Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention.

AIM: To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital. BACKGROUND: Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability. DESIGN: A narrative inquiry. METHODS: Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data. RESULTS: The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation. CONCLUSION: Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly. REPORTING METHOD: The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting. PATIENT OR PUBLIC CONTRIBUTION: The consumer researcher was involved in design, data analysis and publication preparation.

An economic evaluation of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) clinical trial.

BACKGROUND: Early recognition and response to clinical deterioration reduce the frequency of in-hospital cardiac arrests, mortality, and unplanned intensive care unit (ICU) admissions. This study aimed to investigate the impact of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) intervention on hospital costs and patient length of stay (LOS). METHOD: The PRONTO cluster randomised control trial was conducted to improve nurses' responses to patients with abnormal vital signs. Hospital data were collected pre-intervention (T0) at 6 months (T1) and 12 months (T2) post-intervention. The economic evaluation involved a cost-consequence analysis from the hospital's perspective. Generalised estimating equations were used to estimate the parameters for regression models of the difference in costs and LOS between study groups and time points. RESULTS: Hospital admission data for 6065 patients (intervention group, 3102; control group, 2963) were collected from four hospitals for T0, T1 and T2. The intervention cost was 69.61 A$ per admitted patient, including the additional intervention training for nurses and associated labour costs. The results showed cost savings and a shorter LOS in the intervention group between T0 - T1 and T0 - T2 (cost differences T0 - T1: -364 (95% CI -3,782; 3049) A$ and T0 - T2: -1,710 (95% CI -5,162; 1,742) A$; and LOS differences T0 - T1: -1.10 (95% CI -2.44; 0.24) days and T0 & T2: -2.18 (95% CI -3.53; -0.82) days). CONCLUSION: The results of the economic analysis demonstrated that the PRONTO intervention improved nurses' responses to patients with abnormal vital signs and significantly reduced hospital LOS by two days at 12 months in the intervention group compared to baseline. From the hospital's perspective, savings from reduced hospitalisations offset the costs of implementing PRONTO.

Patients in isolation, their physical, environmental and mental health: An exploratory study.

BACKGROUND: Strict patient isolation in hospital is associated with adverse health outcomes. However, there is a lack of high-quality evidence for effective interventions to improve safety and quality of care for these patients. AIMS: To identify patient reported areas for improvement in the care of patients in hospital isolation and to determine the feasibility of collecting patient reported outcomes using validated tools. METHODS: Design An exploratory mixed methods study. Setting A major metropolitan teaching hospital in Melbourne, Australia. Participants Patients in hospital isolation for transmissible infections. Data collection Data were collected by (1) phone interviews with patients in isolation and (2) seven validated measurement tools to assess cognition, loneliness, nutritional status, quality of life, anxiety and depression and physical activity. Data were collected between September and December 2021. Data analysis Interviews were transcribed and analysed using thematic analysis. Quantitative data were analysed descriptively including participant characteristics and outcome data. RESULTS: Participants identified areas for improvement including activities to decrease boredom, more contact with staff to mitigate loneliness and increase comfort care, and formalised communication about clinical treatment and discharge plan. Patients with gastrointestinal symptoms were happier to be alone. There were operational challenges within the health service including delays and miscommunication. Only 70% of the participants completed all questionnaires. CONCLUSION: This study identified areas for improvement in care of patients in isolation and demonstrated that collecting patient reported outcomes using validated tools was feasible. The results of this research will inform development of an intervention to manage adverse effects. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Patients in hospital isolation require additional consideration to ensure that their needs are met to avoid adverse outcomes. The patient experience and comfort can be negatively affected when fundamental care is lacking. REPORTING METHOD (EQUATOR): EQUATOR guidelines for Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR-RHS). PATIENT OR PUBLIC CONTRIBUTION: Thirteen patients in hospital isolation agreed to participate in this study, sharing their experiences through interviews and assessment.

A mixed methods study protocol to identify research priorities for perioperative medicine in Australia.

Background: Clinical research in perioperative medicine requires the perspectives of patients and caregivers to increase its relevance and quality, benefiting both researchers and the community. Identifying these priorities will enable researchers, funders, and governing bodies to efficiently use scarce funding and resources. We aim to identify the top 10 research priorities in perioperative medical research in Australia. Methods: A mixed-methods, exploratory-sequential design will be conducted. The study will include five phases. Initially, a published open-ended survey gathered responses from the population (researchers, healthcare workers, and consumers) regarding uncertainties/questions relevant to the population about perioperative medical research. We collected 544 questions and quantitatively analysed and grouped them according to the Standardised Endpoints in Perioperative Medicine-Core Outcomes Measures in Perioperative and Anaesthetic Care (StEP-COMPAC) endpoints. Using multicriteria decision-making software, workshops combining the population will be conducted to determine the top 10 priorities for perioperative medicine research for the Australian population. Ethics and dissemination: Ethical approval to conduct the study was obtained from the Alfred Health (Australia) Human Research Ethics Committee (ID: 171/19). The findings will be disseminated in peer review publications, conferences, and dissemination across perioperative research networks. The top 10 priorities will be available to inform research funders, grant submissions, guidelines, and the population.

The role of collaborative decision-making in discharge planning: Perspectives from patients, family members and health professionals.

