Indigenous lands and health access: The influence of a sense of place on disparities in post-stroke recovery in Taiwan.

Despite many countries having policies and systems for universal healthcare coverage, health disparity persists, with significant variations in disease prevalence and life expectancy between different groups of people. This focused ethnography explored the post-stroke recovery of Indigenous and non-Indigenous populations in three geographical areas in Taiwan. Forty-eight observations and 24 interviews were carried out with 12 dyads of stroke survivors and family caregivers, revealing their varied experiences of healthcare. Findings indicate that repeatedly engaging in social activities in the same place increases stroke survivors' attachment to the environment, facilitating their reintegration into the community and improving wellbeing following stroke. The significance of 'place' in post-stroke life and healthcare access is particularly salient for Indigenous people's recovery. Indigenous people tend to employ cultural symbols, such as Indigenous languages and kinship ties, to define and interpret their surrounding environment and identity. Indigenous people residing within or close to their own native communities make better recoveries than those based in urban settings, who are attached to and yet located away from their native lands. A sense of place contributes to identity, while loss of it leads to invisibility and healthcare inaccessibility. To promote equitable healthcare access, future policymaking and care practices should address the environmental and cultural geography and structural barriers that impede the connection between minority groups and the mainstream community healthcare system. The study findings suggest extending welfare resources beyond Indigenous administrative regions and establishing partnerships between Indigenous organisations and the mainstream healthcare system. Leveraging Indigenous people's attachment to cultural symbols and increasing healthcare facilities staffed with Indigenous healthcare workers could help ease structural barriers, maintain identifiable Indigenous beneficiaries and increase entry points into the mainstream healthcare system.

Biographical continuation: recovery of stroke survivors and their family caregivers in Taiwan.

AIM: To explore the experiences pertaining to long-term care services from the perspectives of dyads of stroke survivors and their family caregivers in indigenous and non-indigenous communities. BACKGROUND: Stroke occurrence is a life-changing event associated with quality of life for stroke survivors and their families, especially those who provide primary support. Indigenous people are more likely to experience a stroke at a younger age and have a higher likelihood of hospitalisation and death due to health disparities. Few studies have investigated family dyads or indigenous populations to understand their experiences of coping with changed body-self and to contextualise their reintegration into communities post-stroke. METHODS: Ethnographic fieldwork over nine months in 2018-2019 with indigenous, urban-based, and non-indigenous populations, resulting in 48 observations and 24 interviews with 12 dyads in three geo-administrative communities. FINDINGS: The post-stroke recovery trajectory is illuminated, delineating the dyads' life transitions from biographical disruption to biographical continuation. The trajectory is shaped by seven states involving four mindsets and three status passages. The four mindsets are sense of loss and worry, sense of interdependence, sense of independence, and wellbeing state. The status passages identified in this study are acceptance, alteration, and identification. A community-based and family-centred long-term care system, aligning with medical healthcare and community resources, underpinned each dyad's biographical continuation by: (1) providing rehabilitation that afforded time and space for recovery adaptation; (2) acknowledging the individuality of family caregivers and helping to alleviate their multitasking; and (3) reintegrating stroke survivors into their communities. Key to determining the quality of recovery for the indigenous participants was their reintegration into their native community and regaining of identity. Therefore, integrating post-stroke care into various care contexts and incorporating indigenous-specific needs into policymaking can support dyads in adapting to their communities.

Nurse educator competence in four European countries-A comparative cross-sectional study.

AIM: The aim of this article is to describe and compare the nurse educator competences in four European countries using three different evaluators: nurse educators (n = 329), heads of a nursing subject (n = 60) and student nurses (n = 1058). DESIGN: The study was conducted as a comparative cross-sectional survey in Finland, Malta, Slovakia and Spain between May 2021 and February 2022. METHODS: The data were collected with an online survey. The instrument used was a 20-item Tool for Evaluation of Requirements of Nurse Teachers, utilizing a 5-point Likert-type scale. The data were analysed statistically and reported according to STROBE guidelines. RESULTS: Nurse educators' competence evaluated positively in all the groups of evaluators, with a mean of >3.5. The self-evaluation of nurse educators' competence was higher than the other evaluators' evaluations. Having a degree in nursing, having completed some pedagogical studies and longer work experience as a nurse educator had a positive association with higher self-evaluated competence among nurse educators. CONCLUSIONS: Nurse educator competence is at a good level in the selected European countries, but further studies are required to find the reasons behind the differences in evaluations. PUBLIC CONTRIBUTION: Each participating educational institution named a contact person who distributed the surveys to the participants and returned the study's metadata to the researchers.

