Family centred care before and during life-sustaining treatment withdrawal in intensive care: a survey of information provided to families by Australasian critical care nurses

BACKGROUND: A core component of family-centred nursing care during the provision of end-of-life care in intensive care settings is information sharing with families. Yet little is known about information provided in these circumstances.

OBJECTIVE: To identify information most frequently given by critical care nurses to families in preparation for and during withdrawal of life-sustaining treatment.

DESIGN: An online cross-sectional survey.

METHODS: During May 2015, critical care nurses in Australia and New Zealand were invited to complete the Preparing Families for Treatment Withdrawal questionnaire. Data analysis included descriptive statistics to identify areas of information most and least frequently shared with families. Cross tabulations with demographic data were used to explore any associations in the data.

RESULTS: From the responses of 159 critical care nurses, information related to the emotional care and support of the family was most frequently provided to families in preparation for and during withdrawal of life-sustaining treatment. Variation was noted in the frequency of provision of information across body systems and their associated physical changes during the dying process. Significant associations (p<0.05) were identified between the variables gender, nursing experience and critical care experiences and some of the information items most and least frequently provided.

CONCLUSIONS: The provision of information during end-of-life care reflects a family-centred care approach by critical care nurses with information pertaining to emotional care and support of the family paramount. The findings of this study provide a useful framework for the development of interventions to improve practice and support nurses in communicating with families at this time.

Family-centred practice : empowerment, self-efficacy, and challenges for practitioners in early childhood education and care

Family-centred practice has been included in the Victoria, Australia Early Years Learning and Development Framework as a key practice principle for professionals working across all early years programs in that state. While this model of partnership for engaging and collaborating with families has long been used in the early intervention sector, the efficacy of adopting this model more widely across the wider early childhood education and care sector has not been explored. This article presents a discussion on family-centred practice as a model for engaging with families in the care and education of their children. Through an analysis of the underlying philosophy and an examination of the core principles and characteristics, the article explores family-centred practice as it sits within a broader theory of partnership. This analysis identifies that while there are essential principles and characteristics that position the model within a partnership framework, it is the notion of empowerment, an underpinning philosophy guiding the model, that adds another dimension to the way practitioners in early childhood education and care settings collaborate with families. In examining the broader early childhood context, the capacity of many early childhood practitioners to effectively implement empowering behaviours is challenged.

Understanding the experience of inpatient rehabilitation: insights into patient-centred care from patients and family members

The aim of the study was describe the experiences, needs and preferences of recent inpatients of a rehabilitation centre, and the needs of their families. Data were collected in four focus groups, two with patients (n = 13) who had recently completed inpatient rehabilitation following an illness, injury or elective surgery, and two with family members (n = 11). During the focus groups, two researchers facilitated discussion on any topic that participants considered important to the experience of inpatient rehabilitation; participants were encouraged to describe their care, needs and preferences. The focus group discussions were audio-taped and transcribed verbatim. Field notes were hand recorded. Data were analysed and collated into themes. Six key themes emerged. Participants wanted: interactions with friendly, empathetic staff; regular contact with senior staff and all staff to introduce themselves by name and profession; timely communication of accurate information; and rehabilitation services seven days a week. The physical environment had both positive and negative effects on patient well-being. Patients with complex or atypical circumstances required special attention to ensure their needs were met. In conclusion, patients and families identified six important issues that need to be considered during inpatient rehabilitation.

Family-based care in chronic illness management

This paper proposes a research programme to develop and evaluate technologies to support family-based care in chronic illness management.

Obesity prevention in the family day care setting : impact of the romp & chomp intervention on opportunities for children's physical activity and healthy eating

Background The Romp & Chomp intervention reduced the prevalence of overweight/obesity in pre-school children in Geelong, Victoria, Australia through an intervention promoting healthy eating and active play in early childhood settings. This study aims to determine if the intervention successfully created more health promoting family day care (FDC) environments.
Methods The evaluation had a cross-sectional, quasi-experimental design with the intervention FDC service in Geelong and a comparison sample from 17 FDC services across Victoria. A 45-item questionnaire capturing nutrition- and physical activity-related aspects of the policy, socio-cultural and physical environments of the FDC service was completed by FDC care providers (in 2008) in the intervention (n = 28) and comparison (n = 223) samples.
Results Select results showed intervention children spent less time in screen-based activities (P = 0.03), organized active play (P < 0.001) and free inside play (P = 0.03) than comparison children. There were more rules related to healthy eating (P < 0.001), more care provider practices that supported children’s positive meal experiences (P < 0.001), fewer unhealthy food items allowed (P = 0.05), higher odds of staff being trained in nutrition (P = 0.04) and physical activity (P < 0.001), lower odds of having set minimum times for outside (P < 0.001) and organized (P = 0.01) active play, and of rewarding children with food (P < 0.001).
Conclusions Romp & Chomp improved the FDC service to one that discourages sedentary behaviours and promotes opportunities for children to eat nutritious foods. Ongoing investment to increase children’s physical activity within the setting and improving the capacity and health literacy of care providers is required to extend and sustain the improvements.

