenomenological analysis. FINDINGS: interviewees reported significant challenges in trying to enact support for people with YOD, and families. Particular challenges relate to delays in accessing timely diagnosis, and difficulty in accessing relevant, age-appropriate supports. Interviewees experienced ethical tensions working in this area; interviewees were keen to enact support for the person following diagnosis, but felt constrained by service options that were not relevant or readily accessible to the person, and in some instances, traditional dementia services added to, rather than lessened the stress experienced by those involved. CONCLUSION: dementia and health services should be cognisant of the unique challenges of YOD, and models of service provision should aim to respond accordingly. Nurses and other health professionals should be afforded the necessary structures to support people living with YOD. This relates to dedicated YOD models of care, specifically timely diagnosis, post-diagnosis support and community services that enhance personhood and resilience.

Incentivising a career in older adult nursing: The views of student nurses.

BACKGROUND AND AIM: Nurse vacancy rates in older adult services are disproportionately high compared to other areas of nursing. This is partly because few student nurses consider it an attractive career option once qualified due to perceptions of low-status, strenuous nature of the work and impoverished care environments. The study aimed to explore students' perceptions of incentives that could counterbalance the barriers for new graduate nurses joining this speciality. METHODS: A qualitative descriptive design using focus group interviews was carried out with six groups of student nurses (n = 27) following completion of their acute care older adult placements in three hospitals. Data were analysed using thematic analysis. RESULTS: The barriers from students' perspectives were constructed as a vicious cycle of staff shortages and inadequate resources that created impoverished environments leading to a dissonance between ideal and delivered care. Over one-third of students were unlikely to consider a career in older adults nursing, but the remaining students could identify incentives that may tempt them. Four main themes and eight subthemes were identified: gerontological status and leadership (ward leadership; respected others); relational care (legitimising emotional support, care vs. cure goals); quality work environment (pay as recognition, 12-hr shifts); and education-career pathways (gerontological knowledge, career progression). CONCLUSION: Radical new approaches, based on student and nurse engagement, are required to incentivise a career in gerontological nursing. A combination of shorter and longer term strategies that include education-career pathways, a focus on relation care, and improved work conditions including financial incentives should be trialled. IMPLICATIONS FOR PRACTICE: In terms of practice, addressing high nurse vacancy rates in older adult services that negaively impacts on patient outcomes requires a suite of incentives informed by 'what matters' to students and nurses working in the speciality.

A feasibility study of dementia communication training based on the VERA framework for pre-registration nurses: Part II impact on student experience.

BACKGROUND: People living with dementia have complex communication needs, especially during acute hospital admissions. The VERA framework (validation, emotion, reassurance, activity) was designed to promote person centred communication between student nurses and people living with dementia, but there is limited evaluation of its impact. AIM: To measure the impact of dementia communication training (based on VERA) plus older adult unit (OAU) placement on students' ability to recognise opportunities for person centred (PC) communication compared to OAU placement alone. METHOD: A control pre-post-study design was used. Dementia communication training plus follow-up during OAU placement was delivered to 51 students (5 OAU, two hospitals) while 66 students (7 OAUs, five hospitals) acted as controls. The primary outcome was students' ability to recognise PC communication assessed using case vignettes. Data were collected using electronic survey and focus group interviews. Data analysis used independent non-parametric Mann-Whitney U test and thematic analysis. RESULTS: In total 52 students (response rate 40%) completed surveys at the end of placements (38 intervention, 14 control group students). In the intervention group, participants were significantly more likely to identify PC responses with a mean score of 10.5 (SD 3.0) compared with 7.5 (SD 3.0) in the control group (p = 0.006). In focus group interviews (n = 19 students), the main themes were connecting with patients, VERA in practice, communication challenges, and learning environment. VERA was described as a flexible approach that added to participants' communication toolkit. The learning environment, complexity of patients and organisational resources were important contextual factors. CONCLUSION: The VERA framework has potential as a foundation level dementia communication training intervention, but it requires more rigorous testing. Nursing can lead the way in developing and embedding evidence-based, interdisciplinary dementia communication training in preregistration curricula.

A dementia communication training intervention based on the VERA framework for pre-registration nurses: Part I developing and testing an implementation strategy.

BACKGROUND: People living with dementia experience progressive difficulty in expressing physical and emotional needs. Health care staff including student nurses require training to develop compensatory communication strategies. However, there is no standardised foundation level dementia communication training within pre-registration curricula. AIM: This article describes the theoretical underpinnings and development of a foundation level dementia communication skills training based on the VERA (Validation, Emotion, Reassurance, Activity) framework. METHOD: The training strategies drew on behavioural change theory using the COM-B model and Gagné's 9 Events of Instruction. The VERA framework was operationalised using a multicomponent teaching strategy. The intervention was refined based on quality improvement Plan-Do-Study-Act cycles with feedback from people living with dementia, facilitators and student nurses. Data collection used semi-structured questionnaires (n = 51) and four focus group (n = 19) interviews with students. Data analysis involved descriptive statistics and thematic analysis. RESULTS: The intervention was a 2.5-hour face-to-face training session delivered at the start of students' older adult unit placement with follow-up reflection sessions during placement. Training was delivered to 51 students, all students described the training as useful and would recommend it to their peers. Elements of the training that were highly valued were: opportunities to express concerns in caring for people with dementia, applying the VERA framework using role play and outlining realistic expectations of VERA. Students recognised the need for on-going training especially for more complex patients. CONCLUSION: Combining behaviour change and education theory with stakeholder feedback strengthened the development of VERA as a foundation level dementia communication training for pre-registration nurses.

Deprescribing in older adults: a new concept for nurses in administering medicines and as prescribers of medicine.

Deprescribing is a new and emerging theme in the care of older adults living with multimorbidities including frailty. Deprescribing requires a comprehensive review of risk and benefits of a medication in the context of the quality of remaining life and patient and family priorities and preferences. Nursing to date has not engaged with this issue, yet in their roles administering medicines and prescribing medicines they are a fundamental part of the pathway in deprescribing decisions and in supporting patients to make such decisions. In administering medicines, nurses are in a position to observe the degree of difficulty or burden experienced by patients due to polypharmacy or side effects of medicines. While as prescribers for adults with multimorbidities, active review of the risk and benefits of all medicines using evidence-based instruments is part of prescribing responsibility. This article is calling for a critical examination of nurses' roles in deprescribing and in supporting patients to make informed choices about their treatment. There is a need to articulate the role of nursing in this emerging area of medicines management and contribute to a multidisciplinary discourse on deprescribing. Equally professional standards and continuous professional development for nurses as prescribers and administrators of medicines needs to reflect the complexity of an older population. A deprescribing ethos challenges nurses to actively elicit patients' experiences of medicines burden, while nurse prescribers should recognise that appropriate deprescribing is as much a part of their role as appropriate prescribing.

Preparation for a crucial role.

Few nurses can have escaped the predictions on population ageing and the expected increase in the number of older people living with frailty and/or multi-morbidity.