An integrative review of the continuing professional development needs for nurse educators.

OBJECTIVES: The study aimed at describing the field of research in continuing professional development for nurse educators and the continuous education and development needs of nurse educators by asking: What research has been done in the field of continuing professional development of nurse educators? What are the continuing education and development needs and requirements reported for and by nurse educators? DESIGN: An integrative review of peer-reviewed academic literature following a systematic search design. DATA SOURCES: Qualitative, quantitative, and mixed methods publications in CINAHL, Cochrane Library, Web of Science, Embase, ERIC, and PubMed. REVIEW METHODS: Search results were screened for full text and assessed for quality using the Mixed Methods Assessment Tool. Full texts were then thematic analysed using an inductive and reflective process. RESULTS: The number of published academic articles about the continuing professional development for nurse educators is small (n = 13). The themes produced from the articles identify heterogenous development needs for nurse educators, clustered around four themes: (1) professional competencies (2) management and resources, (3) communication and collaboration, and (4) agency. The findings of this review show that nurse educators have multiple roles which have specific and multiple personal and institutional needs. CONCLUSIONS: The results of this review show that the continuing professional development needs are heterogenous between nurse educators, yet share commonalities across departmental teams as a whole, and across different countries. This raises the issue of how these needs can or should be, focused on the sustainable development of nurse educators.

Ambiguous loss in organ donor families: A constructivist grounded theory.

AIMS AND OBJECTIVES: Explore families' experiences when being approached for organ donation authorisation after brainstem death. BACKGROUND: The complexities of potential organ donor families' experiences include challenges related to emotional distress, coping with the loss and the organ donation decision-making process, and support needed. A lack of conceptual clarity was found concerning families' experiences when being approached for organ donation authorisation, which guided the study. DESIGN: Constructivist grounded theory. METHODS: Seventy-one participants, including healthcare professionals and families, were recruited from two large hospitals in Chile between 2017 and 2019. Field notes, documents (n = 80), interviews (n = 27) and focus groups (n = 14) were collected and analysed following Charmaz's constructivist grounded theory principles and practices until theoretical saturation was reached. The study is reported using the COREQ checklist. RESULTS: A third type of ambiguous loss of bereaved families' experience was developed as a fourfold process: (1) impending loss, (2) confirming loss, (3) ambiguous loss and organ donation decision-making and (4) organ donation as a third type of ambiguous loss. This grounded theory expands the concepts of ambiguous loss by Boss, dying by Glaser and Strauss and grief by Brinkmann, enabling explanation of families' experiences. CONCLUSION: Families of potential organ donors develop a highly complex grieving process, which may play a significant role in the organ donation decision-making process. Ambiguity is embedded in how donor families reframe the existence of the donor through the act of giving life. RELEVANCE TO CLINICAL PRACTICE: The findings shed light on families' experiences on the organ donation process after brainstem death. The study can be used in nursing practice, education and to inform policy nationally and globally, mainly due to the current focus on quantitative measures and legislative changes fostering individual decision-making. PATIENT OR PUBLIC CONTRIBUTION: Families contributed through their first-hand experiences of the organ donation process.

Fluctuating power: an exploration of refugee health nursing within the resettlement context in Victoria, Australia.

