A collaborative pharmacist prescribing model for patients with chronic disease(s) attending Australian general practices: Patient and general practitioner perceptions.

A collaborative pharmacist prescribing model for patients with chronic disease(s) attending Australian general practices: patient and general practitioner perceptions. Background: Pharmacists working in general practice settings are slowly emerging in Australia, with comprehensive medication reviews forming a large part of their role in optimising pharmaceutical care. In Australia, pharmacists are entirely reliant on general practitioners (GPs) accepting and implementing their recommendations to manage drug related problems (DRPs). The next step is a model where the pharmacist takes on responsibility for implementing some of their recommendations. Aim: To investigate patient and general practitioner perceptions of a collaborative model of care where the pharmacist has increased responsibility in assisting the general practitioner manage patients with chronic conditions. Method: Semi-structured, phone and face-to-face interviews were conducted with a purposive sample of patients and GPs respectively. Data were transcribed by a professional transcription service, collated using NVivo 12 Plus and analysed using Braun and Clarke's thematic analysis. Provisional codes were generated and clustered into categories, from which themes were identified. Results: Eighteen interviews were conducted (12 patients, 6 GPs). Four themes were identified from the patient interview data: pharmacist attributes; acknowledgement of the impact of the pharmacist, understanding of the GP-pharmacist collaborative model; relationships with and attitudes towards medicines and health care providers. Four themes were identified from the general practitioner interview data: pharmacist attributes; relationships with pharmacists; impressions on collaboration; impressions of the pharmacist's recommendations. Patients' and GPs' perceptions of the collaborative model of care overall were positive, acknowledging the advantages of a patient-centred, interdisciplinary approach and the potential benefits to patients. Conclusion: The GP-pharmacist collaborative model was viewed favourably by patients and GPs, with some GPs articulating the value in the pharmacist's increased responsibility as they implemented some recommendations to manage DRPs.

The Cost Consequences of the Gold Coast Integrated Care Programme.

INTRODUCTION: The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. METHODS: A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. RESULTS: A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. CONCLUSION: The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in health-related quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program.

The Gold Coast Integrated Care Programme: The Perspectives of Patients, Carers, General Practitioners and Healthcare Staff.

INTRODUCTION: The Australian Gold Coast Integrated Care programme trialled an innovative model of care to proactively manage high risk patients with complex and chronic conditions in collaboration with general practitioners. The objective was to enhance coordination and continuity of care across primary and secondary health services from a single point-of-entry multidisciplinary coordination centre. This case study, embedded in the broader trial, analysed the perceptions of patients, healthcare staff and general practitioners on the adequacy, comprehensiveness, timeliness and acceptability of the new model of care to help inform the decision by the health service whether to adopt it beyond the trial. METHODS: This mixed method embedded, explanatory case study design included surveys of general practice staff and focus groups with patients, carers and coordination centre staff. Qualitative data were thematically analysed and findings merged with survey data in a narrative explanatory case report. DISCUSSION: Staff, patients, general practitioners and practice nurses were generally satisfied with services, coordination of care and information sharing but general practice staff satisfaction ratings declined over time. CONCLUSION: The programme enhanced care and coordination of services and was valued by patients and healthcare providers. Study results provide a rationale for adopting the model for those with chronic and complex conditions.

Engaging patients and families in communication across transitions of care: An integrative review.

OBJECTIVE: To determine the current evidence about patient and family engagement in communication with health professionals during transitions of care to, within and from acute care settings. METHODS: An integrative review using seven international databases was conducted for 2003-2017. Forty eligible studies were analysed and synthesised using framework synthesis. RESULTS: Four themes: 1) Partnering in care: patients and families should be partners in decision-making and care; 2) Augmenting communication during transitions: intrinsic and extrinsic factors supported transition communication between patients, families and health professionals; 3) Impeding information exchange: the difficulties faced by patients and families taking an active role in transition; and 4) Outcomes of communication during transitions: reported experiences for patients, families and health professionals. CONCLUSION: While attitudes towards engaging patients and family in transition communication in acute settings are generally positive, current practices are variable. Structural supports for practice are not always present. PRACTICE IMPLICATIONS: Organisational strategies to improve communication must incorporate an understanding of patient needs. A structured approach which considers timing, privacy, location and appropriateness for patients and families is needed. Communication training is required for patients, families and health professionals. Health professionals must respect a patient's right to be informed by regularly communicating.