Family day care educators : an exploration of their understanding and experiences promoting children's social and emotional wellbeing

This study aimed to explore family day care (FDC) educators’ knowledge of child social and emotional wellbeing and mental health problems, the strategies used to promote children’s wellbeing, and barriers and opportunities for promoting children’s social and emotional wellbeing. Thirteen FDC educators participated in individual semi-structured interviews. FDC educators were more comfortable defining children’s social and emotional wellbeing than they were in identifying causes and early signs of mental health problems. Strategies used to promote children’s mental health were largely informal and dependent on educator skills and capacities rather than a systematic scheme-wide approach. Common barriers to mental health promotion were limited financial resources, a need for more training and hesitance raising child mental health issues with parents. There is a need to build FDC educators’ knowledge of child social and emotional wellbeing and for tailored mental health promotion strategies in FDC.

Building the capacity of family day care educators to promote children’s social and emotional wellbeing : an exploratory cluster randomised controlled trial

Background: Childhood mental health problems are highly prevalent, experienced by one in five children living in socioeconomically disadvantaged families. Although childcare settings, including family day care are ideal to promote children’s social and emotional wellbeing at a population level in a sustainable way, family day care educators receive limited training in promoting children’s mental health. This study is an exploratory wait-list control cluster randomised controlled trial to test the appropriateness, acceptability, cost, and effectiveness of “Thrive,” an intervention program to build the capacity of family day care educators to promote children’s social and emotional wellbeing. Thrive aims to increase educators’ knowledge, confidence and skills in promoting children’s social and emotional wellbeing.
Methods/Design: This study involves one family day care organisation based in a low socioeconomic area of Melbourne. All family day care educators (term used for registered carers who provide care for children for financial reimbursement in the carers own home) are eligible to participate in the study. The clusters for randomisation will be the fieldworkers (n = 5) who each supervise 10-15 educators. The intervention group (field workers and educators) will participate in a variety of intervention activities over 12 months, including workshops; activity exchanges with other educators; and focused discussion about children’s social and emotional wellbeing during field worker visits. The control group will continue with their normal work practice. The intervention will be delivered to the intervention group and then to the control group after a time delay of 15 months post intervention commencement. A baseline survey will be conducted with all consenting educators and field workers (n = ~70) assessing outcomes at the cluster and individual level. The survey will also be administered at one month, six months and 12 months post-intervention commencement. The survey consists of questions measuring perceived levels of knowledge, confidence and skills in promoting children’s social and emotional wellbeing. As much of this intervention will be delivered by field workers, field worker-family day care educator relationships are key to its success and thus supervisor support will also be measured. All educators will also have an in-home quality of care assessment at baseline, one month, six months and 12 months post-intervention commencement. Process evaluation will occur at one month, six months and 12 months post-intervention commencement. Information regarding intervention fidelity and economics will also be assessed in the survey.
Discussion: A capacity building intervention in child mental health promotion for family day care is an essential contribution to research, policy and practice. This initiative is the first internationally, and essential in building an evidence base of interventions in this extremely policy-timely setting.

Nurses' understanding of patient-centred care in Bhutan

Aim The purpose of the study was to explore nurses' perceptions and understanding of patient-centred care (PCC) in Bhutan. Background Nurses' perceptions and understanding of PCC in Bhutan are unknown. Methods A non-probability convenience sample was taken and a mixed method (quantitative and qualitative descriptive) used. Survey questionnaires were administered to 87 Bhutanese nurses in three types of hospitals -- the National Referral Hospital, the regional referral hospital and the district hospital. Descriptive statistics including frequency distribution, mean and standard deviation (SD) were used for analysis. Spearman's correlation coefficients were used to investigate relationships between demographic variables. Results The nursing labour force in Bhutan knows which behaviours are considered necessary for practising PCC. The mean (SD) rating of behaviours considered critical for practising PCC was 4.29 (0.22), five being the highest score. Bhutanese nurses described PCC, according to qualitative descriptive analysis, as being based on individual patient assessment (22/87 or 25% of respondents), using a holistic model of care (38/87 or 44%) that was based on evidence (38/87 or 44%). A higher level of education (79/87 or 91%) was found to be the main factor that would facilitate the development of PCC, while inadequate staffing, in terms of insufficient numbers of staff and lack of advanced practitioners (56/87 or 64%), was revealed as the main factor that hinders development of PCC. Conclusion Bhutanese nurses believed certain behaviours were critical to PCC. Reform of higher nursing education, putting an emphasis on PCC, would improve nursing practice and increase its scope.

