Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review.

BACKGROUND: Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom. METHODS: This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. RESULTS: Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics. CONCLUSIONS: Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups. STUDY REGISTRATION: This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

An examination of relational dynamics of power in the context of supported (assisted) decision-making with older people and those with disabilities in an acute healthcare setting.

INTRODUCTION: Supported (assisted) healthcare decision-making (ADM) focuses attention on how people with disabilities, including cognitive impairments, can be best supported to make decisions about their health and social care on an equitable basis with others. Meaningful implementation of legal frameworks for ADM challenges long-held presumptions about who has access to valued decision-making resources, influence and power within a particular socio-cultural setting. This study aims to explore the relational power dynamics around ADM with older people in acute care settings. METHODS: This study adopts a critical hermeneutic approach to qualitatively explore the lived experience of ADM from the perspectives of Health and Social Care Professionals (N = 26). This is supported by an exploration of the experiences of older people (N = 4), older people with a diagnosis of dementia (N = 4) and family carers (N = 5). RESULTS: We present three themes of data analysis that represent three spaces where the relational aspects of power in ADM are manifested. The first space, centralising decision-making power within multidisciplinary teams identified the privileging of physicians in traditional hierarchical leadership models that may lead to the implicit exclusion of family carers and some Health and Social Care Professionals in the ADM process. Privileging cognitive and communication competence identified a tendency to attribute decision-making autonomy to those with cognitive and communication competency. The final space, balancing the duty of care and individual autonomy, recognises acute care settings as typically risk-averse cultures that limit autonomy for decisions that carry risk, especially for those with cognitive impairment. CONCLUSION: Findings indicate the need to address cultural sources of power operating through social norms premised on ageist and ableist ideologies. It is necessary to challenge institutional barriers to meaningful ADM including positional power that is associated with hierarchies of influence and protectionism. Finally, meaningful ADM requires resistance to the disempowerment created by structural, economic and social circumstances which limit choices for decision-making. PATIENT OR PUBLIC CONTRIBUTION: A public and patient involvement panel of older people were consulted in the development of the grant application (HRB: APA-2016-1878). Representatives from Alzheimer's Society Ireland and Family Carers Ireland were steering committee members guiding design and strategy.

Parents' perspectives on reasonable adjustments in acute healthcare for people with intellectual disability: A qualitative descriptive study.

AIM: To describe parents' perspectives on reasonable adjustments in acute healthcare for people with intellectual disability (ID). BACKGROUND: People with ID are vulnerable in terms of their health needs and marginalized when accessing and utilizing acute healthcare services. Reasonable adjustments are positive measures that can help alleviate health disparities. However, despite significant research advocating their use, evidence of implementation of reasonable adjustments in acute healthcare practice is limited. DESIGN: A qualitative descriptive study. METHODS: Qualitative semi-structured interviews were conducted with six parents of children with ID, who had accessed and used acute healthcare services. The interviews were conducted between January and May 2022, audio-recordings were transcribed and thematically analysed. RESULTS: Parents described limited or no experiences of reasonable adjustments when accessing or utilizing acute healthcare services for their children. The findings are captured in three themes; describing the reality, understanding the impact and signposting the future. The findings highlight a lack of implementation of reasonable adjustments in acute healthcare which negatively impacts the experience of all stakeholders. CONCLUSION: There is a pressing need for reasonable adjustments to be implemented at a strategic level across acute healthcare services, so that people with ID and their families can access person-centred acute healthcare when needed. IMPACT: The research findings will inform researchers interested in reasonable adjustments and implementation research, and those interested in advocating for the rights of people with ID. REPORTING METHOD: This study adhered to the Equator research reporting checklist: Consolidated criteria for reporting qualitative research: a 32-item checklist for interviews and focus groups. PATIENT OR PUBLIC CONTRIBUTION: A parent of a child with an ID was part of the research team informing the design, data collection, data analysis and write-up of this article.

Hospital at home for acute medical illness: The 21st century acute medical unit for a changing population.

Recent trends across Europe show a year-on-year increase in the number of patients with acute medical illnesses presenting to hospitals, yet there are no plans for a substantial expansion in acute hospital infrastructure or staffing to address demand. Strategies to meet increasing demand need to consider the fact that there is limited capacity in acute hospitals and focus on new care models in both hospital and community settings. Increasing the efficiency of acute hospital provision by reducing the length of stay entails supporting acute ambulatory care, where patients receive daily acute care interventions but do not stay overnight in the hospitals. This approach may entail daily transfer between home and an acute setting for ongoing treatment, which is unsuitable for some patients living with frailty. Acute hospital at home (HaH) is a care model which, thanks to advances in point of care diagnostic capability, can provide a credible model of acute medical assessment and treatment without the need for hospital transfer. Investment and training to support scaling up of HaH are key strategic aims for integrated healthcare systems.

