Development, reliability and validity of a tool, to measure emergency department clinicians' attitudes towards family presence (FP) during acute deterioration in adult patients.

Despite many studies of family presence during resuscitation, no validated tool exploring the attitudes and beliefs of healthcare staff towards family presence has been published. The aim of this paper is to describe the development of a tool to accurately measure the attitudes and beliefs of emergency department staff towards family presence in the deteriorating adult patient, present the results of validity and reliability testing, and present the final validated tool. Twenty-nine items were developed, informed by themes from the literature and unvalidated published tools related to family presence during resuscitation. The tool was piloted on a sample of 68 emergency nursing and medical staff. Content validity and face validity were established using feedback from participants. Reliability was established by unidimensionality, exploratory factor analysis and internal consistency. Sixteen items were deleted from the original tool due to low item-to-total correlations and low communalities. Exploratory factor analysis of the remaining items revealed four factors with acceptable correlation coefficients and appropriate explanation of variance. Cronbach's alpha for each factor was >0.7 indicating a high degree of internal consistency. The four factors were labelled and arranged in a logical order to form the final tool, the Emergency Department Family Presence Survey.

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.

A critical ethnography of communication processes involving the management of oral chemotherapeutic agents by patients with a primary diagnosis of colorectal cancer: study protocol.

AIM: To describe the protocol used to examine the processes of communication between health professionals, patients and informal carers during the management of oral chemotherapeutic medicines to identify factors that promote or inhibit medicine concordance. BACKGROUND: Ideally communication practices about oral medicines should incorporate shared decision-making, two-way dialogue and an equality of role between practitioner and patient. While there is evidence that healthcare professionals are adopting these concordant elements in general practice there are still some patients who have a passive role during consultations. Considering oral chemotherapeutic medications, there is a paucity of research about communication practices which is surprising given the high risk of toxicity associated with chemotherapy. DESIGN: A critical ethnographic design will be used, incorporating non-participant observations, individual semi-structured and focus-group interviews as several collecting methods. METHODS: Observations will be carried out on the interactions between healthcare professionals (physicians, nurses and pharmacists) and patients in the outpatient departments where prescriptions are explained and supplied and on follow-up consultations where treatment regimens are monitored. Interviews will be conducted with patients and their informal carers. Focus-groups will be carried out with healthcare professionals at the conclusion of the study. These several will be analysed using thematic analysis. This research is funded by the Department for Employment and Learning in Northern Ireland (Awarded February 2012). DISCUSSION: Dissemination of these findings will contribute to the understanding of issues involved when communicating with people about oral chemotherapy. It is anticipated that findings will inform education, practice and policy.

Working with people who have killed: The experience and attitudes of forensic mental health clinicians working with forensic patients

Forensic mental health (FMH) clinicians sometimes feel unsupported and unprepared for their work. This article explores their experiences of working in a FMH setting in Australia. The research examined the clinical context of clinicians working with forensic patients (FP), particularly those individuals who have killed while experiencing a mental illness. A qualitative, exploratory design was selected. Data were collected through focus groups and individual interviews with hospital and community-based forensic clinicians from all professional groups: psychiatric medicine, social work, psychology, mental health nursing, occupational therapy, and psychiatric service officers. The main themes identified were orientation and adjustment to FMH, training in FMH, vicarious traumatization, clinical debriefing and clinical supervision, and therapeutic relationships. Participants described being frustrated and unsupported in making the transition to working with FP and felt conflicted by the emotional response that was generated when developing therapeutic relationships. Recommendations include the development of programmes that might assist clinicians and address gaps in service delivery, such as clinical governance, targeted orientation programmes, and clinical supervision.

Using an evidence-based care bundle to improve Thai emergency nurses' knowledge of care for patients with severe traumatic brain injury

There is known variation in Thai nurses' knowledge regarding the best available evidence for care of patients with severe traumatic brain injury. The purpose of this study was to examine the impact of an evidence-based care bundle on Thai emergency nurses' knowledge regarding management of patients with severe traumatic brain injury. A pre-test/post-test design was used. The study intervention was an evidence-based care bundle for initial nursing management of patients with severe traumatic brain injury. Data were collected from 31 Registered Nurses using multiple choice questions. Results revealed a statistically significant improvement in overall knowledge scores after care bundle implementation (p < 0.001). There were statistically significant improvements in five areas of knowledge: understanding of target end-tidal carbon dioxide levels (p < 0.001), implications of hypocapnia in severe traumatic brain injury (p = 0.01), implications of hypercapnia in severe traumatic brain injury (p = 0.02), importance of maintaining head and neck in neutral position (p = 0.05), and administration of sedatives and analgesics in severe traumatic brain injury (p = 0.01). This study suggested that implementation of an evidence-based care bundle improved emergency nurses' knowledge regarding management of patients with severe traumatic brain injury.

