Exploring the early-stage implementation of a patient engagement support intervention in an integrated-care context-A qualitative study of a participatory process.

AIMS AND OBJECTIVES: To explore: (a) the usual patient education in different care services of an integrated-care organisation, (b) the healthcare professionals' experiences with adding a patient engagement support intervention called PHEinAction in the patient education practice and (c) the co-designed activities to assist the implementation. BACKGROUND: Including individual support for engaging patients in care into patient education practice is a key effort of integrated-care organisations. However, there is a paucity of studies exploring the implementation of similar efforts. DESIGN AND METHODS: We conducted a qualitative study of a participatory process with 26 healthcare professionals-mostly nurses (n = 22) with leading roles (n = 12)-of different care services in one Italian integrated-care organisation. Data were collected through multiple sources (observations and shadowing; interviews; documents/artefacts; workshops) during the first 6 months of the implementation of PHEinAction. A thematic analysis using a hybrid approach was performed. COREQ guidelines were followed. RESULTS: The existing patient education practice of hospital, ambulatory and community healthcare services of the organisation differed in contents, perceived responsibility and focus area. These key aspects of patient education influenced the healthcare professionals' experiences with the implementation. The experiences informed the activities enacted during the participatory process to assist the implementation, from the co-creation of artefacts to the deployment of peer group supervision. CONCLUSION: The implementation of a brief intervention for patient engagement support required a process of adjustment to the single settings and a continuous support to healthcare professionals. It also required performing complementary activities to assist the implementation and its adoption in new care services. RELEVANCE TO CLINICAL PRACTICE: This qualitative study contributes to the understanding of the pitfalls and strategies that may surround embedding patient engagement support in the educational practice of complex organisations, potentially facilitating the deployment to other care settings.

Enzymatic resolution of α-methyleneparaconic acids and evaluation of their biological activity.

Both enantiomers of three biologically relevant paraconic acids-MB-3, methylenolactocin, and C75-were obtained with enantioselectivities up to 99% by kinetic enzymatic resolutions. Good enantiomeric excesses were obtained for MB-3 and methylenolactocin, using α-chymotrypsin and aminoacylase as enantiocomplementary enzymes, while C75 was resolved with aminoacylase. They all were evaluated for their antiproliferative, antibacterial, and antifungal activities, showing weak effects and practically no difference between enantiomers in each case. At high concentrations (16-64 µg/mL), (-)- C75 acted as an antimicrobial agent against Gram-positive bacteria.

Synthesis, enzymatic resolution, and stereochemical characterization of isoparaconic acid derivatives: a combined experimental and theoretical investigation.

Enantiomerically enriched isoparaconic acid derivatives were obtained by kinetic enzymatic resolution. To explain the solvent dependence observed for their optical rotatory power a computational investigation of their chiroptical properties was performed.

On the absolute configuration of chiral 1,4-dihydropyridazines synthesized by organocatalysed reactions.

A computational investigation of the specific optical rotation and of the electronic circular dichroism spectra of two chiral 1,4-dihydropyridazines was performed and compared with existing experimental data to verify a previous assignment of their absolute configuration based on a well-accepted mechanism of catalysis of the organocatalyst used in their synthesis. Both the optical rotation and circular dichroism calculations indicate that the absolute configuration is opposite to the one assigned on the basis of the mechanism originally assumed. An alternative reaction mechanism is therefore suggested.

[What are the alternatives to restraints in clinical practice? Results of a multicentre study]. / Quali alternative alle contenzioni fisiche sono applicate nella pratica quotidiana? Risultati di uno studio multi-metodo multicentrico.

. What are the alternatives to restraints in clinical practice? Results of a multicentre study. INTRODUCTION: Physical restraint is still very widespread and debated due to its implications; however, available literature focuses on prevention, neglecting recommendations on possible alternatives. OBJECTIVE: To explore whether and which alternatives nurses apply before deciding to restrain patients. METHOD: A two-phase multi-centre multi-method study was performed. In the first, a prevalence survey on restraints was conducted; in the second, a short interview was carried out with the nurses responsible for the care of restrained individuals to identify the alternatives implemented before deciding to restrain. RESULTS: 37 facilities in Friuli-Venezia Giulia region were included, 17 Nursing Homes (NHs), 10 Intermediate Units (IUs) and 10 Medical/Surgical wards. On the index day 1818 (78.2%) patients were present in the NHs, 157 in the IUs (6.8%) and 308 in the hospital wards (13.3%) (= 2283). A total of 28.9% (659/2283) patients were restrained (31.3% in NHs; 26.8% in IUs; 15.6% in hospitals). Only for 81 (12.3%) of them the restraints had been preceded by the application of an alternative (e.g., involving family members, lowering the bed, or using pillows). DISCUSSION: In the physical restrain decision-making process, nurses consider few alternatives, approximately one in every eight restraints, more frequently in IUs, less in NHs and never in hospital wards. Those used are simple, and depend on the context and the resources available.

