Livestreaming clinical experience to remotely located learners: A critical narrative review.

CONTEXT: Medical education relies on real patient learning (RPL) to provide medical students with essential clinical experience. However, growing demand for clinical placements continues to be a challenge in providing sufficient RPL opportunities. The COVID-19 pandemic forced academic institutions to rethink the delivery of traditional clinical training and innovations in online clinical learning experiences, specifically livestreamed clinical experiences, have emerged which show promise in addressing the capacity limitations of traditional placements. Although previous reviews have explored the use of livestreamed clinical experiences during the pandemic, there is a lack of rigorous theoretical framing to support these innovations. OBJECTIVES: The aim of this review is two-fold: to examine the effectiveness of livestreamed clinical experiences through an experience-based learning (ExBL) theory perspective and to provide practical recommendations to optimise and implement these innovations. METHODS: A review of literature was conducted to identify journal articles published between September 2019 and January 2023 reporting on innovations relating to livestreamed clinical experiences. The search focused on undergraduate and postgraduate medical education but relevant evidence from other healthcare professions were also included due to a limited evidence base. Strengths and weaknesses were derived from the literature and analysed in relation to ExBL components. RESULTS: Principal strengths of livestreamed clinical experiences included expanded access to RPL opportunities and medical specialties, enhanced standardisation of learning experiences and positive perceptions from students regarding convenience. Clinical educators found these innovations enabled teaching at scale. Patients did not perceive such innovations to negatively impact their standard of care. Limitations included the inability to practice physical examination skills, challenges in ensuring learner engagement and connectivity issues. CONCLUSION: Livestreamed clinical experiences have the potential to effectively expand placement capacity and provide high-quality educational experiences for medical students. Although certain limitations exist, technological and pedagogical adaptations can help overcome these challenges. The application of theoretical frameworks to future online innovations will be fundamental to ensure effective clinical learning.

Infusion pump innovation: Embracing change for patients and bottom lines.

Within the infusion delivery landscape, significant room exists for an improved experience with more intuitive and interoperable solutions. The majority of smart infusion pumps still rely on technology developed more than a decade ago. Many Canadian healthcare institutions regularly undergo a comprehensive re-evaluation of infusion fleets, to modernize infusion delivery for patients across the country. Amid the availability of new technologies with evidence demonstrating their ability to elevate the current standards of care, this article argues for the need for healthcare systems to prepare for, and embrace, change when it comes to new technologies. Clinical informatics consultant, Helen Edwards, delves into why new technologies are needed now more than ever. She shares her experience with the Ivenix Infusion System, capturing how it can help redefine clinical workflows, reduce costs across the entire healthcare continuum, and better support patient care. She also offers insights on how to effectively introduce new technologies and cultivate an environment that is likely to be open and adaptive to the change. As the Canadian healthcare landscape continues to evolve, the proactive adoption of new technologies will be a step towards advancing the outcomes for patients and the sustainability of Canadian healthcare infrastructures.

A qualitative exploration of adherence to wearing removable cast walkers in patients with diabetic foot ulcers.

OBJECTIVE: To explore adherence to wearing removable cast walkers (RCWs) among patients with diabetic foot ulcers (DFUs). METHOD: A qualitative study was conducted by interviewing patients with active DFUs and using knee-high RCWs as their offloading treatment. The interviews were undertaken at two diabetic foot clinics in Jordan, using a semi-structured guide. Data were analysed through content analysis by developing main themes and categories. RESULTS: Following interviews with 10 patients, two main key themes with a total of six categories were identified: theme 1-reporting of adherence levels was inconsistent, included two categories: i) a belief in achieving optimal adherence, and ii) non-adherence was often reported indoors; and theme 2-adherence was a consequence of multiple psychosocial, physiological and environmental factors, which included four categories: i) specific offloading knowledge or beliefs influenced adherence; ii) severity of foot disease influenced adherence; iii) social support benefitted adherence; and iv) physical features of RCWs (the usability of the offloading device) impacted adherence. CONCLUSION: Patients with active DFUs reported inconsistent levels of adherence to wearing RCWs which, after deeper investigation, seemed to be due to participants' misperceptions of the optimal adherence. Adherence to wearing RCWs also seemed to be impacted by multiple psychosocial, physiological and environmental factors.

The Validity and Reliability of Self-Reported Adherence to Using Offloading Treatment in People with Diabetes-Related Foot Ulcers.

