Patient outcomes following medical emergency team review on general wards: Development of predictive models.

AIM: To develop and internally validate risk prediction models for subsequent clinical deterioration, unplanned ICU admission and death among ward patients following medical emergency team (MET) review. DESIGN: A retrospective cohort study of 1500 patients who remained on a general ward following MET review at an Australian quaternary hospital. METHOD: Logistic regression was used to model (1) subsequent MET review within 48 h, (2) unplanned ICU admission within 48 h and (3) hospital mortality. Models included demographic, clinical and illness severity variables. Model performance was evaluated using discrimination and calibration with optimism-corrected bootstrapped estimates. Findings are reported using the TRIPOD guideline for multivariable prediction models for prognosis or diagnosis. There was no patient or public involvement in the development and conduct of this study. RESULTS: Within 48 h of index MET review, 8.3% (n = 125) of patients had a subsequent MET review, 7.2% (n = 108) had an unplanned ICU admission and in-hospital mortality was 16% (n = 240). From clinically preselected predictors, models retained age, sex, comorbidity, resuscitation limitation, acuity-dependency profile, MET activation triggers and whether the patient was within 24 h of hospital admission, ICU discharge or surgery. Models for subsequent MET review, unplanned ICU admission, and death had adequate accuracy in development and bootstrapped validation samples. CONCLUSION: Patients requiring MET review demonstrate complex clinical characteristics and the majority remain on the ward after review for deterioration. A risk score could be used to identify patients at risk of poor outcomes after MET review and support general ward clinical decision-making. RELEVANCE TO CLINICAL PRACTICE: Our risk calculator estimates risk for patient outcomes following MET review using clinical data available at the bedside. Future validation and implementation could support evidence-informed team communication and patient placement decisions.

A facilitator's reflection on the democratizing potential of emancipatory practice development.

Emancipatory practice development (ePD) is a practitioner-led research methodology which enables workplace transformation. Underpinned by the critical paradigm, ePD works through facilitation and workplace learning, with people in their local context on practice issues that are significant to them. Its purpose is to embed safe, person-centred learning cultures which transform individuals and workplaces. In this article, we critically reflect on a year-long ePD study in an acute care hospital ward. We explore the challenges of practice change within systems, building collective strength with frontline collaborations and leadership to sustain new learning cultures. Our work advances practice development dialogue through working closely with the underpinning theories. Our critique analyses how ePD can enact and sustain change within a complex system. We argue that ePD works to strengthen safety cultures by challenging antidemocratic practices through communicative action. By opening communicative spaces, ePD enables staff to collectively deliberate and reach consensus. Their raised awareness supports staff to resist ways of working which conspire against safe patient care. Sustainability of practice change is fostered by the co-operative democracies created within the frontline team and meso level enablement. We conclude that the democratising potential of ePDt generates staff agency at the frontline.

The illness severity of ward remaining patients reviewed by the medical emergency team: A retrospective cohort study.

BACKGROUND: Although progress has been made in identifying and responding to acutely deteriorating ward patients, judgements about the level of care required for patients after medical emergency team review are complex, rarely including a formal assessment of illness severity. This challenges staff and resource management practices and patient safety. OBJECTIVE: This study sought to quantify the illness severity of ward patients after medical emergency team review. RESEARCH DESIGN AND SETTING: This retrospective cohort study examined the clinical records of 1500 randomly sampled adult ward patients following medical emergency team review at a metropolitan tertiary hospital. Outcome measures were the derivation of patient acuity and dependency scores using sequential organ failure assessment and nursing activities score instruments. Findings are reported using the STROBE guideline for cohort studies. NO PATIENT OR PUBLIC CONTRIBUTION: No direct patient contact was made during the data collection and analysis phases of the study. RESULTS: Patients were male (52.6%), unplanned (73.9%) medical admissions (57.5%), median age of 67 years. The median sequential organ failure assessment score was 4% and 20% of patients demonstrated multiple organ system failure requiring non typical monitoring and coordination arrangements for at least 24 h. The median nursing activities score was 86% suggestive of a near 1:1 nurse-to-patient ratio. More than half of all patients required enhanced levels of assistance with mobilization (58.8%) and hygiene (53.9%) activities. CONCLUSIONS: Patients who remain on the ward following medical emergency team review had complex combinations of organ dysfunction, with levels of dependency similar to those found in intensive care units. This has implications for ward and patient safety and continuity of care arrangements. RELEVANCE TO CLINICAL PRACTICE: Profiling illness severity at the conclusion of the medical emergency team review may help determine the need for special resource and staffing arrangements or placement within the ward environment.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.