Nursing educator perspectives of overseas qualified nurses' intercultural clinical communication: barriers, enablers and engagement strategies

AIMS AND OBJECTIVES: To understand the intercultural communication experiences and associated communication training needs of overseas qualified nurses in the Australian healthcare system from the unique perspectives of nurse educators teaching in accredited bridging programmes. BACKGROUND: Overseas qualified nurses are an integral part of the nursing workforce in migration destination countries. Communication training needs are more complex when there are cultural, ethnic and language differences between nurses, other health professionals and patients. DESIGN: A qualitative, exploratory research design using semi-structured interviews. METHODS: All (nine) organisations involved in conducting the Australian Health Practitioner Regulation Agency approved preregistration bridging programmes for overseas qualified nurses within the state of Victoria, Australia, were involved in the study. Participants were 12 nurse educators employed in these organisations. Thematic analysis was undertaken. RESULTS: Three macro themes emerged about the overseas qualified nurses' intercultural communication: (1) pre-existing barriers and enablers to intercultural communication, for example, nurses' reluctance to engage in communicative strategies that build rapport with patients, (2) transitional behaviours and impact on communication, including maintenance of perceived cultural hierarchies between health professionals and (3) development of communicative competence, including expanding one's repertoire of conversational gambits. CONCLUSIONS: The findings point to the domains and causes of communication challenges facing overseas qualified nurses in new healthcare settings as well as strategies that the nurse educators and nurses can adopt. Communication cannot be merely regarded as a skill that can be taught in a didactic programme. Comprehensive understanding is needed about the sociocultural dimensions of these nurses' orientation, which can impact on how they communicate in their new healthcare settings. RELEVANCE TO CLINICAL PRACTICE: The findings can act as triggers for discussion with overseas qualified nurses and other health professionals to raise awareness about the aspects of intercultural communication and to debate alternative viewpoints and explanations. They can also inform changes in the structure and content of the bridging programmes.

Leadership and teamwork in medical emergencies: Performance of nursing students and registered nurses in simulated patient scenarios

Aims and objectives: To examine nursing students' and registered nurses' teamwork skills whilst managing simulated deteriorating patients. Background: Studies continue to show the lack of timely recognition of patient deterioration. Management of deteriorating patients can be influenced by education and experience. Design: Mixed methods study conducted in two universities and a rural hospital in Victoria, and one university in Queensland, Australia. Methods: Three simulation scenarios (chest pain, hypovolaemic shock and respiratory distress) were completed in teams of three by 97 nursing students and 44 registered nurses, equating to a total of 32 student and 15 registered nurse teams. Data were obtained from (1) Objective Structured Clinical Examination rating to assess performance; (2) Team Emergency Assessment Measure scores to assess teamwork; (3) simulation video footage; (4) reflective interview during participants' review of video footage. Qualitative thematic analysis of video and interview data was undertaken. Results: Objective structured clinical examination performance was similar across registered nurses and students (mean 54% and 49%); however, Team Emergency Assessment Measure scores differed significantly between the two groups (57% vs 38%, t = 6·841, p < 0·01). In both groups, there was a correlation between technical (Objective Structured Clinical Examination) and nontechnical (Team Emergency Assessment Measure) scores for the respiratory distress scenario (student teams: r = 0·530, p = 0·004, registered nurse teams r = 0·903, p < 0·01) and hypovolaemia scenario (student teams: r = 0·534, p = 0·02, registered nurse teams: r = 0·535, p = 0·049). Themes generated from the analysis of the combined quantitative and qualitative data were as follows: (1) leadership and followership behaviours; (2) help-seeking behaviours; (3) reliance on previous experience; (4) fixation on a single detail; and (5) team support. Conclusions: There is scope to improve leadership, team work and task management skills for registered nurses and nursing students. Simulation appears to be beneficial in enabling less experienced staff to assess their teamwork skills. Relevance to clinical practice: There is a need to encourage less experienced staff to become leaders and for all staff to develop improved teamwork skills for medical emergencies.