First chemoenzymatic synthesis of (+)-2-carboxypyrrolidine-3-acetic acid, the nucleus of kainoid amino acids.

The distinctive nucleus of kainoid amino acids, (2S,3R)-(+)-2-carboxypyrrolidine-3-acetic acid 6, was synthesized by a chemoenzymatic process, exploiting the diastereomeric cis/trans methyl pyroglutamate derivatives 10a-c/11a-c as key intermediates. These mixtures, when subjected to a kinetic resolution mediated by α-chymotrypsin, reacted diastereo-, regio-, and enantioselectively to give the trans derivatives (+)-10a-c possessing the correct (2S,3R) configuration. Subsequently, the desired product (2S,3R)-(+)-6 could be obtained after well-established transformations.

Optically active α-phenylethylamine as efficient organocatalyst in the solvent-free reactions between 2,3-butanedione and conjugated nitroolefins.

(R)-(+) and (S)-(-)-1-phenylethylamine have been shown to promote highly diastereoselective and complementary enantioselective formal [3 + 2]carbocyclization reactions between 2,3-butanedione and conjugated nitroalkenes with formation of enantiomerically rich 2-hydroxy-3-nitrocyclopentanone derivatives. The reactions were carried out both in solvent and under solvent-free conditions. The absolute configurations of the products were assigned by X-ray and circular dichroism spectra analyses.

[Emerging ethical issues in clinical practice: a regional survey]. / Questioni etiche emergenti nella pratica clinica: risultati di un'indagine regionale.

. Emerging ethical issues in clinical practice: a regional survey. INTRODUCTION: In 2016, the Friuli Venezia Giulia Region established the Clinical Ethics Committees in every health agency of the Region. To initiate a proactive way of "doing ethics" giving voice to those who face clinical-ethical problems, a survey was carried out in six health agencies. AIM: To identify the most relevant ethical issues. METHODS: Survey through self-administered questionnaires, which explore: a) the ethical dimension of work in health care; b) situations of potential moral conflict; c) death and dying; (d) how ethical issues are handled and the role of ethic committees. RESULTS: 2.774 questionnaires were collected. Almost all respondents (97%) consider ethics an integral dimension of the health profession; 35% report a lack of education on bioethic issues. Behaviors that generated moral suffering (lack of respect of patients as persons 43%; aggressive medical treatment 29%). End-of-life ethical issues were the most controversial wellas the discharge of not self-sufficient patients without a social network. Restraints use was a source of conflict; receive education on; 60% of health professionals did receive education on death and dying death and dying; 51% felt inadequate in dealing with these issues. Only 8% referred to use ethical advice. CONCLUSIONS: Ethical Committees could play a role in fostering debate, proposing methods for detecting, describing and analysing ethical dilemmas, to supporting professionals in difficult clinical choices.

Between Restrictive and Supportive Devices in the Context of Physical Restraints: Findings from a Large Mixed-Method Study Design.

Physical restraints are still a common problem across healthcare settings: they are triggered by patient-related factors, nurses, and context-related factors. However, the role of some devices (e.g., bed rails), and those applied according to relatives'/patients' requests have been little investigated to date. A mixed-method study in 2018, according to the Good Reporting of a Mixed Methods Study criteria was performed. In the quantitative phase, patients with one or more physical restraint(s) as detected through observation of a single index day in 37 Italian facilities (27 long-term, 10 hospital units, =4562 patients) were identified. Then, for each patient with one or more restraint(s), the nurse responsible was interviewed to gather purposes and reasons for physical restraints use. A thematic analysis of the narratives was conducted to (a) clarify the decision-making framework that had been used and (b) to assess the differences, if any, between hospital and long-term settings. The categories 'Restrictive' and 'Supportive' devices aimed at 'Preventing risks' and at 'Promoting support', respectively, have emerged. Reasons triggering 'restrictive devices' involved patients' risks, the health professionals' and/or the relatives' concerns. In contrast, the 'supportive' ones were triggered by patients' problems/needs. 'Restrictive' and 'Supportive' devices were applied based on the decision of the team or through a process of shared decision-making involving relatives and patients. According to the framework that emerged, long-term care patients are at increased risk of being treated with 'restrictive devices' (Odds Ratio 1.87, Confidence Interval 95% 1.44; 2.43; p < 0.001) as compared to those hospitalized. This study contributes to the improvement in knowledge of the definition, classification and measurement of physical devices across settings.