BACKGROUND: Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated. METHODS: For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it. FINDINGS: We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97-1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84-0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01-1·12, p=0·015), but not in intervention hospitals (1·00, 0·95-1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92-0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86-0·99, p=0·045), readmissions (0·93, 0·89-0·97, p<0·0001), and LOS (IRR 0·97, 0·94-0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing. INTERPRETATION: Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment. FUNDING: Queensland Health, National Institutes of Health, National Institute of Nursing Research.

Building effective engagement for implementation with i-PARIHS: a collaborative enquiry into paediatric pain care in the emergency department.

BACKGROUND: Pain is a central and distressing experience for children in the emergency department (ED). Despite the harmful effects of pain, ED care often falls short of providing timely and effective pain relief. Knowledge translation research targeting systems of care holds potential to transform paediatric pain care. This article reports on the first stages of an implementation project aimed at embedding effective and sustainable practice change in an Australian children's hospital ED. METHODS: The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework underpinned a cooperative process of engagement to establish a practitioner-led, interprofessional research collaborative. The Kids Pain Collaborative (KPC) aimed to co-design innovation in paediatric ED pain care, facilitating an extensive reconnaissance of research evidence, clinician and family experiences, and local evaluation data. This critical appraisal of the context and culture of pain management generated foci for innovation and facilitation of implementation action cycles. RESULTS: Engaging in a complex process of facilitated critical reflection, the KPC unpacked deeply embedded assumptions and organisational practices for pain care that worked against what they wanted to achieve as a team. A culture of rules-based pain management and command and control leadership produced self-defeating practices and ultimately breakdowns in pain care. By raising a critical awareness of context, and building consensus on the evidence for change, the KPC has established a whole of ED shared vision for prioritising pain care. CONCLUSIONS: In-depth key stakeholder collaboration and appraisal of context is the first step in innovation of practice change. The KPC provided a space for collaborative enquiry where ED clinicians and researchers could develop context-specific innovation and implementation strategy. We provide an example of the prospective application of i-PARIHS in transforming ED pain care, using a collaborative and participatory approach that has successfully enabled high levels of departmental engagement, motivation and ownership of KPC implementation as the facilitation journey unfolds.

Building safety cultures at the frontline: An emancipatory Practice Development approach for strengthening nursing surveillance on an acute care ward.

AIM: To evaluate an emancipatory Practice Development approach for strengthening nursing surveillance on a single medical-surgical ward. BACKGROUND: Registered nurses keep patients safe in acute care settings through the complex process of nursing surveillance. Our interest was understanding how frontline teams can build safety cultures that enable proactive nursing surveillance in acute care wards. DESIGN: A year-long emancipatory Practice Development project. METHODS: A collaborative relationship was established around a shared interest of nursing surveillance capacity and researcher embedded on a medical-surgical ward. Critical analysis of workplace observations and reflection with staff generated key sites for collective action. Ward engagement was supported by creative Practice Development methods including holistic facilitation, critical reflection and action learning. An action learning set was established with a group of clinical nurses, facilitating practitioner-led change initiatives which strengthened nursing surveillance and workplace learning. Evaluation supported an iterative approach, building on what worked in an acute care context. Immersive researcher evaluation, drawing on multiple data sources, generated an analysis of how ward nursing surveillance capacity can be strengthened. COREQ criteria guided reporting. RESULTS: The ward moved through a turbulent and transformative process of resistance and retreat towards a new learning culture where nursing surveillance was visible and valued. Staff developed and sustained innovations including the 'My MET Call series', a 'Shared GCS initiative', an enhanced 'Team Safety Huddle', and staff-led Practice Development workshops. These new practices affirmed nurses' agency, asserted nurses' clinical knowledge, positioned nurses to participate in team decision-making and humanised care. CONCLUSION: Working collaboratively with frontline staff enabled bottom-up sustainable innovation to strengthen nursing surveillance capacity where it mattered most, at the point of care. RELEVANCE TO CLINICAL PRACTICE: Emancipatory Practice Development enables the profound impact of small-scale, microsystem level practice transformation. It is an accessible methodology for clinical teams to develop effective workplace cultures.