Patient participation in nursing care on medical wards: An integrative review

BACKGROUND: Patient participation is a way for patients to engage in their nursing care. In view of the possible link between patient participation and safety, there is a need for an updated review to assess patient participation in nursing care. OBJECTIVES: To investigate patients' and nurses' perceptions of and behaviours towards patient participation in nursing care in the context of hospital medical wards. DESIGN: Integrative review. DATA SOURCES: Three search strategies were employed in August 2013; a computerised database search of Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Medline and PsychINFO; reference lists were hand-searched; and forward citation searching was executed. REVIEW METHODS: After reviewing the studies, extracting study data and completing summary tables the methodological quality was assessed using the Mixed-Methods Assessment Tool by two reviewers. Reviewers met then to discuss discrepancies as well as the overall strengths and limitations of the studies. Discrepancies were overcome through consensus or a third reviewer adjudicated the issue. Within and across study analysis and synthesis of the findings sections was undertaken using thematic synthesis. RESULTS: Eight studies met inclusion criteria. Four themes were identified - enacting participation, challenges to participation, promoting participation and types of participation. Most studies included were conducted in Europe. The majority of studies used qualitative methodologies, with all studies sampling patients; nurses were included in three studies. Data were largely collected using self-reported perceptions; two studies included observational data. Methodological issues included a lack of reflexivity, un-validated data collection tools, sampling issues and low response rates. CONCLUSIONS: On medical wards, patients and nurses desire, perceive or enact patient participation passively. Challenging factors for patient participation include patients' willingness, nurses' approach and confusion around expectations and roles. Information-sharing was identified as an activity that promotes patient participation, suggesting nurses encourage active communication with patients in practice. Involving patients in assessment and care planning may also enhance patient participation. For education, enhancing nurses' understanding of the attributes of patient participation, as well as patient-centred care approaches may be beneficial for medical ward nurses. From here, researchers need to examine ways to overcome the barriers to patient participation; further nurse participants and observational data is required on medical wards.

Psychosocial aspects in home hemodialysis: A review

Psychosocial aspects related to home hemodialysis (HD) play an important role in the success of home HD programs. Once patients commence HD at home, unique psychosocial issues related to patient and care partner burden can emerge. Proactive professional support, peer support, respite care, travel support, and financial support from the home HD health care team must be a priority for patient care. If the psychosocial aspects are not proactively addressed, patients receiving HD at home may return to in-center HD and the program may struggle as a result. This review provides a psychosocial guide for new start-up home HD programs.

Nurses' views of patient participation in nursing care

AIMS: To explore nurses' views of patient participation in nursing care on medical wards. BACKGROUND: Nurses have frequent contact with patients, highlighting their potential role in enabling patient participation. However, some nurses' actions and attitudes act as barriers, failing to achieve core requirements of patient participation. Discovering nurses' views may assist in developing strategies to encourage patient participation in hospitals. DESIGN: Interpretive study. METHODS: Twenty nurses were recruited from four medical wards, located in two Australian hospitals. In-depth semi-structured interviews were conducted between November 2013-March 2014 and analysed using content analysis. FINDINGS: Five categories emerged from the nurses' views. The first category, acknowledging patients as partners, showed nurses respected patients as legitimate participants. In the second category, managing risk, nurses emphasized the need to monitor participation to ensure rules and patient safety were maintained. Enabling participation was the third category, which demonstrated nurses' strategies that enhanced patients' participation. The fourth category was hindering participation; encapsulating nurses' difficulty in engaging patients with certain characteristics. In the final category, realizing participation, nurses believed patients could be involved in physical activities or clinical communication. CONCLUSION: Nurses have a crucial role in promoting patient participation. Through acknowledging and enabling participation, nurses may facilitate patient participation in a range of nursing activities. The nurse's role in enacting participation is complex, having to accommodate each patient's risks and characteristics, highlighting the need for good assessment skills. Education, policy and research strategies are essential to foster nurses' pivotal role in patient participation.