Impact of home healthcare on end-of-life outcomes for people with dementia: a systematic review.

BACKGROUND: Home healthcare (HHC) comprises clinical services provided by medical professionals for people living at home with various levels of care needs and health conditions. HHC may reduce care transitions from home to acute hospitals, but its long-term impact on homebound people living with dementia (PLWD) towards end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD. METHODS: Design: Systematic review of quantitative and qualitative original studies which examine the association between HHC and targeted outcomes. INTERVENTIONS: HHC. PARTICIPANTS: At least 80% of study participants had dementia and lived at home. MEASUREMENTS: Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included hospice palliative care, advance care planning, continuity of care, and place of death. We briefly reviewed selected national policy to provide contextual information regarding these outcomes. RESULTS: From 6831 articles initially identified, we included five studies comprising data on 4493 participants from USA, Japan, and Italy. No included studies received a "high" quality rating. We synthesised core properties related to HHC at three implementational levels. Micro-level: HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. HHC may increase palliative care referrals. Advance care planning was an important factor influencing end-of-life outcomes. Meso-level: challenges for HHC providers in medical decision-making and initiating palliative care for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is highlighted but not well examined. Macro-level: reforms of national policy or financial schemes are found in some countries but the effects are not clearly understood. CONCLUSIONS: This review highlights the dearth of dementia-specific research regarding the impact of HHC on end-of-life outcomes. Effects of advance care planning during HHC, the integration between health and social care, and coordination between primary HHC and specialist geriatric/ palliative care services require further investigation.

The components of personal passports for people living with dementia in an acute healthcare setting: an integrative review.

AIM: To explore the components of personal passports for people living with dementia in an acute healthcare setting. BACKGROUND: Globally, supporting people with dementia poses a prominent health and social care challenge. Importance for people with dementia in an acute healthcare setting includes social relationships and communication with healthcare staff. A personal passport is an international initiative designed to support the personhood of the person living with dementia. METHODS: This integrative review is based on the methodology of Whittmore and Knafl (2005). The Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist were adhered to. A database search of PubMed, MEDLINE, CINAHL, Scopus and EBSCO databases was systematically performed. RESULTS: This integrative review identified nine research studies on the components of personal passports that met the inclusion and exclusion criteria. A constant comparative method of data analysis identified five key pivotal themes: person-centredness, communication, family/carer involvement, education and leadership. CONCLUSION: The use of personal passports supports the provision of person-centred care for people living with dementia through enhancing the well-being of both the person and their families/caregivers. RELEVANCE TO CLINICAL PRACTICE: Personal passports are an important document and should be determined by the person with dementia, their care needs and the caregiver's role in meeting these needs.

Postoperative duration of opioid use and acute healthcare services use in cancer patients hospitalized for thoracic surgery.

BACKGROUND: Postoperative pain control is an important cancer care component. However, opioid consumption has resulted in a surge of adverse events, with thoracic surgery patients having the highest rate of persistent use. The effect of opioid duration post-discharge and the risk of increased acute healthcare use in this population remains unclear. METHODS: A prospective cohort of non-metastatic cancer patients was assembled from an academic health center in Montreal (Canada). Clinical data linked to administrative claims from the universal healthcare program was used to determine the association between time-varying opioid patterns and emergency department (ED) visits/re-admissions/death 3 months following thoracic surgery. RESULTS: Of the 610 patients, 77% had at least one opioid dispensed post-discharge. Compared to non-opioid users, <15 days of use was associated with a 42% decreased risk of acute healthcare events, adjusted HR 0.58, 95% CI (0.40-0.85); longer durations were not associated with an increased risk. Compared to short-term use (<15 days), use of >30 days was associated with a 72% increased risk of the outcome, aHR: 1.72, 95% CI (1.01-2.93). CONCLUSION: There was a variation in the risk of acute healthcare use associated with postsurgical opioid use. Findings from this study may be used to inform postoperative prescribing practices.

Advancing towards contemporary practice: a systematic review of organisational performance measures for non-acute health charities.

