Costs and clinical benefits of enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy: an updated systematic review and meta-analysis.

PURPOSE: ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However, evidence on cost benefit of ERAS in pancreaticoduodenectomy remains scarce. This review aimed to investigate cost benefit, compliance, and clinical benefits of ERAS in pancreaticoduodenectomy. METHODS: A comprehensive literature search was conducted on Medline, Embase, PubMed, CINAHL and the Cochrane library to identify studies conducted between 2000 and 2021, comparing effect of ERAS programmes and traditional care on hospital cost, length of stay (LOS), complications, delayed gastric emptying (DGE), readmission, reoperation, mortality, and compliance. RESULTS: The search yielded 3 RCTs and 28 cohort studies. Hospital costs were significantly reduced in the ERAS group (SMD = - 1.41; CL, - 2.05 to - 0.77; P < 0.00001). LOS was shortened by 3.15 days (MD = - 3.15; CI, - 3.94 to - 2.36; P < 0.00001) in the ERAS group. Fewer patients in the ERAS group had complications (RR = 0.83; CI, 0.76-0.91; P < 0.0001). Incidences of DGE significantly decreased in the ERAS group (RR = 0.72; CI, 0.55-0.94; P = 0.01). The number of deaths was fewer in the ERAS group (RR = 0.76; CI, 0.58-1.00; P = 0.05). CONCLUSION: This review demonstrated that ERAS is safe and feasible in pancreaticoduodenectomy, improves clinical outcome such as LOS, complications, DGE and mortality rates, without changing readmissions and reoperations, while delivering significant cost savings. Higher compliance is associated with better clinical outcomes, especially LOS and complications.

It's ok to be different: Supporting black and minority ethnic nurses and midwives in their professional development in the UK.

BACKGROUND: A significant proportion of the United Kingdom's (UK's) healthcare workforce comprises people from Black and Minority Ethnic (BME) backgrounds. Evidence shows that this population is under-represented at senior management levels. A collaborative leadership development initiative for BME nurses and midwives, by involving their line managers and mentors, was designed and implemented in a Scottish Health Board. AIM: This paper affirms the importance of a collaborative initiative that is targeted to support BME nurses and midwives for leadership development and career progression, and the promotion of an inclusive organisational culture to improve team work, and service standards. METHOD: This initiative adopted an Action Research approach. The programme began with collectively exploring participants' understanding of BME workforce development challenges, then planning and delivering a targeted leadership development training, and then evaluating it, in a cyclical way. FINDINGS: With support from the project facilitators, line managers and mentors, a significant number of BME participants have gone on to achieve career progression. Participating line-managers and mentors have gained an in-depth and nuance understanding of workforce diversity, individuals' potentials, unconscious biases, and the importance of an inclusive organisational culture. All participants reported that they have learned to become more reflective in their professional practice, and more able to explore, embrace, and promote inclusive workplace culture. BME participants reported feeling that they were valued members of staff, and that this had led to a positive impact on team work and better patientcare outcome. CONCLUSION: The project has opened a new window into the world of the BME workforce. Findings highlight the value of a diverse workforce, and of an inclusive organisational culture being crucial for effective team work, and of overall benefit to workforce management. Finally, a collaborative initiative like this can successfully improve team work to deliver better patient care.

Nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment process in an intensive care unit.

AIMS: To explore nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment in an intensive care unit. BACKGROUND: In South Korea, withholding or withdrawing life-sustaining treatment is legalised by the enforcement of the Hospice, Palliative Care and Life-sustaining Treatment Decision-making Act (2018). The Act (2018) is the first legal ground for making decisions regarding life-sustaining treatment in South Korea. DESIGN: Focused ethnography. The standards for reporting qualitative research checklist is used. METHODS: Interview data are collected between August 2018 and January 2019 using semi-structured interviews with 23 nurses, 10 physicians and four family members in a South Korean intensive care unit. The interview data are analysed following the thematic analysis of Braun and Clarke. RESULTS: An overarching theme of 'constructing death' is identified from the experiences of nurses, physicians and family members regarding withholding or withdrawing life-sustaining treatment in a South Korean intensive care unit. Family members had the strongest power in the withholding or withdrawing life-sustaining treatment process whilst the process had to be based on medical consideration. All the research participants shared the purpose and motivation of withholding or withdrawing life-sustaining treatment as the dying patient's dignity. Due to the South Korean national health insurance system, the relationships between medical staff and family members were driven by customer ideology. CONCLUSION: The impact and linkage of the context of familism culture and health insurance with the process of withholding or withdrawing life-sustaining treatment in South Korea are shown in this research. The findings of this research inspire future studies to uncover the impact of the cultural context in the decision-making process of a patient's death, to explore the dynamics of family members under cultural values and to explore the influence of the healthcare system and medical costs on the relationships between medical staff and family members. RELEVANCE TO CLINICAL PRACTICE: By integrating the experiences of nurses, physicians and family members, the findings of this study inform the shared values in the context of familism culture and the health insurance system. In particular, understanding family dynamics when a patient's dying and death as a result of withholding or withdrawing life-sustaining treatment informs nurses to provide quality of care in the intensive care setting. Therefore, the findings of this research contribute to distinguishing the priority in care when withholding or withdrawing life-sustaining treatment, rapidly changing the aims of care from the patient's recovery to a dignified death.