Nursing handover from ICU to cardiac ward: standardised tools to reduce safety risks

BACKGROUND: Standardising handover processes and content, and using context-specific checklists are proposed as solutions to mitigate risks for preventable errors and patient harm associated with clinical handovers. OBJECTIVES: Adapt existing tools to standardise nursing handover from the intensive care unit (ICU) to the cardiac ward and assess patient safety risks before and after pilot implementation. METHODS: A three-stage, pre-post interrupted time-series design was used. Data were collected using naturalistic observations and audio-recording of 40 handovers and focus groups with 11 nurses. In Stage 1, examination of existing practice using observation of 20 handovers and a focus group interview provided baseline data. In Stage 2, existing tools for high-risk handovers were adapted to create tools specific to ICU-to-ward handovers. The adapted tools were introduced to staff using principles from evidence-based frameworks for practice change. In Stage 3, observation of 20 handovers and a focus group with five nurses were used to verify the design of tools to standardise handover by ICU nurses transferring care of cardiac surgical patients to ward nurses. RESULTS: Stage 1 data revealed variable and unsafe ICU-to-ward handover practices: incomplete ward preparation; failure to check patient identity; handover located away from patients; and information gaps. Analyses informed adaptation of process, content and checklist tools to standardise handover in Stage 2. Compared with baseline data, Stage 3 observations revealed nurses used the tools consistently, ward readiness to receive patients (10% vs 95%), checking patient identity (0% vs 100%), delivery of handover at the bedside (25% vs 100%) and communication of complete information (40% vs 100%) improved. CONCLUSION: Clinician adoption of tools to standardise ICU-to-ward handover of cardiac surgical patients reduced handover variability and patient safety risks. The study outcomes provide context-specific tools to guide handover processes and delivery of verbal content, a safety checklist, and a risk recognition matrix.

The construction of a subset of ICNP® for patients with dementia: a Delphi consensus and a group interview study

BACKGROUND: The International Classification for Nursing Practice (ICNP®) 2013 includes over 4000 concepts for global nursing diagnoses, outcomes and interventions and is a large and complex set of standardised nursing concepts and expressions. Nurses may use subsets from the ICNP as concepts and expressions for research, education and clinical practice. The objective of this study was to identify and validate concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia.

METHOD: The process model for developing ICNP subsets was followed, according to the guidelines adopted by the International Council of Nursing (ICN). To identify relevant and useful concepts for the subset, a modified form of the Delphi method was used. Six nurses working in healthcare services in three municipalities in Norway with postgraduate education in geriatric psychiatry and dementia care participated in two Delphi sessions. The participants reviewed and scored the concepts included in the suggested subset and had an opportunity to rewrite them and offer alternatives. To validate the subset after the Delphi study, a group interview was conducted with six other nurses with postgraduate education in geriatric psychiatry and dementia care. The group interview was recorded and transcribed, and summative content analysis was used.

RESULTS: Suitable concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia were identified. In total, 301 concepts were identified, including 77 nursing diagnoses, 78 outcomes and 146 nursing interventions. An increased focus on concepts to describe basic psychosocial needs such as identity, comfort, connection, inclusion and engagement was recommended by nurses in the validation process.

CONCLUSIONS: Relevant and pre-formulated nursing diagnoses, goals and interventions were identified, which can be used to develop care plans and facilitate accuracy in the documentation of individuals with dementia. The participants believed that it may be difficult to find formulations for all steps of the nursing process. In particular, nursing diagnoses and psychosocial needs are often inadequately documented. The participants highlighted the need for the subset to contain essential information about psychosocial needs and communication.

A prospective observational study of prevalence and outcomes of patients with Gold Standard Framework criteria in a tertiary regional Australian Hospital

OBJECTIVES: Report the use of an objective tool, UK Gold Standards Framework (GSF) criteria, to describe the prevalence, recognition and outcomes of patients with palliative care needs in an Australian acute health setting. The rationale for this is to enable hospital doctors to identify patients who should have a patient-centred discussion about goals of care in hospital.

DESIGN: Prospective, observational, cohort study.

PARTICIPANTS: Adult in-patients during two separate 24 h periods.

MAIN OUTCOME MEASURES: Prevalence of in-patients with GSF criteria, documentation of treatment limitations, hospital and 1 year survival, admission and discharge destination and multivariate regression analysis of factors associated with the presence of hospital treatment limitations and 1 year survival.