Background: The Refugee Health Program (RHP) is a nurse-led community initiative, introduced in 2005 with the aim of responding to complex health issues of refugees arriving in Victoria, Australia. Little is known about refugee health nursing in the resettlement context and the impact of dedicated refugee healthcare. Aim: To explore the experiences and perspectives of Refugee Health Nurses (RHNs), Refugee Health Managers (managers) and refugees, gaining insight into professional relationships and the complexities of offering a specialised refugee health service. Method: A focused ethnographic approach incorporated semi-structured interviews with five RHNs, two managers and eight refugees, two focus groups with refugees and participant observation within the RHP during April 2017 to December 2017. Data collection was undertaken across two sites and interviews, focus groups and observations were transcribed and thematically analysed. Social constructionism asserts that the focus of enquiry should be on interaction, group processes and social practices. Emphasis is placed upon relationships between RHNs, managers and refugees, with knowledge viewed as relational and interactional. Results: Professional relationships between RHNs and refugees are complex, with power oscillating between them. Contrary to discourses of 'vulnerability' of refugees, both RHNs and refugees demonstrated power in their relationships with each other. Nurses also suggested that these relationships were stressful and could lead to burnout. Key themes were developed: (1) nursing autonomy and gatekeeping; (2) vicarious trauma and burnout; and (3) refugee negotiation of care. Conclusions: The balance of power is central to therapeutic relationships. In relationships between RHNs and refugees, power fluctuates as RHNs are exposed to vicarious trauma and symptoms of burnout, while refugees exercise agency by recognising benefits to specialised care. In developing effective therapeutic relationships between RHNs and refugees, attention should be paid to how care is delivered to protect RHNs from burnout while ensuring that refugees receive appropriate care.

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.

Edgework emotion management: A constructivist grounded theory of organ donation nurses' experiences and practices.

AIMS AND OBJECTIVES: To explore nurses' experiences when approaching families for organ donation authorisation to guide nursing practice. BACKGROUND: Organ donation after brainstem death implies that bereaved families are approached to discuss organ donation authorisation, and in many countries, specialist nurses do this approach. The literature describes the social, psychological and emotional challenges of health professionals in this role. However, lack of conceptual clarity regarding nurses' experiences on approaching families to guide nursing practice was found. DESIGN: Constructivist grounded theory. METHODS: Between October 2017 and July 2019, seven months of observations were conducted across two large public hospitals in Chile. Field notes, documents (n = 80), interviews (n = 27) and focus groups (n = 14) with 71 participants (51 healthcare professionals and 20 bereaved families) were included. Data collection and analysis followed the principles and practices of Charmaz' constructivist grounded theory. The COREQ checklist was followed in reporting the study. RESULTS: Edgework emotion management of organ donation nurses was developed as a threefold process: 1) being present to recognise inner and family emotions, 2) being on an emotional edge when approaching families and 3) extending the emotional edge to make sense of their experiences. The grounded theory was conceptualised using edgework emotion management by Lois (2003), which allowed to elucidate organ donation nurses' experiences and practices on managing their emotions. CONCLUSIONS: Organ donation nurses develop a sophisticated and complex emotional regulation process to approach and care for families when negotiating organ donation authorisation for transplantation. RELEVANCE TO CLINICAL PRACTICE: The experiences of specialist organ donation nurses entail a sophisticated emotion management process, which may explain the complexities of a critical role within healthcare institutions. Findings can be locally and internationally used to understand, educate and guide nursing practice, in an area of increasing specialisation and staffing shortages such as organ donation and transplantation.

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.

Family INvolvement in inTensive care: A qualitative exploration of critically ill patients, their families and critical care nurses (INpuT study).

AIMS AND OBJECTIVES: To understand the different factors that impact on the involvement of adult family members in the care of critically ill patients from the perspective of patients, families and nurses, with the aim to inform the enactment of a patient- and family-centred care intervention to support the patient-family-nurse partnership in care involvement. BACKGROUND: Existing evidence lacks theoretical underpinning and clarity to support enactment of patient- and family-centred care and involvement of families in the care of the critically ill patient. DESIGN: Qualitative exploratory design using thematic analysis. METHODS: This study was conducted at two adult intensive care units in two tertiary university hospitals in the central belt of Scotland. Between 2013-2014, we conducted semi-structured interviews with critically ill survivors (n = 19) and adult family members (n = 21), and five focus groups with nurses (n = 15) across both settings. Data were digitally recorded, transcribed verbatim, and uploaded in NVivo 10. Data were analysed thematically using a constructivist epistemology. Ethical approval was obtained prior to data collection. Data are reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. RESULTS: Family's situational awareness; the perceived self in care partnership; rapport and trust; and personal and family attributes were the main factors that affected family involvement in care. Two key themes were identified as principles to enact patient- and family-centred care in adult intensive care units: "Need for 'Doing family'" and "Negotiations in care involvement." CONCLUSIONS: Negotiating involvement in care requires consideration of patients' and family members' values of doing family and the development of a constructive patient-family-nurses' partnership. RELEVANCE TO CLINICAL PRACTICE: Future policy and research should consider patients' and family's needs to demonstrate family bonds within a negotiated process in care participation, when developing tools and frameworks to promote patient- and family-centred care in adult intensive care units.