A Constructivist Grounded Theory of Staff Experiences Relating to Early Mobilisation of Mechanically Ventilated Patients in Intensive Care.

Early mobilisation of mechanically ventilated patients has been suggested to be effective in mitigating muscle weakness, yet it is not a common practice. Understanding staff experiences is crucial to gain insights into what might facilitate or hinder its implementation. In this constructivist grounded theory study, data from two Scottish intensive care units were collected to understand healthcare staff experiences relating to early mobilisation in mechanical ventilation. Data included observations of mobilisation activities, individual staff interviews and two focus groups with multidisciplinary staff. Managing Risks emerged as the core category and was theorised using the concept of risk. The middle-range theory developed in this study suggests that the process of early mobilisation starts by staff defining patient status and includes a process of negotiating patient safety, which in turn enables performing accountable mobilisation within the dynamic context of an intensive care unit setting.

Theorising survivorship after intensive care: A systematic review of patient and family experiences.

AIMS AND OBJECTIVE: This systematic literature review explores and maps what we know about survivorship to understand how survivorship can be theoretically defined. BACKGROUND: Survivorship of critical illness has been identified as a challenge for the 21st Century. Whilst the use of the term 'survivorship' is now common in critical care, it has been borrowed from the cancer literature where the discourse on what survivorship means in a cancer context is ongoing and remains largely descriptive. In the absence of a theoretical understanding, the term 'survivorship' is often used in critical illness in a generic way, limiting our understanding of what survivorship is. The current COVID-19 pandemic adds to an urgency of understanding what intensive care unit (ICU) survivorship might mean, given the emerging long-term consequences of this patient cohort. We set out to explore how survivorship after critical illness is being conceptualised and what the implications might be for clinical practice and research. DESIGN: Integrated systematic literature review. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed. RESULTS: The three main themes around which the reviewed studies were organised are: (a) healthcare system; (b) ICU survivors' families; and (c) ICU survivor's identity. These three themes feed into an overarching core theme of 'ICU Survivorship Experiences'. These themes map our current knowledge of what happens when a patient survives a critical illness and where we are in understanding ICU survivorship. CONCLUSION: We mapped in this systematic review the different pieces of the jigsaw that emerge following critical illness to understand and see the bigger picture of what happens after patients survive critical illness. It is evident that existing research has mapped these connections, but what we have not managed to do yet is defining what survivorship is theoretically. We offer a preliminary definition of survivorship as a process but are aware that this definition needs to be developed further with patients and families.

A survey about postoperative delirium in older patients among nurses and anaesthetists: implications for future practice and policy.

BACKGROUND: Postoperative delirium is a major complication associated with anaesthesia and surgery, more commonly seen in older people. AIMS: The aims of this study were to explore the knowledge and understanding of anaesthetists and nurses involved in anaesthesia through their responses to two case scenarios of postoperative delirium experienced by older people. METHODS: A 30-item online survey was sent to 500 potential respondents. RESULTS: Two hundred and twenty-six practitioners from Australia, New Zealand and Scotland responded. Most had no workplace protocols for anaesthesia planning in older people. There was substantial variability in practice in relation to postoperative delirium screening, detection, prevention and management. CONCLUSIONS: Improvements in education and awareness, together with a more coherent approach, for example, as recommended in the European Society of Anaesthesiology Guidelines, could help to reduce the impact of postoperative delirium in older people. This should be combined with ongoing research into perioperative optimisation of detection, prevention and management of postoperative delirium.

A qualitative study of experiences of health and social care in home mechanical ventilation.