Evaluation of the Gold Coast Integrated Care for patients with chronic disease or high risk of hospitalisation through a non-randomised controlled clinical trial: a pilot study protocol.

INTRODUCTION: Chronic diseases are the leading cause of illness, disability and death in Australia. The prevalence and associated health expenditure are projected to soar. There is no 'whole system' approach to healthcare in Australia. To overcome this fragmentation, the Gold Coast Hospital and Health Service (GCHHS) is developing a new model known as Gold Coast Integrated Care (GCIC). To evaluate GCIC a 4-year pilot trial commenced in March 2015. This protocol paper describes the evaluation of GCIC. METHODS AND ANALYSIS: A pragmatic non-randomised controlled clinical trial is conducted to test the hypothesis that GCIC will result in improved health and well-being at no additional cost to the healthcare system. Using a mixed methods approach, impact, outcome and process evaluations will be undertaken to assess the effectiveness and acceptability, including the balance of costs between primary and public secondary care sectors, staff and training requirements, clinical service delivery, and trial implementation.Fifteen general practices have agreed to deliver GCIC. One thousand five hundred of their adult patients with treated chronic diseases, high risk of hospitalisation or healthcare utilisation were recruited to the intervention arm. Approximately 3000 patients not associated with the participating general practices were identified as controls using propensity matching which will provide service utilisation and disease data for usual care.Baseline data and follow-up observations are collected annually until the end of 2018. Quantitative analyses will measure patient healthcare costs, utilisation of health services, and health outcomes, and general practice clinical service delivery according to clinical guidelines (number of foot exams, HbA1c tests). Qualitative analyses will focus on patient and staff experiences, satisfaction, engagement and implementation of the programme as planned. ETHICS AND DISSEMINATION: Approval was received from the GCHHS and Griffith University. The study is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12616000821493). Findings will be communicated via yearly reports to funding bodies and scientific publications. TRIAL REGISTRATION NUMBER: ACTRN12616000821493; Pre-results.

Best practice in clinical facilitation of undergraduate nursing students.

Clinical facilitation is critical to successful student clinical experience. The research reported in this paper used an interpretive case study to explore perspectives of clinical facilitators on what constitutes best practice in clinical facilitation of undergraduate nursing students. Eleven clinical facilitators from South East Queensland, Australia, participated in focus groups, interviews and a concept mapping exercise to gather their perspectives on best practice. The data gathered information regarding their prior and current experiences as registered nurses and facilitators, considering reasons they became clinical facilitators, their educational background and self-perceived adequacy of their knowledge for clinical facilitation. Analysis was through constant comparison. Findings of the study provided in-depth insight into the role of clinical facilitators, with best practice conceptualised via three main themes; 'assessing', 'learning to facilitate' and 'facilitating effectively'. While they felt there was some autonomy in the role, the clinical facilitators sought a closer liaison with academic staff and feedback about their performance, in particular their assessment of the students. Key strategies identified for improving best practice included educational support for the clinical facilitators, networking, and mentoring from more experienced clinical facilitators. When implemented, these strategies will help develop the clinical facilitators' skills and ensure quality clinical experiences for undergraduate nursing students.

Engaging patients and families in communication across transitions of care: an integrative review protocol.

AIM: To describe an integrative review protocol to analyse and synthesize peer-reviewed research evidence in relation to engagement of patients and their families in communication during transitions of care to, in and from acute care settings. BACKGROUND: Communication at transitions of care in acute care settings can be complex and challenging, with important information about patients not always clearly transferred between responsible healthcare providers. Involving patients and their families in communication during transitions of care may improve the transfer of clinical information and patient outcomes and prevent adverse events during hospitalization and following discharge. Recently, optimizing patient and family participation during care transitions has been acknowledged as central to the implementation of patient-centred care. DESIGN: Integrative review with potential for meta-analysis and application of framework synthesis. REVIEW METHOD: The review will evaluate and synthesize qualitative and quantitative research evidence identified through a systematic search. Primary studies will be selected according to inclusion criteria. Data collection, quality appraisal and analysis of the evidence will be conducted by at least two authors. Nine electronic databases (including CINAHL and Medline) will be searched. The search will be restricted to 10 years up to December 2013. Data analysis will include content and thematic analysis. DISCUSSION: The review will seek to identify all types of patient engagement activities employed during transitions of care communication. The review will identify enablers for and barriers to engagement for patients, families and health professionals. Key strategies and tools for improving patient engagement, clinical communication and promoting patient-centred care will be recommended based on findings.