A bundled phosphate control intervention (4Ds) for adults with end-stage kidney disease receiving haemodialysis: A cluster randomized controlled trial.

AIM: To evaluate the effectiveness of a bundled self-management intervention (taking control of your phosphate with the 4Ds) to improve phosphate control among adults receiving haemodialysis. BACKGROUND: Hyperphosphataemia occurs in end-stage kidney disease and is managed by diet, drinks, drugs (phosphate binder medication), and dialysis (the 4Ds). Adherence to the 4Ds is challenging for patients. DESIGN: A pragmatic cluster randomized controlled trial with repeated measures. METHODS: Participants were adults receiving haemodialysis with high serum phosphate (>1.6 mmol/L for at least 3 months) recruited between August 2017 -May 2018. Cluster randomization was according to haemodialysis treatment shifts. The 'teach-back' intervention was designed to improve phosphate control. Expected outcomes were reduced serum phosphate and increased knowledge of phosphate in end-stage kidney disease, self-efficacy and adherence to diet, drugs, and dialysis. RESULTS: There were no differences between groups at baseline. Both groups had similar mean serum phosphate over time; at three months, 46% of the intervention group achieved reductions that met the target serum phosphate level compared with 33% of the control group. There were significant improvements in knowledge of phosphate in end-stage kidney disease, self-efficacy and adherence to diet, drugs, and dialysis (missing) in the intervention group compared with control group. CONCLUSION: The 4Ds, a bundled self-management intervention, was effective in improving patient confidence and adherence to phosphate control methods. IMPACT: The 4Ds intervention bundles together four essential strategies for preventing and controlling hyperphosphataemia in end-stage kidney disease. TRIAL REGISTRATION: ACTRN12617000703303 Registered 16/05/2017.

Validation of the Australian version of the Chronic Kidney Disease Self-Management instrument.

AIM: The aim of this study is to evaluate the validity and reliability of the modified Chronic Kidney Disease Self-Management instrument in an English-speaking population. BACKGROUND: There is growing evidence that self-management behaviours can improve outcomes for people with chronic kidney disease. However, there are few suitable instruments available. DESIGN: The study was cross sectional, with a test-retest protocol. METHOD: Adults with chronic kidney disease attending a primary health care between June and December 2015 completed the Chronic Kidney Disease Self-Management instrument. Construct validity was determined using exploratory factor analysis, internal consistency and test-retest reliability using Cronbach's α and intraclass correlation. For convergent validity, the relationships between knowledge, self-efficacy and self-management were investigated. RESULTS: The Australian version of the Chronic Kidney Disease Self-Management instrument has 17 items grouped into four factors: self-integration, seeking social support, adherence to lifestyle modification and problem solving. The instrument demonstrated good reliability. Self-efficacy was positively correlated with self-management scores, although there was no correlation between chronic kidney disease knowledge and self-management. CONCLUSIONS: The Australian version of the Chronic Kidney Disease Self-Management instrument was found to be a valid and reliable patient-reported outcome measure. It can be used in clinical practice to support self-management, as well as future research.

The illness severity of patients reviewed by the medical emergency team: A scoping review.

BACKGROUND: Medical emergency teams (METs) are internationally used to manage hospitalised deteriorating patients. Although triggers for MET review and hospital outcomes have previously been widely reported, the illness severity at the point of MET review has not been reported. As such, levels of clinical acuity and patient dependency representing the risk of exposure to short-term adverse clinical outcomes remain largely unknown. OBJECTIVE: This scoping review sought to understand the illness severity of MET review recipients in terms of acuity and dependency. METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The published and grey literature since 2009 was searched to identify relevant articles reporting illness severity scores associated with hospitalised adult inpatients reviewed by a MET. After applying the inclusion and exclusion criteria, 17 articles (16 quantitative studies, one mixed-methods study) were reviewed, summarised, collated, and reported. RESULTS: A total of 17 studies reported clinical acuity metrics for patients reviewed by a MET. No studies described an integrated risk score encompassing acuity, patient dependency, or wider parameters that might be associated with increased patient risk or the need for intervention. Multi-MET review, the use of specialist interventions, and delayed/transfer to the intensive care unit were associated with a greater risk of clinical deterioration, higher clinical acuity score, and predicted mortality risk. A single dependency metric was not reported although organisational levels of care, the duration of MET review, MET interventions, chronic illness, and frailty were inferred proxy measures. CONCLUSION: Of the 17 studies reviewed, no single study provided an integrated assessment of illness severity from which to stratify risk or support patient management processes. Patients reviewed by a MET have variable and rapidly changing health needs that make them particularly vulnerable. The lack of high-quality data reporting acuity and dependency limits our understanding of true clinical risk and subsequent opportunities for pathway development.