BACKGROUND: Organisational performance measurement is a recognised business management tool and essential for survival and success. There is a paucity of methodological studies of organisational performance measurement relating to non-acute healthcare charities and this study is the first to suggest a set of evidence-informed organisational performance measures for the sector. METHODS: This study was designed using a two-staged approach. A systematic review of peer-reviewed journal literature between 2003 and 2016 was conducted according to the twenty-seven (27) point checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) complemented by a thematic analysis of eligible data using a cutting and sorting technique to generate a set of common measures of organisational performance for non-acute health charities. RESULTS: Not one study was found relating to organisational performance of non-acute healthcare charities however four records met eligibility criteria relating to non-acute or primary healthcare services with charitable fundraising capability. Three were case studies of specific organisations that related their approach to organisational performance measurement, while the fourth compared a case study organisation to a public service. Three different organisational performance frameworks and 20 organisational performance measures were used across the four studies. CONCLUSIONS: The study concluded that (1) demonstration of organisational performance is relevant to non-acute health charities; (2) organisational performance measurement is feasible in this sector; (3) an evidence-based organisational performance measurement framework for the sector has not yet been developed nor has an existing organisational performance measurement framework been adapted for the sector, although the Balanced Scorecard is likely to be an effective option and (4) five leading measures - Quality of Service; Finance; Stakeholders (Customers and Clients); People and Culture; and Governance and Business Management; could be used to determine organisational performance in these sectors. Finally, 'Mission and Purpose' could be explored as a potential measure. Further research to understand why there is such limited published organisational performance evidence for the sector could be useful. Case studies of organisational measurement strategies of successful non-acute healthcare charities and research into important factors for organisational performance implementation in the sector may contribute to greater uptake and knowledge dissemination.

Screening for hand dermatitis in healthcare workers: Comparing workplace screening with dermatologist photo screening.

BACKGROUND: Healthcare workers are at increased risk for occupational contact dermatitis, owing to wet work exposure. Early detection and management improves outcomes. Although several diagnostic tools are available, none is appropriate for rapid screening. OBJECTIVES: To assess the validity and feasibility of the Hand Dermatitis Screening Tool in the acute healthcare sector. METHODS: Screening of 508 employees at three hospitals in Ontario, Canada was performed with the Hand Dermatitis Screening Tool either by an occupational health nurse (N = 225) or by self-administration (N = 283). Two occupational dermatologists rated photographs of participants' hands. RESULTS: Of the participants, 30.5% screened positive for hand dermatitis. A positive screen was associated with wet work, history of eczema, dermatitis, or other rash, and currently having a rash. Ninety-four per cent of participants reported that using the tool took <2 minutes, 99% indicated that the tool was easy to use, and 86% stated that workplace screening was very important. Workplace and dermatologist photo screening showed fair agreement. CONCLUSIONS: The prevalence of hand dermatitis and identified risk factors were consistent with the literature. These findings, along with positive feasibility results, support further testing of the tool despite only fair agreement between workplace and dermatologist screening.

Evaluating patient experiences in decentralised acute care using the Picker Patient Experience Questionnaire; methodological and clinical findings.

BACKGROUND: Decentralised acute care services have, through the establishment of municipality acute wards (MAWs), been launched in Norway. The aim is to provide treatment for patients who otherwise would need hospitalisation. Currently there is a lack of studies investigating patient experiences in such services. The aims of this study were therefore to a) translate and validate the Picker Patient Experience Questionnaire (PPE-15) in Norwegian, and b) assess patient experiences in decentralised acute care, and potential factors associated with these experiences. METHODS: Patients were recruited from five municipal acute wards in southeastern Norway during the period from June 2014 to June 2015. Data on socio-demographics, length of stay and comorbidity (Charlson comorbidity index (CCI)) were collected. Patients completed the Picker Patient Experience Questionnaire (PPE-15) and the EuroQOL 5-dimension, 3-level version. Convergent validity of the PPE-15 was assessed by correlation of items in PPE-15 and the Nordic Patient Experience Questionnaire (NORPEQ). A retest of the PPE-15 was performed in a subgroup of patients approximately 3 weeks after baseline assessment. Test-retest agreement was assessed with Cohens' unweighted Kappa. RESULTS: A total of 479 patients responded, median age 78.0 years and 41.8% men. A total of 68 patients participated in the retest. Testing of convergent validity revealed an overall weak to moderate correlation. Kappa statistics showed from fair to good test-retest agreement. Most problems were related to continuity and transition, while fewest problems were related to respect for patient preferences. A higher Charlson comorbidity score was the only variable that was negatively associated with patient experience. CONCLUSION: Patients reported problems in several items of the PPE-15 after discharge from decentralised acute wards. The findings from the current study may be helpful for planning ways to improve quality of care, e.g., by providing feedback to healthcare personnel or by using patient experience as a quality indicator.