Adherence to using offloading treatment is crucial to healing diabetes-related foot ulcers (DFUs). Offloading adherence is recommended to be measured using objective monitors. However, self-reported adherence is commonly used and has unknown validity and reliability. This study aimed to assess the validity and reliability of self-reported adherence to using removable cast walker (RCW) offloading treatment among people with DFUs. Fifty-three participants with DFUs using RCWs were included. Each participant self-reported their percentage adherence to using their RCW of total daily steps. Participants also had adherence objectively measured using dual activity monitors. After one week, a subset of 19 participants again self-reported their percentage adherence to investigate test-retest reliability. Validity was tested using Pearson's r and Bland-Altman tests, and reliability using Cohen's kappa. Median (IQR) self-reported adherence was greater than objectively measured adherence (90% (60-100) vs. 35% (19-47), p < 0.01). There was fair agreement (r = 0.46; p < 0.01) and large 95% limits of agreement with significant proportional bias (ß = 0.46, p < 0.01) for validity, and minimal agreement for test-retest reliability (K = 0.36; p < 0.01). The validity and reliability of self-reported offloading adherence in people with DFU are fair at best. People with DFU significantly overestimate their offloading adherence. Clinicians and researchers should instead use objective adherence measures.

International validation of a venous leg ulcer risk assessment tool.

OBJECTIVE: To internationally validate a tool for predicting the risk of delayed healing of venous leg ulcers (VLUs). METHOD: A 10-item tool including sociodemographic factors, venous history, ulcer and lower limb characteristics, compression and mobility items to determine the risk of delayed healing of VLUs has previously been developed and validated in Australia. This study prospectively validated this tool using receiver operating characteristic (ROC) methods; using the area under the curve (AUC) to quantify the discriminatory capability of the tool to analyse the international populations of the UK, Austria and New Zealand. RESULTS: The validation of the tool in the UK, Austria and New Zealand has indicated that the model has moderate discrimination and goodness-of-fit with an AUC of 0.74 (95% CI: 0.66-0.82) for the total risk assessment score. CONCLUSION: The international validation of a risk assessment tool for delayed healing of VLUs will allow clinicians globally to be able to determine realistic outcomes from an early assessment and to be able to guide early tailored interventions to address the specific modifiable risk factors and thus promote timely healing.

Differences in adherence to using removable cast walker treatment during daytime and nighttime weight-bearing activities in people with diabetes-related foot ulcers.

Aims: Patients' adherence to using knee-high offloading treatment is critical to effective healing of diabetes-related foot ulcers (DFUs). Previous studies have found that patients generally have low adherence to using removable knee-high offloading treatments, yet no study has investigated whether their adherence differs during daytime and nighttime. This study aimed to investigate the levels and factors associated with adherence to using knee-high removable cast walker (RCW) treatment during daytime and nighttime weight-bearing activities in people with DFUs. Methods: This was a secondary analysis of data collected from a multi-centre cross-sectional study investigating adherence to using knee-high RCWs among 57 participants with DFUs. All participants had multiple socio-demographic, physiological and psychosocial factors collected, before having their adherence to using RCWs during weight-bearing activity monitored over a 1-week period using the dual activity monitor method. Adherence data were categorised into daytime (06:00-18:00) and nighttime (18:00-06:00) periods and calculated separately. Multiple linear regression was used to identify factors associated with daytime and nighttime adherence. Results: Mean adherence to using RCW during weight-bearing activities in people with DFUs was higher during daytime compared with nighttime [39.9% (SD = 18.9) versus 20.4% (SD = 16.7), p < 0.001]. Factors independently associated with lower adherence during daytime were being male, longer diabetes duration, not having peripheral artery disease (PAD), and higher perceived RCW heaviness. Factors associated with lower adherence during nighttime were higher mean daytime steps, not having retinopathy and having dyslipidaemia. Conclusions: Adherence to using RCWs during weight-bearing activities reduced significantly at nighttime compared with daytime among people with DFUs, and this was associated with different factors. Interventions to improve adherence, in research and clinical practice, should incorporate methods to target daytime or nighttime adherence specifically.

Surgical wound assessment tool: Construct validity and inter-rater reliability of a tool designed for nurses.