Effectiveness of self-management programme in people with chronic kidney disease: A pragmatic randomized controlled trial.

AIMS: To examine the effectiveness of a self-management intervention compared with usual care in adults with chronic kidney disease (CKD) on self-management, knowledge, self-efficacy, health-related quality of life, and blood pressure. DESIGN: A parallel group randomized controlled trial. METHODS: Patients aged ≥ 18 years with CKD stages 3-5 were recruited between November 2015 and June 2016. Participants were randomly allocated into either the intervention (N = 68) or control group (N = 67). The control group received usual care, while the intervention group received usual care plus a self-management programme from a nurse. The intervention was guided by social cognitive theory (SCT) and included a face-to-face educational session followed by telephone support. Both groups were followed for 16 weeks. RESULTS: There were no significant differences in self-management, knowledge, self-efficacy, health-related quality of life, and blood pressure between the two groups at baseline. At week 16, compared with the control group, large effect sizes for improved self-management, knowledge, and self-efficacy were detected. For health-related quality of life, the physical and mental health components significantly improved. However, no significant differences in either systolic or diastolic blood pressures were found. CONCLUSION: In earlier stages of CKD, a simple self-management education benefits patients. IMPACT: Effective self-management in the earlier stages of CKD contributes to slowing its progression, improving health outcomes and lowering the burden on healthcare systems. This study demonstrated that SCT increases CKD self-management by strengthening knowledge and self-efficacy. Nurses can give this education. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000038493.

Strengthening nursing surveillance in general wards: A practice development approach.

AIMS AND OBJECTIVES: To explore the context and culture of nursing surveillance on an acute care ward. BACKGROUND: Prevention of patient deterioration is primarily a nursing responsibility in hospital. Registered nurses make judgements and act on emerging threats to patient safety through a process of nursing surveillance. Organisational factors that weaken nursing surveillance capacity on general wards increase the need for patient rescue at the end point of clinical deterioration with poorer outcomes. Yet little is known about cultures that enable and sustain ward nursing surveillance for patient safety. DESIGN: Workplace observations and semistructured interviews using a critical lens as the first stage of a larger emancipatory practice development project. METHODS: Researcher immersion including 96 hr of nonparticipant observation with 12 semistructured interviews during July-August 2017. This study adhered to the COREQ guidelines. RESULTS: We offer a metaphor of nursing surveillance as the threads that support the very fabric of acute care nursing work. These hidden threads enable nurses to weave the tapestry of care that keeps patients safe. This tapestry is vulnerable to internal and external forces, which weaken the structure, putting patients and staff at risk. CONCLUSION: Understanding local context is essential to supporting practice change. This workplace observation challenges us to find ways to creatively engage nurses with the underlying cultural and systems issues that so often remain hidden from view in the deteriorating patient literature. RELEVANCE TO CLINICAL PRACTICE: Building cultural values that strengthen nursing surveillance is a prerequisite for safe and effective hospital care. As such, practice-based research that empowers frontline nurses and teams to develop person-centred workplace cultures can hold the key to unlocking sustainable improvements in patient safety.

Psychometric evaluation of the culturally and linguistically translated Vietnamese chronic kidney disease self-management instrument.