AIM: To contribute insight into health and social care integration through an exploration of the care experiences of adults with degenerative neuromuscular conditions who use a mechanical ventilator at home. DESIGN: Descriptive qualitative research. METHODS: Seventeen semi-structured interviews were conducted with patients and family carers living in Scotland during 2015-2016 and thematically analysed. RESULTS: To achieve a satisfying life, home ventilated participants required help from a variety of health and social care services, as well as care from family. Examples of successful care were identified, but there were also serious failures and conflict with services. Identifying how care fails or succeeds for this patient population and their families requires an understanding of the interdependency of health and social care. This was achieved by examining health and social care provision from the experiential perspective of care-users to provide insights into how disconnected provision has an impact on users' lives in numerous, idiosyncratic ways.

Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities.

BACKGROUND: Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature. METHODS: Whittemore and Knafl's framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies. RESULTS: Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients' characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation. CONCLUSIONS: This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.

Delivering direct patient care in the haemodialysis unit: a focused ethnographic study of care delivery.

BACKGROUND: Direct patient care is a term used within nursing and healthcare to help quantify and qualify care delivery. Direct patient care time is considered as a valuable measure by healthcare providers to indicate efficiency and to quantify nursing work, however little is understood of the patient experience and care delivery in haemodialysis settings. AIM: The aim of this study was to gain an understanding of patients' and nursing staff perceptions and experiences of 'direct patient care' within one haemodialysis unit. METHODS: A focused ethnographic approach utilised participant observations, informal questioning, photographs and 27 semi-structured interviews of registered nurses, clinical support workers and patients. Observation notes and interviews were transcribed and thematically analysed. RESULTS: The key finding was the construction and reconceptualisation of care delivery in this setting. Care was identified to be delivered in two distinct ways, both of which allowed patients to feel cared for. 'Active care' where patients feel cared for when they are being dealt with directly by staff and 'Passive care' where patients feel cared for through staff availability and visibility. CONCLUSION: Developing this understanding of patient care delivery in this specialism has highlighted some important aspects to the way care can be delivered which challenges current traditional understandings of direct patient care. Time spent with a patient is not the only important consideration to patient experience in haemodialysis. This understanding of passive care could improve care experiences in this setting.

A qualitative exploration of nurses leaving nursing practice in China.

AIM: This paper reports a theoretical understanding of nurses leaving nursing practice by exploring the processes of decision-making by registered nurses in China on exiting clinical care. BACKGROUND: The loss of nurses through their voluntarily leaving nursing practice has not attracted much attention in China. There is a lack of an effective way to understand and communicate nursing workforce mobility in China and worldwide. DESIGN: This qualitative study draws on the constant comparative method following a grounded theory approach. METHOD: In-depth interviews with 19 nurses who had left nursing practice were theoretically sampled from one provincial capital city in China during August 2009-March 2010. RESULTS: The core category 'Mismatching Expectations: Individual vs. Organizational' emerged from leavers' accounts of their leaving. By illuminating the interrelationship between the core category and the main category 'Individual Perception of Power,' four nursing behaviour patterns were identified: (1) Voluntary leaving; (2) Passive staying; (3) Adaptive staying and (4) Active staying.

The impact of safety and quality of health care on Chinese nursing career decision-making.

AIM: The aim of the study was to understand why nurses leave nursing practice in China by exploring the process from recruitment to final exit. This report examines the impact of safety and quality of health care on nursing career decision-making from the leavers' perspective. BACKGROUND: The nursing shortage in China is more serious than in most developed countries, but the loss of nurses through voluntarily leaving nursing practice has not attracted much attention. METHOD: This qualitative study draws on a grounded theory approach. In-depth interviews with 19 nurses who have left nursing practice and were theoretically sampled from one provincial capital city in Mainland China. FINDING: 'Loss of confidence in the safety and quality of health care' became one of the main categories from all leavers' accounts of their decision to leave nursing practice. It emerged from three themes 'Perceiving risk in clinical practice', 'Recognising organisational barriers to safety' and 'Failing to meet expectations of patients'. DISCUSSION: The findings indicate that the essential work value of nursing to the leavers is the safety and quality of care for their patients. When nurses perceived that they could not fulfil this essential work value in their nursing practice, some of them could not accept the compromise to their value of nursing and left voluntarily to get away from the physical and mental stress. However, some nurses had to stay and accept the limitations on the safety and quality of health care. CONCLUSION: The study suggests that well-qualified nurses voluntarily leaving nursing practice is a danger signal for patients and hospitals, and has caused deterioration in nursing morale for both current and potential nursing workforces. It suggests that safety and quality of health care could be improved when individual nurses are empowered to exercise nursing autonomy with organisational and managerial support. IMPLICATIONS FOR NURSING MANAGEMENT: The priority retention strategies need to remove organisational barriers to the safety and quality of health care. Under the current nursing shortage, Chinese hospital managers might consider recruiting nurses and care assistants of different educational levels, which would effectively improve nursing team work and support nurses' to stay and actively achieve their work values for the safety and quality of health care.