AIMS AND OBJECTIVES: To validate construct validity and inter-rater reliability of a surgical wound assessment tool. BACKGROUND: Wound assessment is central to appropriate wound management. However, limited standard surgical wound assessment tools are available to assist nurses in assessing and recording progress in the healing of surgical wounds. DESIGN: A prospective observational study was utilised to test the validity and reliability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline was used. METHODS: Convenience sampling was used to recruit 260 patients who underwent elective or emergency surgery at a hospital in Vietnam. Exploratory factor analysis was used to examine the construct validity of the surgical wound assessment tool. Inter-rater reliability was calculated using the intraclass correlation coefficient and Cohen's kappa to determine reliability of the overall scale and identified items. RESULTS: The results of the exploratory factor analysis supported a three-component structure of the surgical wound assessment tool. The intraclass correlation coefficient value of the overall scale was 0.79 (95% CI 0.67-0.89), p < .001, confirming excellent inter-rater reliability. Cohen's kappa value ranged from 0.5 to 1, demonstrating moderate to almost perfect level of agreement for individual items, except for one item on pain. CONCLUSION: The surgical wound assessment tool was deemed to be acceptable, valid and reliable for monitoring the status of surgical wound healing. However, further modification and testing are needed to strengthen the tool and to determine the applicability of the tool in other populations. RELEVANCE TO CLINICAL PRACTICE: The application of the SWAT would improve the assessment of surgical wounds in daily nursing practice which will promote improved postoperative wound management. It is an easy and practical tool for enhancing inter-disciplinary communication and care outcomes for all patients with surgical wounds.

Cross-Cultural Adaptation and Reliability Testing of Arabic Versions of Several Diabetic Foot Psychosocial Scales.

The main aims of this study were cross-cultural adaptation and reliability testing of an Arabic version of Foot Care Confidence Scale (FCCS), Foot Care Outcomes Expectations Scale (FCOES), Patient Interpretation of Neuropathy Scales (PINS), Neuropathy-specific Quality of Life Scales (NQOLS), and offloading-related Visual Analog Scales (VAS). Two phases of translation and reliability testing were conducted in Jordan. Phase 1 included 2 forward and backward translations with 2 panel consensuses (translators, clinicians, and experts). In Phase 2, Cronbach's alpha (α) and intraclass correlation coefficient (ICC) were used to test the internal consistency and stability (test-retest) of the Arabic scales in a sample of a total of 90 Jordanian participants with diabetic foot ulcers. Phase 1 resulted in Arabic translation and cross-cultural adaptation of the study scales. Phase 2 resulted in acceptable internal consistency of the translated scales (α = 0.74-0.91), except for the PIN "self/practitioner blame" and "acute ulcer onset" scales (α = 0.57, 0.49, respectively). Test-retest results (ICC) were: FCCS (0.85); FCOES (0.78); PINS (0.043-0.85); NQOLS (0.76-0.90); and offloading-related VAS (0.43-0.90). This study showed evidence of cultural appropriateness and reliability of most of the translated scales, for possible future implementation for the Arabic population.

Development of a surgical wound assessment tool to measure healing and risk factors for delayed wound healing in Vietnam: a Delphi process.

OBJECTIVE: To identify items and develop a surgical wound assessment tool (SWAT) to measure progress in healing and early detection of risk factors for delayed healing in surgical wounds in patients in Vietnam. METHOD: The development process included two phases: (i) development of the initial SWAT based on evidence-based guidelines, results of a literature review and consultation with surgeons; and (ii) a Delphi process with wound care nurse experts to refine and provide consensus on a final version of the SWAT. Data collection took place between April-August 2017. RESULTS: In phase one, 22 items were included and were evaluated by ten Vietnamese surgeons, with item-content validity index (I-CVI) scores of 1.00 in 17 out of 22 items. The remaining items had I-CVI ranking of 0.8 to 0.9. The overall scale-content validity index was 0.97. Eight more items were recommended for inclusion, increasing the total to 30 items. In phase two, 21 Vietnamese nurse wound care experts completed all three rounds of the Delphi process. After three rounds, 24 items out of 30 reached full consensus for the final tool. CONCLUSION: This study was the first step to confirm the content validity of the newly developed SWAT. Further development of the tool including the evaluation of validity and reliability was undertaken to strengthen the tool.

Factors associated with adherence to using removable cast walker treatment among patients with diabetes-related foot ulcers.

INTRODUCTION: Adherence to using knee-high offloading treatment is critical for healing diabetes-related foot ulcers (DFUs). However, few studies have investigated patients' adherence to using knee-high offloading treatment. We aimed to investigate the levels and factors associated with adherence to using knee-high removable cast walker (RCW) treatment among patients with DFUs. RESEARCH DESIGN AND METHODS: In this multicenter cross-sectional study, we investigated adherence to using knee-high RCWs in 57 participants with DFUs. All participants were clinically examined for multiple sociodemographic, physiological, and psychosocial factors. Each participant's adherence level to using RCWs was then objectively measured using dual activity monitors (attached to the wrist and RCW) over a 1-week period. Multiple linear regression was undertaken to determine those factors independently associated with adherence levels. RESULTS: The mean adherence level to using RCWs was 33.6% (SD 16.5) of weight-bearing activity. Factors independently associated with lower adherence levels were being male, longer diabetes duration, not having peripheral artery disease (PAD), and having higher perceived RCW heaviness (p≤0.05). No associations were found with psychosocial factors. CONCLUSIONS: Patients with DFUs adhered to using their RCWs on average for only a third of their prescribed weight-bearing treatment duration. Factors linked to lower RCW adherence levels were being male, longer diabetes duration, not having PAD, and perceived heavier RCWs. These findings highlight the importance of using gold standard non-removable knee-high offloading device treatment. Furthermore, these findings suggest, when gold standard devices are containdicated, that these factors be considered when prescribing the second choice RCW offloading treatment to optimise adherence. Regardless, further longitudinal studies are needed to confirm these factors.