RESULTS: Of 626 in-patients reviewed, 171 (27.3%) had at least one GSF criterion, with documentation of a treatment limitation discussion in 60 (30.5%) of those patients who had GSF criteria. Hospital mortality was 9.9%, 1 year mortality 50.3% and 3-year mortality 70.2% in patients with GSF criteria. One-year mortality was highest in patients with GSF cancer (73%), renal failure (67%) and heart failure (60%) criteria. Multivariate analysis revealed age, hospital length of stay and presence of the GSF chronic obstructive pulmonary disease criteria were independently associated with the likelihood of an in-hospital treatment limitation. Non-survivors at 3 years were more likely to have a GSF cancer (25% vs 6%, p=0.004), neurological (10% vs 3%, p=0.04), or frailty (45% vs 3%, p=0.04) criteria. After multivariate logistic regression GSF cancer criteria, renal failure criteria and the presence of two or more GSF clinical criteria were independently associated with increased risk of death at 3 years. Patients returning home to live reduced from 69% (preadmission) to 27% after discharge.

CONCLUSIONS: The use of an objective clinical tool identifies a high prevalence of patients with palliative care needs in the acute tertiary Australian hospital setting, with a high 1 year mortality and poor return to independence in this population. The low rate of documentation of discussions about treatment limitations in this population suggests palliative care needs are not recognised and discussed in the majority of patients.

TRIAL REGISTRATION NUMBER: 11/121.

Multicenter randomized controlled trial of a home walking intervention after outpatient cardiac rehabilitation on health-related quality of life in women

BACKGROUND: Poor health-related quality of life (HRQL) has been shown to be predictive of adverse outcomes in cardiac patients. As women with coronary heart disease have been shown to have lower HRQL than men with coronary heart disease, women are at greater risk of a poor clinical outcome. This study tested the effect of a 12-week home walking intervention after completion of outpatient cardiac rehabilitation (OCR) on HRQL and maintenance of physical activity among women. DESIGN: Multicenter two-group randomized trial. METHODS: After completion of OCR, participants were randomly allocated to the intervention or usual care groups. The outcomes were HRQL (assessed using the MacNew Heart Disease HRQL instrument) and self-reported physical activity (assessed using the Stages of Change model of exercise behavior) at 3, 6, and 12 months after OCR. RESULTS: Seventy-two women were randomized to the intervention and 81 to usual care. Attrition was greater in the treatment group (13 vs. 1%). HRQL scores increased relative to the base level in both arms and were significantly higher in the intervention group at 6 months, but not at 3 or 12 months. Maintenance of physical activity declined over time in both groups, however, this decline was significantly reduced among women in the intervention group. CONCLUSION: HRQL improved in both groups, but seemed to increase earlier among women in the intervention group. As maintenance of physical activity was higher among women in the intervention group, this minimal intervention could be used to facilitate women's progression from supervised to independent exercise.

Engaging patients and families in communication across transitions of care: an integrative review protocol

AIM: To describe an integrative review protocol to analyse and synthesize peer-reviewed research evidence in relation to engagement of patients and their families in communication during transitions of care to, in and from acute care settings.

BACKGROUND: Communication at transitions of care in acute care settings can be complex and challenging, with important information about patients not always clearly transferred between responsible healthcare providers. Involving patients and their families in communication during transitions of care may improve the transfer of clinical information and patient outcomes and prevent adverse events during hospitalization and following discharge. Recently, optimizing patient and family participation during care transitions has been acknowledged as central to the implementation of patient-centred care.

DESIGN: Integrative review with potential for meta-analysis and application of framework synthesis.

REVIEW METHOD: The review will evaluate and synthesize qualitative and quantitative research evidence identified through a systematic search. Primary studies will be selected according to inclusion criteria. Data collection, quality appraisal and analysis of the evidence will be conducted by at least two authors. Nine electronic databases (including CINAHL and Medline) will be searched. The search will be restricted to 10 years up to December 2013. Data analysis will include content and thematic analysis.

DISCUSSION: The review will seek to identify all types of patient engagement activities employed during transitions of care communication. The review will identify enablers for and barriers to engagement for patients, families and health professionals. Key strategies and tools for improving patient engagement, clinical communication and promoting patient-centred care will be recommended based on findings.