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.

A family intervention to reduce delirium in hospitalised ICU patients: A feasibility randomised controlled trial.

BACKGROUND: Family members could play an important role in preventing and reducing the development of delirium in Intensive Care Units (ICU) patients. This study sought to assess the feasibility of design and recruitment, and acceptability for family members and nurses of a family delivered intervention to reduce delirium in ICU patients. METHOD: A single centre randomised controlled trial in an Australian medical/surgical ICU was conducted. Sixty-one family members were randomised (29 in intervention and 32 in non-intervention group). Following instructions, the intervention comprised the family members providing orientation or memory clues (family photographs, orientation to surroundings) to their relative each day. In addition, family members conducted sensory checks (vision and hearing with glasses and hearing aids); and therapeutic or cognitive stimulation (discussing family life, reminiscing) daily. Eleven ICU nurses were interviewed to gain insight into the feasibility and acceptability of implementing the intervention from their perspective. RESULTS: Recruitment rate was 28% of eligible patients (recruited n=90, attrition n=1). Following instruction by the research nurse the family member delivered the intervention which was assessed to be feasible and acceptable by family members and nurses. Protocol adherence could be improved with alternative data collection methods. Nurses considered the activities acceptable. CONCLUSION: The study was able to recruit, randomise and retain family member participants. Further strategies are required to assess intervention fidelity and improve data collection.

'Intensive care unit survivorship' - a constructivist grounded theory of surviving critical illness.

AIMS AND OBJECTIVES: To theorise intensive care unit survivorship after a critical illness based on longitudinal qualitative data. BACKGROUND: Increasingly, patients survive episodes of critical illness. However, the short- and long-term impact of critical illness includes physical, psychological, social and economic challenges long after hospital discharge. An appreciation is emerging that care needs to extend beyond critical illness to enable patients to reclaim their lives postdischarge with the term 'survivorship' being increasingly used in this context. What constitutes critical illness survivorship has, to date, not been theoretically explored. DESIGN: Longitudinal qualitative and constructivist grounded theory. Interviews (n = 46) with 17 participants were conducted at four time points: (1) before discharge from hospital, (2) four to six weeks postdischarge, (3) six months and (4) 12 months postdischarge across two adult intensive care unit setting. METHOD: Individual face-to-face interviews. Data analysis followed the principles of Charmaz's constructivist grounded theory. 'Intensive care unit survivorship' emerged as the core category and was theorised using concepts such as status passages, liminality and temporality to understand the various transitions participants made postcritical illness. FINDINGS: Intensive care unit survivorship describes the unscheduled status passage of falling critically ill and being taken to the threshold of life and the journey to a life postcritical illness. Surviving critical illness goes beyond recovery; surviving means 'moving on' to life postcritical illness. 'Moving on' incorporates a redefinition of self that incorporates any lingering intensive care unit legacies and being in control of one's life again. RELEVANCE TO CLINICAL PRACTICE: For healthcare professionals and policymakers, it is important to realise that recovery and transitioning through to survivorship happen within an individual's time frame, not a schedule imposed by the healthcare system. Currently, there are no care pathways or policies in place for critical illness survivors that would support intensive care unit survivors and their families in the transitions to survivorship.

Patient, family-centred care interventions within the adult ICU setting: An integrative review.