A qualitative study of patient experiences of decentralized acute healthcare services.

OBJECTIVE: Municipality acute wards (MAWs) have recently been launched in Norway as an alternative to hospitalizations, and are aimed at providing treatment for patients who otherwise would have been hospitalized. The objective of this study was to explore how patients normally admitted to hospitals perceived the quality and safety of treatment in MAWs. DESIGN: The study had a qualitative design. Thematic analysis was used to analyze the data. SETTING: The study was conducted in a county in south-eastern Norway and included five different MAWs. PATIENTS: Semi-structured interviews were conducted with 27 participants who had required acute health care and who had been discharged from the five MAWs. RESULTS: Three subthemes were identified that related to the overarching theme of hospital-like standards ("almost a hospital, but…"), namely (a) treatment and competence, (b) location and physical environment, and (c) adequate time for care. Participants reported the treatment to be comparable to hospital care, but they also experienced limitations. Participants spoke positively about MAW personnel and the advantages of having a single patient room, a calm environment, and proximity to home. CONCLUSIONS: Participants felt safe when treated at MAWs, even though they realized that the diagnostic services were not similar to that in hospitals. Geographical proximity, treatment facilities and time for care positively distinguished MAWs from hospitals, while the lack of diagnostic resources was stressed as a limitation. Key points Municipality acute wards (MAWs) have been implemented across Norway. Research on patient perspectives on the decentralization of acute healthcare in MAWs is lacking. • Patients perceive decentralized acute healthcare and treatment as being comparable to the quality they would have expected in hospitals. • Geographical proximity, a home-like atmosphere and time for care were aspects stressed as positive features of the decentralized services. • Lack of diagnostic resources was seen as a limitation.

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation.

BACKGROUND: over the last decade, high demand for acute healthcare services by long-term residents of residential care facilities (RCFs) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include comprehensive care planning, management of inter-current illness and rapid access to acute care substitution services. OBJECTIVE: to evaluate whether the RECIPE service decreased acute healthcare utilisation. DESIGN: a retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment. SETTING: a 300-bed metropolitan teaching hospital in Australia and 73 RCFs within its catchment. SUBJECTS: there were 1,327 patients enrolled in the service with a median age of 84 years; 61% were female. METHODS: data were collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative data set. Primary outcomes change in admission rates, length of stay and bed days per quarter. RESULTS: in the 2 years prior to enrolment, the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (P = 0.046). Prior to enrolment, the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (P = 0.003). CONCLUSIONS: this study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates.

Mortality rate and its determinants among people with dementia receiving home healthcare: a nationwide cohort study.

People with dementia (PwD) who receive home healthcare (HHC) may have distressing symptoms, complex care needs and high mortality rates. However, there are few studies investigating the determinants of mortality in HHC recipients. To identify end-of-life care needs and tailor individualized care goals, we aim to explore the mortality rate and its determinants among PwD receiving HHC. We conducted a retrospective cohort study using a Taiwanese national population database. People with new dementia diagnosis in 2007-2016 who received HHC were included. We calculated the accumulative mortality rate and applied Poisson regression model to estimate the risk of mortality for each variable (adjusted risk ratios, aRR) with a 95% confidence interval (CI). We included 95,831 PwD and 57,036 (59.5%) of them died during the follow-up period (30.5% died in the first-year). Among comorbidities, cirrhosis was associated with the highest mortality risks (aRR 1.65, 95% CI 1.49-1.83). Among HHC-related factors, higher visit frequency of HHC (> 2 versus ≦1 times/month, aRR 3.52, 95% CI 3.39-3.66) and higher level of resource utilization group (RUG, RUG 4 versus 1, aRR = 1.38, 95% CI 1.25-1.51) were risk factor of mortality risk. Meanwhile, HHC provided by physician and nurse was related to reduced mortality risk (aRR 0.79, 95% CI 0.77-0.81) compared to those provided by nurse only. Anticipatory care planning and timely end-of life care should be integrated in light of the high mortality rate among PwD receiving HHC. Determinants associated with increased mortality risk facilitate the identification of high risk group and tailoring the appropriate care goals. Trial registration number: ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.