Patient engagement in clinical communication: an exploratory study.

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

The Gold Coast Integrated Care Model.

This article outlines the development of the Australian Gold Coast Integrated Care Model based on the elements identified in contemporary research literature as essential for successful integration of care between primary care, and acute hospital services. The objectives of the model are to proactively manage high risk patients with complex and chronic conditions in collaboration with General Practitioners to ultimately reduce presentations to the health service emergency department, improve the capacity of specialist outpatients, and decrease planned and unplanned admission rates. Central to the model is a shared care record which is maintained and accessed by staff in the Coordination Centre. We provide a process map outlining the care protocols from initial assessment to care of the patient presenting for emergency care. The model is being evaluated over a pilot three year proof of concept phase to determine economic and process perspectives. If found to be cost-effective, acceptable to patients and professionals and as good as or better than usual care in terms of outcomes, the strategic intent is to scale the programme beyond the local health service.

Perceptions of interprofessional education in the Australian Advanced Life Support in Obstetrics (ALSO) course.

BACKGROUND AND OBJECTIVES: Interprofessional education (IPE) was investigated in the context of an evaluation of the Advanced Life Support in Obstetrics (ALSO) course in Australia. Our objectives were to examine doctors' and midwives' perceptions regarding interprofessional learning and measure changes in self-reported confidence in specific interprofessional clinical situations. METHODS: A prospective, mixed methods design was used to survey 165 ALSO course participants before the course and 6 weeks after the course (n=101). Quantitative data were analysed using the Wilcoxon signed rank test, and all P levels lower than .05 were considered significant. Qualitative data were analyzed using content analysis. RESULTS: There were significant increases in midwives' confidence in all four aspects of interprofessional interaction measured 6 weeks following the course. However, the doctors only reported a significant increase in one aspect, the confidence that their clinical decisions were respected by the midwives with whom they worked. The qualitative data demonstrated an appreciation of different professional approaches to clinical situations and the importance of teamwork, communication, respect, and understanding. While most participants were positive about the advantages of IPE, just under half also believed there were some disadvantages, particularly due to the variable learning needs of individual professionals. CONCLUSIONS: Both doctors and midwives reported various benefits from IPE, and many believed that IPE assisted maternity team collaboration and communication in the workplace. However, educators need to skillfully manage IPE sessions to ensure a similar distribution of learning and that opportunities for discussion are equivalent for all individuals and professional groups.

Factors influencing nurses to withhold surgical patients' oral medications pre- and postoperatively.

BACKGROUND: Little is known about the influences on nurses' decisions to withhold surgical patients' oral medications pre and postoperatively or the degree to which decisions are consistent. The literature is devoid of information that clarifies whether or at what point withholding a particular oral medication may constitute a medication error. PURPOSE: This study sought to redress this gap in knowledge and identify factors influencing nurses' decisions about withholding surgical patients' oral medications. METHODS: This interpretive study recruited a convenience sample consisting of nine nurses from surgical wards in public and private hospitals on the Gold Coast, Queensland and northern New South Wales to participate in individual interviews. Data were transcribed and analysed using inductive content analysis to identify common themes. FINDINGS: Three main themes illustrated important influences on nurses 'decisions, including ward culture, nurses' perceptions of their roles and patient factors. CONCLUSIONS: The complex issues surrounding nurses' decisions when withholding surgical patients' oral medications are identified in this research. The findings will help to inform quality and safety in future medication management and lead to higher quality and safer patient care.

Perceived changes in the knowledge and confidence of doctors and midwives to manage obstetric emergencies following completion of an Advanced Life Support in Obstetrics course in Australia.