Demonstrable professionalism : linking patient-centred care and revalidation

The move by the Medical Board of Australia to commence a conversation with the medical profession about revalidation reflects that patient-centred care is at the heart of good medical practice. Patients judge their doctors' commitment to them based on whether their individual interactions with doctors meet their needs. We argue that ensuring that doctors are continuing to perform at a level that the community regards as acceptable is a demonstration of an individual doctor's professionalism and thus their commitment to patient-centred care. This impacts on the profession as a whole, which needs to commit to what we call 'demonstrable professionalism' - the ongoing and active demonstration of performance that the community regards as acceptable. This needs to be supported by organisations in which doctors work, reflecting the importance of organisational context to clinical practice. Revalidation processes thus need both to reflect the work of doctors and be meaningful to the community. The move to consider revalidation of doctors by regulatory authorities should not be seen by the profession as a threat, but more as an opportunity to demonstrate the profession's commitment to patient-centred care

Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review

 Background
Provision of high quality transitional care is a challenge for health care providers in many western countries. This systematic review was conducted to (1) identify and synthesise research, using randomised control trial designs, on the quality of transitional care interventions compared with standard hospital discharge for older people with chronic illnesses, and (2) make recommendations for research and practice.

Methods
Eight databases were searched; CINAHL, Psychinfo, Medline, Proquest, Academic Search Complete, Masterfile Premier, SocIndex, Humanities and Social Sciences Collection, in addition to the Cochrane Collaboration, Joanna Briggs Institute and Google Scholar. Results were screened to identify peer reviewed journal articles reporting analysis of quality indicator outcomes in relation to a transitional care intervention involving discharge care in hospital and follow-up support in the home. Studies were limited to those published between January 1990 and May 2013. Study participants included people 60 years of age or older living in their own homes who were undergoing care transitions from hospital to home. Data relating to study characteristics and research findings were extracted from the included articles. Two reviewers independently assessed studies for risk of bias.

Results
Twelve articles met the inclusion criteria. Transitional care interventions reported in most studies reduced re-hospitalizations, with the exception of general practitioner and primary care nurse models. All 12 studies included outcome measures of re-hospitalization and length of stay indicating a quality focus on effectiveness, efficiency, and safety/risk. Patient satisfaction was assessed in six of the 12 studies and was mostly found to be high. Other outcomes reflecting person and family centred care were limited including those pertaining to the patient and carer experience, carer burden and support, and emotional support for older people and their carers. Limited outcome measures were reported reflecting timeliness, equity, efficiencies for community providers, and symptom management.

Conclusions
Gaps in the evidence base were apparent in the quality domains of timeliness, equity, efficiencies for community providers, effectiveness/symptom management, and domains of person and family centred care. Further research that involves the person and their family/caregiver in transitional care interventions is needed.

Fair relationships and policies to support family day care educators’ mental health: a qualitative study

High quality child care is a population health investment that relies on the capacity of providers. The mental health and wellbeing of child care educators is fundamental to care quality and turnover, yet sector views on the relationship between working conditions and mental health and wellbeing are scarce. This paper examines child care educators' and sector key informants' perspectives on how working in family day care influences educator's mental health and wellbeing.

Families' experiences of their interactions with staff in an Australian intensive care unit (ICU): a qualitative study

Nursing is characterised as a profession that provides holistic, person-centred care. Due to the condition of the critically ill, a family-centred care model is more applicable in this context. Furthermore, families are at risk of emotional and psychological distress, as a result of the admission of their relative to intensive care. The families' experiences of their interactions in intensive care have the potential to enhance or minimise this risk. This paper presents a subset of findings from a broader study exploring families of critically ill patients' experiences of their interactions with staff, their environment, the patient and other families, when their relative is admitted to an Australian intensive care unit. By developing an understanding of their experience, nurses are able to implement interventions to minimise the families' distress, while providing more holistic, person- and family-centred care.