Taking Care of Business: Privileging Private Sector Hospitals During the COVID Crisis.

In the early days of the COVID crisis, many commentators argued that it presented opportunities for progressive change, notably toward redress of structural inequalities in health. As with the financial slump of 2008, however, such notions have proved almost ridiculously optimistic as it has been capital, through its near symbiosis with the state, that has been best able to respond, with the English government-the devolved nations adopted a markedly different approach-taking every opportunity to ensure the pandemic has proved a bonanza for private-sector healthcare interests. However, this has not just been about individual contracts in, for example, test and trace, vaccination, or personal protective equipment; the crisis has been used to both rescue the private acute market following 2 years of contracted revenues and to provide enormous stimulus for its future growth. This has required the support of several organizations acting in concert, including the NHS Confederation and the Royal Colleges. While the pandemic has served to illuminate such relationships, the author also argues that the oft-recurring governmental praise of the NHS needs to be matched by genuine investment in public hospitals.

Stigmatisation of those with mental health conditions in the acute general hospital setting. A qualitative framework synthesis.

RATIONALE: Patients with long-term mental health conditions often have complex physical, mental, and social needs. They are frequent users of the acute general healthcare system, but can experience stigmatising attitudes and behaviours, and structural discrimination. We wished to improve understanding of stigmatisation in the acute healthcare setting, to target areas for future intervention. OBJECTIVE: A synthesis of qualitative literature was undertaken in order to understand how patients with long-term mental health conditions are stigmatised, or otherwise treated, within the acute healthcare system. METHOD: A theory-driven framework approach was implemented. Existing stigma theory was used to outline a framework for categorizing stigmatising and non-stigmatising phenomena within the acute healthcare system. RESULTS: A systematic literature search of qualitative studies identified a sample of 51 studies that would inform the framework. Using data in these studies, a final theoretical 'best fit' framework was developed. In this framework there is an overarching pattern of labelling and stereotyping, plus five ways in which patients with mental health conditions are stigmatised in the acute healthcare system: devaluation, social control, avoidance, rejection, and failure to act. In addition, the framework outlines positive attitudes and behaviours - valuing, adjustment, responding, legitimising, and positive action - which contrast with the stigmatisation patterns. CONCLUSIONS: The study offers a framework for identifying stigmatisation and positive treatment of those with mental health conditions in an acute health setting. This framework is of potential value in targeting areas for improved quality of care and may have utility beyond this setting and stigmatised group.

What outcomes are associated with developing and implementing co-produced interventions in acute healthcare settings? A rapid evidence synthesis.

BACKGROUND: Co-production is defined as the voluntary or involuntary involvement of users in the design, management, delivery and/or evaluation of services. Interest in co-production as an intervention for improving healthcare quality is increasing. In the acute healthcare context, co-production is promoted as harnessing the knowledge of patients, carers and staff to make changes about which they care most. However, little is known regarding the impact of co-production on patient, staff or organisational outcomes in these settings. AIMS: To identify and appraise reported outcomes of co-production as an intervention to improve quality of services in acute healthcare settings. DESIGN: Rapid evidence synthesis. DATA SOURCES: Medline, Cinahl, Web of Science, Embase, HMIC, Cochrane Database of Systematic Reviews, SCIE, Proquest Dissertation and Theses, EThOS, OpenGrey; CoDesign; The Design Journal; Design Issues. STUDY SELECTION: Studies reporting patient, staff or organisational outcomes associated with using co-production in an acute healthcare setting. FINDINGS: 712 titles and abstracts were screened; 24 papers underwent full-text review, and 11 papers were included in the evidence synthesis. One study was a feasibility randomised controlled trial, three were process evaluations and seven used descriptive qualitative approaches. Reported outcomes related to (a) the value of patient and staff involvement in co-production processes; (b) the generation of ideas for changes to processes, practices and clinical environments; and (c) tangible service changes and impacts on patient experiences. Only one study included cost analysis; none reported an economic evaluation. No studies assessed the sustainability of any changes made. CONCLUSIONS: Despite increasing interest in and advocacy for co-production, there is a lack of rigorous evaluation in acute healthcare settings. Future studies should evaluate clinical and service outcomes as well as the cost-effectiveness of co-production relative to other forms of quality improvement. Potentially broader impacts on the values and behaviours of participants should also be considered.