Efficient chemoenzymatic synthesis of chiral pincer ligands.

Chiral, nonracemic pincer ligands based on the 6-phenyl-2-aminomethylpyridine and 2-aminomethylbenzo[h]quinoline scaffolds were obtained by a chemoenzymatic approach starting from 2-pyridyl and 2-benzoquinolyl ethanone. In the enantiodifferentiating step, secondary alcohols of opposite absolute configuration were obtained by a baker's yeast reduction of the ketones and by lipase-mediated dynamic kinetic resolution of the racemic alcohols. Their transformation into homochiral 1-methyl-1-heteroarylethanamines occurred without loss of optical purity, giving access to pincer ligands used in enantioselective catalysis.

Fertilizing a Patient Engagement Ecosystem to Innovate Healthcare: Toward the First Italian Consensus Conference on Patient Engagement.

Currently we observe a gap between theory and practices of patient engagement. If both scholars and health practitioners do agree on the urgency to realize patient engagement, no shared guidelines exist so far to orient clinical practice. Despite a supportive policy context, progress to achieve greater patient engagement is patchy and slow and often concentrated at the level of policy regulation without dialoguing with practitioners from the clinical field as well as patients and families. Though individual clinicians, care teams and health organizations may be interested and deeply committed to engage patients and family members in the medical course, they may lack clarity about how to achieve this goal. This contributes to a wide "system" inertia-really difficult to be overcome-and put at risk any form of innovation in this filed. As a result, patient engagement risk today to be a buzz words, rather than a real guidance for practice. To make the field clearer, we promoted an Italian Consensus Conference on Patient Engagement (ICCPE) in order to set the ground for drafting recommendations for the provision of effective patient engagement interventions. The ICCPE will conclude in June 2017. This document reports on the preliminary phases of this process. In the paper, we advise the importance of "fertilizing a patient engagement ecosystem": an oversimplifying approach to patient engagement promotion appears the result of a common illusion. Patient "disengagement" is a symptom that needs a more holistic and complex approach to solve its underlined causes. Preliminary principles to promote a patient engagement ecosystem are provided in the paper.

An Educational Intervention to Train Professional Nurses in Promoting Patient Engagement: A Pilot Feasibility Study.

Introduction: Growing evidence recognizes that patients who are motivated to take an active role in their care can experience a range of health benefits and reduced healthcare costs. Nurses play a critical role in the effort to make patients fully engaged in their disease management. Trainings devoted to increase nurses' skills and knowledge to assess and promote patient engagement are today a medical education priority. To address this goal, we developed a program of nurse education training in patient engagement strategies (NET-PES). This paper presents pilot feasibility study and preliminary participants outcomes for NET-PES. Methods: This is a pilot feasibility study of a 2-session program on patient engagement designed to improve professional nurses' ability to engage chronic patients in their medical journey; the training mainly focused on passing patient engagement assessment skills to clinicians as a crucial mean to improve care experience. A pre-post pilot evaluation of NET-PES included 46 nurses working with chronic conditions. A course specific competence test has been developed and validated to measure patient engagement skills. The design included self-report questionnaire completed before and after the training for evaluation purposes. Participants met in a large group for didactic presentations and then they were split into small groups in which they used role-play and case discussion to reflect upon the value of patient engagement measurement in relation to difficult cases from own practice. Results: Forty-six nurses participated in the training program. The satisfaction questionnaire showed that the program met the educational objectives and was considered to be useful and relevant by the participants. Results demonstrated changes on clinicians' attitudes and skills in promoting engagement. Moreover, practitioners demonstrated increases on confidence regarding their ability to support their patients' engagement in the care process. Conclusions: Learning programs teaching nurses about patient engagement strategies and assessment measures in clinical practice are key in supporting the realization of patient engagement in healthcare. Training nurses in this area is feasible and accepted and might have an impact on their ability to engage patients in the chronic care journey. Due to the limitation of the research design, further research is needed to assess the effectiveness of such a program and to verify if the benefits envisaged in this pilot are maintained on a long-term perspective and to test results by employing a randomized control study design.