AIMS: To translate and psychometrically test the modified chronic kidney disease self-management instrument in Vietnamese language. BACKGROUND: Research on chronic kidney disease self-management is increasing although few patient-reported outcome measures are available in other languages. DESIGN: This study involved instrument modification, translation, and cultural adaptation into Vietnamese followed by psychometric evaluation in a target population. METHODS: Following modification, the instrument was translated by bilingual independent translators, and then an expert panel assessed content face validity. Reliability of the instrument was assessed by internal consistency and test-retest reliability in a sample of 293 people with chronic kidney disease. Then exploratory factor analysis was used to evaluate construct validity of the Vietnamese version. RESULTS: The Vietnamese chronic kidney disease self-management instrument demonstrated excellent content face validity and internal consistency. The test-retest indicated good stability of the instrument over a 2-week period. Four factors were identified using exploratory factor analysis and were named understanding my kidney disease, taking action to manage my kidney disease, seeking social support, and adhering to a healthy diet. CONCLUSIONS: The translated and modified version is a valid, reliable, and feasible patient-reported outcome measure of self-management behaviour in Vietnamese-speaking populations.

Meeting patients where they are: improving outcomes in early chronic kidney disease with tailored self-management support (the CKD-SMS study).

BACKGROUND: To achieve optimal health outcomes, people with chronic kidney disease must make changes in their everyday lives to self-manage their condition. This can be challenging, and there is a need for self-management support interventions which assist people to become successful self-managers. While interventions have been developed, the literature in this area is sparse and limited by lack of both individualisation and sound theoretical basis. The aim of this study was to implement and evaluate the Chronic Kidney Disease-Self-Management Support intervention: a theory-based, person-centred self-management intervention for people with chronic kidney disease stages 1-4. METHODS: A single-sample, pre-post study of an individualised, 12-week intervention based upon principles of social-cognitive theory and person-centred care was conducted with patients attending outpatient renal clinics in Queensland, Australia (N = 66). Data were collected at T0 (pre-intervention) and T1 (post-intervention). Primary outcomes were self-efficacy and self-management behaviour. RESULTS: There were significant, small-to-medium improvements in primary outcomes (self-efficacy: mean difference + 0.8, 95% CI 0.3-1.2, d = 0.4; self-management behaviour: mean difference + 6.2, 95% CI 4.5-7.9, d = 0.8). There were further significant improvements in secondary outcomes (blood pressure, disease-specific knowledge, physical activity, fruit and vegetable consumption, alcohol consumption, health-related quality of life, psychological distress, and communication with healthcare providers), with effect sizes ranging from negligible to large (all ps < .05). CONCLUSIONS: Social-cognitive theory shows promise as a framework for providing effective person-centred self-management support to patients within this population, and longer-term evaluation is needed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000066280 . Retrospectively registered 17/01/2018.

A bundled phosphate control intervention (4Ds) for adults with end-stage kidney disease receiving haemodialysis: A cluster randomized controlled trial protocol.

AIM: To evaluate the effectiveness of a bundled self-management intervention (Taking control of your phosphate with the 4Ds) to improve phosphate control among adults receiving haemodialysis. BACKGROUND: Hyperphosphataemia occurs in end-stage kidney disease and is associated with increased morbidity and mortality. While hyperphosphataemia can be managed through four methods (food, drinks, drugs and dialysis) adherence to these methods is challenging for patients. Studies also tend to focus on one method of phosphate control rather than bundling all methods together into a theoretically driven intervention. DESIGN: A multisite cluster randomized controlled trial with repeated measures. METHODS: Adults receiving haemodialysis with high serum phosphate levels (>1.6 millimoles per litre for at least 3 months) will be cluster randomized to standard care or intervention according to haemodialysis treatment shift. Informed by social cognitive theory, the intervention focuses on improving self-efficacy and incorporates the "teach-back" method of patient education. The intervention brings together essential phosphate control strategies of diet, drinks, drugs (phosphate binders) and dialysis prescription in a 12-week self-management education programme. The primary outcome is serum phosphate level. Secondary outcomes are knowledge of and adherence to phosphate control strategies and self-efficacy for managing kidney disease. DISCUSSION: Efforts to improve phosphate control have been undertaken although the optimal approach remains unclear. This study will make an important contribution to building an evidence base of phosphate control nursing intervention that can be delivered during routine haemodialysis. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry Number ACTRN12617000703303.

Person-centred care in chronic kidney disease: a cross-sectional study of patients' desires for self-management support.