Long-term care placement: The transitional support needs and preferences of spousal dementia caregivers.

BACKGROUND AND OBJECTIVES: Many spousal caregivers experience stress, depression, loneliness, guilt and grief when placing a partner with dementia into long-term care. However, there is little research about their transitional support experiences, needs and preferences. This study aimed to gain a deeper understanding of these issues from spousal caregiver and long-term care facility staff perspectives, to inform subsequent support and intervention development. RESEARCH DESIGN AND METHODS: Semi-structured interviews and small group discussions were held separately with spousal caregivers (n = 9) and care facility staff (n = 11). Criterion and variation sampling aimed to ensure a range of experiences and perspectives. The 'Framework' approach was utilised for data analysis. Interpretation was with respect to underpinning models of stress-grief process in dementia caregiving. FINDINGS: A range of informational, psychoeducational and psychosocial supports were identified to help spousal caregivers cope better with the stressors and losses experienced throughout the transition from home to long-term care. Improved education about disease progression, information relating to long-term care provision, peer support and dementia-specific grief counselling were deemed important. Opportunities for better support within care facilities were also identified. Support should be tailored to individual needs and preferences. DISCUSSION AND IMPLICATIONS: The findings suggest a supportive care framework be developed, encompassing the trajectory from assessment for and admission into long-term care to end-of-life and post-bereavement support. Spousal caregivers should have their support needs assessed by trained health or social care professionals and be offered a range of support options as appropriate.

Pilot Study of the Residential Care Transition Module to Support Australian Spouses of People with Dementia.

OBJECTIVES: Spouses are at risk of poor psychosocial outcomes following placement of their partner with dementia into long-term care. The Residential Care Transition Module (RCTM) is a psychosocial intervention developed in the United States to support carers post-placement. This study aimed to test the RCTM delivered by telephone to Australian spousal carers. METHODS: A small-scale RCT [N = 21] was conducted to test feasibility of recruitment, retention, acceptability, and preliminary effects on measures of stress, grief, depression, guilt, quality-of-life, and satisfaction with care, compared to a group receiving printed information. RESULTS: The Transition Counselor and study participants considered the intervention delivery, dose, and content as acceptable. Retention was high (91%). At follow-up, significant time effects were found for stress, depression and "nursing home hassles." A significant interaction effect was found for quality-of-life in favor of the comparison group. No effects were found for guilt or overall grief, however a promising result regarding the sub-scale of "acceptance of loss" was found in favor of the RCTM. CONCLUSIONS: The delivery of the RCTM to Australian spousal carers was feasible and acceptable. CLINICAL IMPLICATIONS: The RCTM shows potential for improving support to spouses of people with dementia following long-term care placement.

Postoperative wound assessment documentation and acute care nurses' perception of factors impacting wound documentation: A mixed methods study.

BACKGROUND: Wound care documentation is an essential component of best practice wound management in order to enhance inter-disciplinary communication and patient care. However, evidence suggests that wound care documentation is often carried out poorly and sporadically. OBJECTIVES: Determine postoperative wound assessment documentation by acute care nurses and explore their perception of factors constraining adequate nursing documentation. METHODS: A two-phase sequential exploratory mixed methods design was used. Phase one: A retrospective clinical chart audit of nurses' documentation was undertaken. A random selection of 200 medical records were reviewed over 3 months at a provincial hospital in Vietnam. Phase two: semi-structured interviews were conducted with 13 surgical nurses to explore their perceptions of factors influencing appropriate documentation. Inductive qualitative content analysis was applied for qualitative data. This manuscript adheres to COREQ guidelines for reporting the qualitative phase. FINDINGS: Phase one: 200 records were audited. Less than 10% of preoperative factors (such as co-morbidities, smoking and nutrition status) related to the risk of delayed wound healing were documented. During the first 5 days postoperation, there was no documentation about incision location, wound dimension, wound bed (in wounds healing by secondary intention) or odour. In less than 10% colour and type of exudate were recorded. Phase two: Emerging key categories were: unimportance of nursing documentation, difficulty to change existing practice, and personal factors. CONCLUSION: This study indicated that surgical wound assessment documentation was insufficient and inconsistent among nurses. Nurses viewed the wound assessment documentation as unimportant. Therefore, extensive exploration of strategies is required to enhance the quality of wound assessment documentation.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis.