OBJECTIVES: Patient, Family-Centred Care (PFCC) is internationally advocated as a way to improve patient care. The aim of this integrative review was to extend the knowledge and understanding by synthesising empirical evidence of PFCC interventions within the adult intensive care unit (ICU) setting. REVIEW METHOD USED: An integrative review methodological framework was employed, permitting the inclusion of all research designs. A comprehensive and systematic search, selection, quality appraisal, and data extraction of research were conducted to synthesise knowledge and identify research gaps. DATA SOURCES: A systematic search of the following databases was conducted: MEDLINE; CINHAL; PsycINFO; Cochrane Library; Web of Science-Current Contents Connect; Web of Science-Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global. Primary research in adult ICUs was included. REVIEW METHODS: Data extracted from the studies included authors, year, country of origin, design, setting, sample, intervention, data collection strategies, main findings and limitations. Study quality was assessed using the Mixed Methods Appraisal Tool. RESULTS: Forty-two articles met the inclusion criteria and were included in the review. Only a third of the papers stated the theory underpinning their study. Three themes emerged with interventions predominantly around Interacting with the target sample; Culture and Connection and Service Delivery interventions were also identified. Few studies integrated more than one dimension of PFCC. CONCLUSIONS: Research into PFCC interventions is diverse; however, few researchers present a multi-dimensional approach incorporating a culture shift to enact PFCC throughout the ICU trajectory. There is an opportunity for future research to describe, develop, and test instruments that measure PFCC based on its multiple dimensions and not on one component in isolation. Importantly, for PFCC to successfully individualise quality patient care, a commitment and enactment of partnerships between health care professionals, patients, and family members is imperative.

Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Unit Discharge: The RECOVER Randomized Clinical Trial.

IMPORTANCE: Critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. OBJECTIVE: To evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post-intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. DESIGN, SETTING, AND PARTICIPANTS: A parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. INTERVENTIONS: During the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. MAIN OUTCOMES AND MEASURES: The Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). RESULTS: Median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, -0.2 [95% CI, -1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, -0.1 [95% CI, -3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, -3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. CONCLUSIONS AND RELEVANCE: Post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery. TRIAL REGISTRATION: isrctn.com Identifier: ISRCTN09412438.

How do intensive care nurses perceive families in intensive care? Insights from the United Kingdom and Australia.

AIMS AND OBJECTIVES: To compare how intensive care nurses in the UK and Australia (AU) perceive families in intensive care units (ICUs). BACKGROUND: International healthcare research and practice is often based on an underlying assumption of a person- or family-centred ideology. While nurses in ICUs acknowledge the importance of patients' families, a true integration of families as units of care is often not realised. DESIGN: Data from ICU nurses from two international studies: (1) a constructivist grounded theory study in the UK and (2) a quasi-experimental non-equivalent clinical study in AU. Data were collected in tertiary adult ICUs in the UK and AU. Nurse-to-patient ratio for high-acuity patients was 1:1 in both units. PARTICIPANTS: Twenty ICU nurses in five focus groups (UK study) and 197 surveys were sent out to ICU nurses in AU (response rate 26%). RESULTS: Evidence from both studies makes visible the contribution of family care in adult ICUs. Nurses remaining in control and initiating family member care involvement are less likely to perceive families as a burden. The AU study indicated that when nurses partner with families to deliver care, there was a minimal effect on their workload. The nurses concluded that inviting family members to be a part of the patient's care should be usual practice in ICUs. CONCLUSION: Nurses should promote, facilitate and invite the integration of families in care in today's healthcare system. This is mandatory as families are the caring resource for these patients during an often prolonged recovery trajectory. RELEVANCE TO CLINICAL PRACTICE: Families are more likely to be successfully integrated into a more active involvement with ICU patients when they are not perceived as a burden. Inviting and supporting family members is not necessarily time-consuming and starts the journey of supporting ICU survivors' recovery journey.

Shifting the balance of care? A qualitative study of policy implementation in community nursing.

AIM: This qualitative study examined the interaction between policy implementation and service organisation and delivery for community nursing services. BACKGROUND: Leadership in nursing is at the fore front of the policy agenda for shifting the balance of care from hospitals to the community setting and for improving the quality of healthcare services. Yet, little is known about the implementation of policy within the community setting. METHOD: A qualitative, interpretive analysis including semi-structured interviews with nurse leaders (n = 12) and community nurses (n = 27) and three focus groups (n = 13) with community nurses (Total N = 39) in three Health Boards in Scotland. RESULTS: Policy implementation is not adequately integrated between primary and secondary care service at the point of care delivery. The 'top down approach' to policy implementation for shifting the balance of care is currently at odds with the grass roots service organisation and delivery in the community setting. CONCLUSIONS: The aspirations of integrated, collaborative health and social care require more clinicians working at the frontline in both primary and secondary care to value more the work of colleagues in the different sectors. IMPLICATION FOR NURSING MANAGEMENT: The current 'top down approach' to policy implementation encourages resistance in the frontline community nurses rather than commitment. A more 'bottom up' integrated approach to policy implementation is therefore required.