BACKGROUND: People with chronic kidney disease (CKD) must self-manage their illness to assist with slowing disease-progression, but this is a complex task requiring support from healthcare professionals. Despite the established importance of person-centred care, people with CKD are rarely consulted regarding their desires for self-management support (SMS). METHODS: A cross-sectional survey was conducted face-to-face in a Queensland primary care clinic and distributed Australia-wide via an online interface promoted by Kidney Health Australia during 2015. Participants were ≥18 years old and had a self-reported doctor's diagnosis of CKD (any stage; N = 97). The survey was based upon existent literature which identified 10 areas that those with CKD believe require additional support. Descriptive data were generated and Mann-Whitney U tests were performed to compare the desires of different groups of participants. RESULTS: Of the 97 participants, 36 completed a hardcopy survey in clinic, and 61 completed the online version. Just over half (60.8%) were female, age ranged from 16-89 (M = 56.44), and time since diagnosis ranged from just diagnosed to 60 years (Mdn = 8.08 years). Strong interest in receiving additional support across all 10 areas was reported (Mdns = 8.00-10.00), with "keeping a positive attitude and taking care of mental and physical health" receiving the highest rating. Those who were: younger (p < .001); more highly educated (p < .001); working (p < .001); diagnosed longer ago (p = .015); and women (p = .050) expressed stronger overall desire for additional support. CONCLUSIONS: In addition to information about CKD and medications, everyday strategies ought to be prioritised in patient education. Varying levels of engagement and eagerness to learn more about self-management highlight the need for a person-centred approach to SMS.

Towards a symptom cluster model in chronic kidney disease: A structural equation approach.

AIMS: The aim of this study was to test a symptom cluster model in chronic kidney disease patients based on the Theory of Unpleasant Symptoms, accounting for the relationships between influencing factors, symptom experience and consequences for quality of life. BACKGROUND: The evaluation of symptom clusters is a new field of scientific inquiry directed towards more focused symptom management. Yet, little is known about relationships between symptom clusters, predictors and the synergistic effect of multiple symptoms on outcomes. DESIGN: Cross-sectional. METHODS: Data were collected from 436 patients with advanced stages of chronic kidney disease during July 2013-February 2014 using validated measures of symptom burden and quality of life. Analysis involved structural equation modelling. RESULTS: The final model demonstrated good fit with the data and provided strong evidence for the predicted relationships. Psychological distress, stage of chronic kidney disease and age explained most of the variance in symptom experience. Symptom clusters had a strong negative effect on quality of life, with fatigue, sexual symptoms and restless legs being the strongest predictors. Overall, the model explained more than half of the deterioration in quality of life. However, a reciprocal path between quality of life and symptom experience was not found. CONCLUSIONS: Interventions targeting symptom clusters could greatly improve quality of life in patients with chronic kidney disease. The symptom cluster model presented has important clinical and heuristic implications, serving as a framework to encourage and guide new lines of intervention research to reduce symptom burden in chronic kidney disease.

Supporting Staff to Identify Residents in Pain: A Controlled Pretest-Posttest Study in Residential Aged Care.

Practical strategies are needed to improve pain awareness among aged care staff and promote a systematic approach to pain identification using evidence-based tools. The purpose of this study was to evaluate a pain identification tool for use by nursing and nonprofessional staff in residential aged care facilities (RACFs). A controlled pretest-posttest intervention design was conducted in two RACFs in Brisbane, Australia. Completed surveys were returned by 216 staff and 74 residents at baseline and 218 staff and 94 residents at 3-month follow-up. Chart audits were conducted on 308 residents at baseline and 328 at follow-up. Groups were compared on: (1) staff knowledge and attitudes regarding pain, perceived confidence and skills for pain assessment, and perceived quality of pain management; (2) frequency of pain assessments and use of pain interventions; and (3) residents' perceptions of the quality of pain management. Both groups had high knowledge scores and reported high levels of confidence, skills, and perceived quality of pain management at baseline and follow-up. The intervention group showed significant improvement in routine pain assessment and use of nonpharmacological pain interventions. However, due to unexpected changes in control group conditions, both groups increased episodic pain assessment. Overall, staff believed the intervention was clinically useful and fostered a team approach to pain assessment. We found the introduction of pain identification resources with implementation strategies to support frontline staff was partially effective in improving staff and resident outcomes. Nonetheless, our findings confirm the need for change and importance of translational pain research in RACFs.