Recruitment, selection and retention of nursing and midwifery students in Scottish Universities.

BACKGROUND: High attrition rates from pre-registration nursing and midwifery programmes have been reported in both the UK and in other countries. OBJECTIVES: A study was conducted to identify best practice in recruitment, selection and retention across Scottish Universities providing pre-registration programmes. DESIGN: A survey of all universities providing pre-registration programmes in Scotland was conducted. Semi-structured interviews were conducted with key personnel in each university. Documentary evidence was collected to supplement interview data and evidence recruitment, selection and retention practices. SETTINGS: All universities in Scotland providing pre-registration nursing and/or midwifery programmes. PARTICIPANTS: All 10 identified universities agreed to take part and a total of 18 interviews were conducted. METHODS: Semi-structured face to face and telephone interviews were conducted. Relevant documentary evidence was collected. All data were subject to thematic analysis. FINDINGS: Universities are predominantly concerned with recruiting to the institution and not to the professions. Interviews are widely used, and are a requirement in the United Kingdom. However, there is no evidence base within the literature that they have predictive validity despite creating scales and scoring systems which are largely unvalidated. The study identified initiatives aimed at addressing attrition/retention, however most had not been evaluated often due to the multi-factorial nature of attrition/retention and difficulties with measurement. CONCLUSIONS: Recruitment selection and retention initiatives were rarely evaluated, and if so, adopted a relatively superficial approach. Evidence from existing studies to support practices was mostly weakly supportive or absent. The study highlights the need for a coordinated approach, supporting the development of a robust evidence base through the evaluation of local initiatives, and evaluation of new strategies. Evaluation strategies must take account of the local context to facilitate transferability of findings across different settings.

Pain management and satisfaction in postsurgical patients.

AIMS AND OBJECTIVES: To examine the relationship between patient satisfaction and the incidence of severe and enduring pain through a health board wide hospital satisfaction questionnaire. BACKGROUND: The incidence and management of acute postoperative pain and its relationship to patient satisfaction have been of great interest to clinicians over the last 20 years. Evidence suggests that despite many moves to address this problem with the advent of acute pain nurse specialists and dedicated pain teams, severe and enduring pain continues to be a problem. However, patients appear to report high satisfaction levels. DESIGN: The study design was a postal questionnaire the results of which were analysed statistically. METHODS: The postal questionnaire was sent to patients who had been discharged from acute hospitals in one health board in the previous two weeks. A total of three large acute hospitals were included. The data were analysed to produce descriptive statistics for all patients on the pain questions and then for patients with severe and enduring pain on the variables of age, gender, ethnic group, responses to pain questions and type of admission. RESULTS: Twenty-six percent of patients reported having pain all or most of the time. Patients suffering from severe and enduring pain were younger females. CONCLUSION: Acute postoperative pain continues to be a problem, although patients continue reporting moderate satisfaction levels. RELEVANCE TO CLINICAL PRACTICE: Acute postoperative pain is an ongoing issue for postsurgical patients. It is crucial to understand and recognise issues that can adversely contribute to increased pain severity.

A mutant allele of MRE11 found in mismatch repair-deficient tumor cells suppresses the cellular response to DNA replication fork stress in a dominant negative manner.

The interaction of ataxia-telangiectasia mutated (ATM) and the Mre11/Rad50/Nbs1 (MRN) complex is critical for the response of cells to DNA double-strand breaks; however, little is known of the role of these proteins in response to DNA replication stress. Here, we report a mutant allele of MRE11 found in a colon cancer cell line that sensitizes cells to agents causing replication fork stress. The mutant Mre11 weakly interacts with Rad50 relative to wild type and shows little affinity for Nbs1. The mutant protein lacks 3'-5' exonuclease activity as a result of loss of part of the conserved nuclease domain; however, it retains binding affinity for single-stranded DNA (ssDNA), double-stranded DNA with a 3' single-strand overhang, and fork-like structures containing ssDNA regions. In cells, the mutant protein shows a time- and dose-dependent accumulation in chromatin after thymidine treatment that corresponds with increased recruitment and hyperphosphorylation of replication protein A. ATM autophosphorylation, Mre11 foci, and thymidine-induced homologous recombination are suppressed in cells expressing the mutant allele. Together, our results suggest that the mutant Mre11 suppresses the cellular response to replication stress by binding to ssDNA regions at disrupted forks and impeding replication restart in a dominant negative manner.