BACKGROUND: Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature. METHODS: We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death). RESULTS: One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries. CONCLUSIONS: Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.

Surgical wound assessment in Vietnam: a think-aloud technique and interview analysis.

OBJECTIVE: To identify the key components of a surgical wound assessment tool that nurses in Vietnam could use when conducting a surgical wound assessment. The study also explored Vietnamese nurses' perceptions of current practices in surgical wound assessment and assessed their requirements for a surgical wound assessment tool. METHOD: Registered nurses from surgical wards in a Vietnamese hospital were invited to participate in this descriptive, qualitative study. A combination of the think-aloud technique and semi-structured interviews was undertaken. Transcribed responses were analysed using inductive content analysis to indicate how Vietnamese nurses undertook wound assessment and the data they collected. RESULTS: A total of 13 nurses took part. Data from both the think-aloud process and interviews indicated that nurses evaluated surgical wounds based on their experience and observation without using standard guidelines. Some components, such as wound edge, periwound skin, exudate volume and signs of infection, were identified by the nurses. Other wound characteristics, such as wound site, wound bed, exudate and pain, and risk factors were less frequently collected. Nurses expressed their need for a tool with comprehensive content, precise terms, user-friendly language and a scoring system to facilitate their wound assessment. CONCLUSION: Hospitals in Vietnam need a standard tool to help nurses improve surgical wound assessment in daily nursing practice, and to enhance multidisciplinary communication and patient care.

Exploring the prevalence and management of wounds for people with dementia in long-term care.

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Validation of predictive factors for infection in adults with chronic leg ulcers: A prospective longitudinal study.

AIMS AND OBJECTIVES: To validate the ability of factors to predict infection in adults with chronic leg ulcers over a 12-week period. BACKGROUND: Leg ulcers affect ~3% of older adults and are often hard to heal. Infection is a leading contributor for delayed healing, causing delayed wound healing, increased hospitalisation, increased healthcare costs and reduced patient quality of life. The importance of early identification of infection has been highlighted for decades, yet little is known about factors that are associated with increased risk of infection in this specific population. DESIGN: A longitudinal, prospective observational study in a single centre. METHODS: Between August 2017 and May 2018, a total of 65 adults with chronic leg ulcers were prospectively observed for a 12-week period. Patients were recruited from an outpatient wound clinic at a tertiary hospital in Australia. Data were collected from recruitment (baseline) and each visit (weekly or fortnightly) up until 12 weeks. Descriptive statistics were calculated for all variables. A Cox proportional hazards regression model was used to identify predictive factors for infection. The TRIPOD guidelines for reporting were followed (See Data S1). RESULTS: The sample consisted of 65 adults with chronic leg ulcers, and 9.2% of these had their ulcer infected at baseline. Two predictive factors, using walking aids and gout, were found to be significantly related to increased likelihood of developing infection within 12 weeks. CONCLUSION: The present study showed that patients who either used walking aids or were diagnosed with gout were at greater risk of infection compared to those without these factors. RELEVANCE TO CLINICAL PRACTICE: These findings provide new information for clinicians in early identification of patients at risk of infection, and for patients in enhancing their awareness of their own risk.

Access to Opioids for Patients with Advanced Disease.

Pain at the end of life is common in both malignant and non-malignant disease. It is feared by patients, their families and careers, and professionals. Effective pain control can be achieved for the majority of patients at the end of life using a multimodal approach. Pharmacological management relies predominantly on strong opioids. In spite of this, evidence suggests that under treatment of pain is common resulting in unnecessary suffering. Multiple barriers to use of opioids have been identified. Patient barriers include reluctance to report pain and to take analgesics. Professional barriers include inadequate pain assessment and lack of specialist knowledge and confidence in opioid therapy. Fear of side effects including respiratory depression affects patients and professionals alike. The impact of the "opioid epidemic", with increasing prescribed and illicit opioid use around the world, has also led to increasingly stringent regulation and concern about under prescribing in palliative care. System barriers to use of opioids at the end of life result from limited opioid availability in some countries and also inconsistent and limited access to palliative care. Multiple interventions have been developed to address these barriers, targeted at patients, professionals and systems. There is increasing evidence to suggest that complex interventions combining a number of different approaches are most effective in optimising pain outcomes for patients at the end of life.