Multidimensional symptom clusters: an exploratory factor analysis in advanced chronic kidney disease.

AIMS: To explore the existence of symptom clusters in advanced chronic kidney disease. BACKGROUND: People with chronic kidney disease commonly report multiple symptoms. However, the complex relationships among these symptoms are still poorly understood. DESIGN: Cross-sectional. METHODS: A total of 436 people with stage 4 and 5 chronic kidney disease were recruited from three tertiary hospitals during 2013-2014. Participants completed the Chronic Kidney Disease-Symptom Burden Index that assesses four symptom dimensions (occurrence, distress, severity and frequency) of 32 symptoms. Exploratory factor analysis was used to identify symptom clusters across each symptom dimension. Core symptoms in each cluster were determined based on stability across dimensions and clinical plausibility. A high cutoff of 0·50 for factor loading was used for all analyses. RESULTS: Five symptom clusters were consistently identified across all symptom dimensions: fluid volume symptoms, neuromuscular symptoms, gastrointestinal symptoms, sexual symptoms and psychological symptoms. Overall, clusters ranged from 2-10 symptoms. Several symptoms were also interconnected with multiple clusters. Fatigue cross-loaded on all five clusters, whereas sleep disturbance and restless leg symptoms cross-loaded across three clusters. CONCLUSIONS: Adopting a symptom cluster approach has the potential to significantly advance symptom assessment and nursing care for people in advanced stages of chronic kidney disease. Routine clinical assessment and management strategies targeted at the cluster level should have synergistic effects in reducing symptoms. Fatigue is a pervasive symptom in advanced chronic kidney disease that is interconnected with global symptom burden, suggesting better management of symptom clusters may also reduce fatigue.

Nursing physical assessment for patient safety in general wards: reaching consensus on core skills.

AIMS AND OBJECTIVES: To determine consensus across acute care specialty areas on core physical assessment skills necessary for early recognition of changes in patient status in general wards. BACKGROUND: Current approaches to physical assessment are inconsistent and have not evolved to meet increased patient and system demands. New models of nursing assessment are needed in general wards that ensure a proactive and patient safety approach. DESIGN: A modified Delphi study. METHODS: Focus group interviews with 150 acute care registered nurses at a large tertiary referral hospital generated a framework of core skills that were developed into a web-based survey. We then sought consensus with a panel of 35 senior acute care registered nurses following a classical Delphi approach over three rounds. Consensus was predefined as at least 80% agreement for each skill across specialty areas. RESULTS: Content analysis of focus group transcripts identified 40 discrete core physical assessment skills. In the Delphi rounds, 16 of these were consensus validated as core skills and were conceptually aligned with the primary survey: (Airway) Assess airway patency; (Breathing) Measure respiratory rate, Evaluate work of breathing, Measure oxygen saturation; (Circulation) Palpate pulse rate and rhythm, Measure blood pressure by auscultation, Assess urine output; (Disability) Assess level of consciousness, Evaluate speech, Assess for pain; (Exposure) Measure body temperature, Inspect skin integrity, Inspect and palpate skin for signs of pressure injury, Observe any wounds, dressings, drains and invasive lines, Observe ability to transfer and mobilise, Assess bowel movements. CONCLUSIONS: Among a large and diverse group of experienced acute care registered nurses consensus was achieved on a structured core physical assessment to detect early changes in patient status. RELEVANCE TO CLINICAL PRACTICE: Although further research is needed to refine the model, clinical application should promote systematic assessment and clinical reasoning at the bedside.

Nursing and Medical Perceptions of a Hospital Rapid Response System: New Process But Same Old Game?

Perhaps no other patient safety intervention depends so acutely on effective interprofessional teamwork for patient survival than the hospital rapid response system. Yet, little is known about nurse-physician relationships when rescuing at-risk patients. This study compared nursing and medical staff perceptions of a mature rapid response system at a large tertiary hospital. Findings indicate that the rapid response system may be failing to address a hierarchical culture and systems-level barriers to early recognition and response to patient deterioration.