BACKGROUND: The Advanced Life Support in Obstetrics (ALSO) course is an internationally recognised interprofessional course to support health professionals to develop and maintain the knowledge and skills to manage obstetric emergencies. AIMS: This study investigated changes in confidence and perceived changes in the knowledge of doctors and midwives to manage specific obstetric emergency situations following completion of an ALSO course in Australia. METHODS: A prospective repeated-measures survey design was used to survey 165 course attendees from four Australian states pre- and postcourse and at six weeks (n = 101). Data were analysed using a Friedman two-way repeated-measures analysis of variance and the Wilcoxon signed rank test. RESULTS: There was a significant improvement in confidence and perceived knowledge of the recommended management of all 17 emergency situations immediately postcourse (P < 0.001) and at six weeks postcourse (P < 0.001) when compared to precourse levels for both groups of health professionals. However, a significant decrease in knowledge and confidence for many emergency situations from immediately postcourse to six weeks postcourse (P < 0.05) was also observed in both groups. CONCLUSIONS: Completion of the Australian ALSO course in Australia has a positive effect on the confidence and perceived knowledge of doctors and midwives to manage obstetric emergencies. However, there needs to be some means of reinforcing the effects of the course for longer term maintenance of knowledge and confidence.

Family members' perceptions of the nursing bedside handover.

AIMS AND OBJECTIVES: To explore families' perceptions of shift-to-shift bedside handover. BACKGROUND: The potential role families can play in bedside handover is unknown. Understanding family members' perceptions can provide a foundation for nurses to tailor their bedside handover to family members' perceptions, encouraging their involvement and potentially improving patient care. DESIGN: Qualitative study, using case study methodology. METHODS: The study was conducted with eight family members in one rehabilitation ward in Queensland, Australia, in 2009. Data included observations of bedside handover, field notes and in-depth interviews. Thematic analysis of data was conducted to identify unique and common themes indicative of family perceptions. RESULTS: Three major themes emerged. The first, understanding the situation, consisted of three subthemes: feeling informed, understanding the patient's condition and understanding patient's treatment. The second theme was interacting with nursing staff, with five subthemes, including sharing information, clarifying information, assisting in care, asking questions and interpreting for the patient. The final subtheme was finding value, which contained five subthemes: feeling at ease, feeling included, valuing individualisation, preparing for the future and maintaining patient privacy. CONCLUSIONS: Bedside handover provides an opportunity to involve family members in patient care and promote family-centred care core concepts. Family members value the chance to participate and can ultimately improve the accuracy of handover communication. RELEVANCE TO CLINICAL PRACTICE: Bedside handover is beneficial for nurses, patients and family members and embodies patient and family-centred care. Managers should consider its implementation in hospitals, developing strategies such as standard operating protocols for a more family inclusive approach to communication. Nurses may require further training to best undertake bedside handover and involve family members in care. The study suggests expansion of research into this important area of family-centred care.

Nurses' use of situation awareness in decision-making: an integrative review.

AIM: To critically review the literature related to situation awareness and clinical decision-making by nurses. BACKGROUND: International recognition that situation awareness positively contributes to clinical decision-making has led to a growing body of healthcare literature. To date, research has predominately focused on anaesthetists and surgeons using measurement frameworks from the aviation industry. The evidence focussing directly on situation awareness in decision-making by nurses remains limited. DATA SOURCES: Databases: PROQUEST, Web of Science, CINAHL, and PUBMED. REVIEW METHODS: An integrative review was undertaken following an extensive literature search with the date range January 1965 - March 2011. English language literature reviews, primary qualitative, quantitative and mixed method studies describing situation awareness in decision-making by or including nurses were included. RESULTS: Five empirical studies of nurses' situation awareness were reviewed. Of these, three included decision-making and situation awareness by nurses in inter-professional teams; two related solely to situation awareness and decision-making by nurses. Findings from the five studies could be grouped under three themes: individual factors influencing situation awareness, interpersonal behaviours influencing situation awareness and situation awareness improving working relationships and patient care. CONCLUSION: Further investigation is needed to identify the situation awareness skills that are vital to decision-making by nurses. Elucidating essential skills sets associated with situation awareness may inform the development of education and training to enhance clinical decision-making by nurses.

Patients' perspectives of bedside nursing handover.

BACKGROUND: Patient participation in handover is one aspect of patient-centred care, where patients are considered partners in care. Understanding the patient perspective provides a foundation for nurses to tailor their bedside handovers to reflect patients' thoughts and beliefs and encourage their active involvement in decision-making. AIM: This study examined patients' perspectives of participation in shift-to-shift bedside nursing handover. METHODS: A descriptive case study was conducted with 10 patients in one Queensland hospital who had experienced bedside handover during their hospitalisation in 2009. Participants were asked their views about bedside handover including its benefits and limitations, their existing and potential role in handover, the role of family members, and issues related to confidentiality. Data were analysed using thematic content analysis. FINDINGS: Four themes emerged from the analysis. First, patients appreciated being acknowledged as partners in their care. Second, they viewed bedside handover as an opportunity to amend any inaccuracies in the information being communicated. Third, some preferred passive engagement rather than being fully engaged in the handover. Fourth, most patients appreciated the inclusive approach of handover as nurse-patient interaction. CONCLUSIONS: Bedside handover provides an opportunity for patients to be involved as active participants in their care. They value having access to information on an ongoing basis, and although not all choose the same level of interaction, they see their role as important in maintaining accuracy, which promotes safe, high quality care.

Empowerment and enterprise: the political economy of nursing.

Throughout the past decades, Australian nursing has made significant advances in the clinical, research, and political arenas. Capitalising on these advances is a critical step in empowering the professions and a sound investment in the health of the nation. There remains a need to energise and empower the professions, to see our work as an enterprise that has value and a sense of worth because of our professional activities as well as for the political and economic contributions we make to health and wellbeing, quality of life and social justice. The contributions made by nurses and midwives need to be articulated in the policy arena, focused in professional decision-making and elaborated in our research agendas. Our professional organisations provide opportunities for solidarity, and the leverage we need to effect change at the bedside, the community and the whole of society. Renewed commitment to primary health care at the global, national and community level provides a timely rallying call to the professions to refine the way we articulate our position in health care, re-commit to culturally appropriate, socially just actions and embolden our professional goals to inspire the next generations of nurses for a more equitable future.

Implementing bedside handover: strategies for change management.

AIMS AND OBJECTIVES: To identify factors influencing change in two hospitals that moved from taped and verbal nursing handover to bedside handover. BACKGROUND: Bedside handover is based on patient-centred care, where patients participate in communicating relevant and timely information for care planning. Patient input reduces care fragmentation, miscommunication-related adverse events, readmissions, duplication of services and enhances satisfaction and continuity of care. DESIGN: Analysing change management was a component of a study aimed at developing a standard operating protocol for bedside handover communication. The research was undertaken in two regional acute care hospitals in two different states of Australia. METHOD: Data collection included 532 semi-structured observations in six wards in the two hospitals and 34 in-depth interviews conducted with a purposive sample of nursing staff involved in the handovers. Observation and interview data were analysed separately then combined to generate thematic analysis of factors influencing the change process in the transition to bedside handover. RESULTS AND CONCLUSION: Themes included embedding the change as part of the big picture, the need to link the project to standardisation initiatives, providing reassurance on safety and quality, smoothing out logistical difficulties and learning to listen. We conclude that change is more likely to be successful when it is part of a broader initiative such as a quality improvement strategy. RELEVANCE TO CLINICAL PRACTICE: Nurses are generally supportive of quality improvement initiatives, particularly those aimed at standardising care. For successful implementation, change managers should be mindful of clinicians' attitudes, motivation and concerns and their need for reassurance when changing their practice. This is particularly important when change is dramatic, as in moving from verbal handover, conducted in the safety of the nursing office, to bedside handover where there is greater transparency and accountability for the accuracy and appropriateness of communication content and processes.

Bedside nursing handover: a case study.

A case study of six wards in two hospitals was undertaken to describe the structures, processes and perceptions of outcomes of bedside handover in nursing. A total of 532 bedside handovers were observed and 34 interviews with nurses were conducted. Important structural elements related to the staff, patients, the handover sheet and the bedside chart. A number of processes before, during and after the handover were implemented. They included processes for managing patients and their visitors, sensitive information, and the flow of communication for variable shift starting times. Other key processes identified were the implementation of a safety scan and medication check. The situation, background, assessment and recommendations approach was used only in specific circumstances. Perceived outcomes were categorized as improving accuracy and service delivery, and promoting patient-centred care. Although the move to bedside handover is not the norm, it reflects a patient-centred approach.