AIM: To explore discharge planning with a range of key stakeholders in subacute care, including consumers. DESIGN: Qualitative descriptive study. METHODS: Patients (n = 16), families (n = 16), clinicians (n = 17) and managers (n = 12) participated in semi-structured interviews or focus groups. Following transcription, data were analysed thematically. RESULTS: The overarching facilitator of effective discharge planning was collaborative communication, leading to shared expectations by all stakeholders. Collaborative communication was underpinned by four key themes: patient- and family-centred decision-making, early goal setting, strong inter- and intra-disciplinary teamwork, and robust patient/family education. CONCLUSION: Effective planning for discharge from subacute care is enabled by shared expectations and collaborative communication between key stakeholders. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Effective discharge planning processes are underpinned by effective inter- and intra-disciplinary teamwork. Healthcare networks should foster environments that promote effective communication between and within multidisciplinary team members as well as with patients and their families. Applying these principles to discharge planning may assist in reducing length of stays and rates of preventable readmissions post-discharge. IMPACT: This study addressed a lack of knowledge about effective discharge planning in Australian subacute care. It found that collaborative communication between stakeholders was an overarching facilitator of effective discharge planning. This finding impacts subacute service design and professional education. REPORTING METHOD: COREQ guidelines were followed in reporting this study. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution in the design, data analysis or preparation of the manuscript.

Defining ready for discharge from sub-acute care: a qualitative exploration from multiple stakeholder perspectives.

BACKGROUND: Planning discharges from subacute care facilities is becoming increasingly complex due to an ageing population and a high demand on services. The use of non-standardised assessments to determine a patient's readiness for discharge places a heavy reliance on a clinician's judgement which can be influenced by system pressures, past experiences and team dynamics. The current literature focusses heavily on discharge-readiness from clinicians' perspectives and in the acute care setting. This paper aimed to explore the perceptions of discharge-readiness from the perspectives of key stakeholders in subacute care: inpatients, family members, clinicians and managers. METHODS: A qualitative descriptive study was conducted, exploring the views of inpatients (n = 16), family members (n = 16), clinicians (n = 17) and managers (n = 12). Participants with cognitive deficits and those who did not speak English were excluded from this study. Semi-structured interviews and focus groups were conducted and audio-recorded. Following transcription, inductive thematic analysis was completed. RESULTS: Participants identified that there are both patient-related and environmental factors that influence discharge-readiness. Patient-related factors discussed included continence, functional mobility, cognition, pain and medication management skills. Environmental factors centred around the discharge (home) environment, and were suggested to include a safe physical environment alongside a robust social environment which was suggested to assist to fill any gaps in functional capabilities (i.e. patient-related factors). CONCLUSIONS: These findings make a unique contribution to the literature by providing a thorough exploration of determining discharge-readiness as a combined narrative from the perspectives from key stakeholders. Findings from this qualitative study identified key personal and environmental factors influencing patients' discharge-readiness, which may allow health services to streamline the determination of discharge-readiness from subacute care. Understanding how these factors might be assessed within a discharge pathway warrants further attention.

Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning.

A nurse-led critical care outreach service (NLCCOS) can support staff education and decision making in the wards, managing at-risk patients with ward nurses to avoid further deterioration. We aimed to investigate the characteristics of patients identified as at-risk, the types of treatments they required to prevent deterioration, the education initiated by the NLCCOS, and the perceived experiences of ward nurses. This prospective observational pilot study using mixed methods took place in one medical and one surgical ward at a university hospital in Denmark. Participants were patients nominated as at-risk by head nurses in each ward, the ward nurses, and nurses from the NLCCOS. In total, 100 patients were reviewed, 51 medical and 49 surgical patients, over a six-month period. Most patients (70%) visited by the NLCCOS had a compromised respiratory status, and ward nurses received teaching and advice regarding interventions. Sixty-one surveys were collected from ward nurses on their learning experience. Over 90% (n = 55) of nurses believed they had learned from, and were more confident with, managing patients following the experience. The main educational areas were respiratory therapy, invasive procedures, medications, and benefits of mobilization. Further research needs to measure the impact of the intervention on patient outcomes and MET call frequency over time in larger samples.

Staff experiences, perceptions of care, and communication in the intensive care unit during the COVID-19 pandemic in Australia.

BACKGROUND: In 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission. AIM: The aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale. METHODS: This was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis. FINDINGS: Four major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods. CONCLUSION: The results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.

Consumer Engagement in Perioperative Clinical Trials.

Consumer engagement (patient and public involvement) in perioperative medicine research is in its infancy. The patient experience and family/carer perspectives can provide an extra layer of insight to give more understanding as to what, why, and how we do research. Patients who have undergone surgery have a unique understanding of the issues, concerns, wants, and needs that they learned as a patient-they, therefore, can be considered as a professional given their experience(s)-thus warranting recognition as a partner in research. Knowledge of the consumer engagement literature and availability of resources should support anesthesia researchers aiming to include these perspectives in their research. This includes several existing engagement frameworks and assessment tools. We provide a framework for consumer engagement for adoption into anesthesia and other perioperative research. By incorporating the patient or caregiver into the design, funding application(s), data collection, and interpretation of the findings can be beneficial to all. This includes promoting knowledge and access to clinical trials, the wording of participant consent and information forms, methods of data collection, selection of important outcomes, and dissemination of results.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration.

BACKGROUND: Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients. METHODS: In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat. RESULTS: From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)). CONCLUSION: Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes. TRIAL REGISTRATION NUMBER: ACTRN12616000544471p.

A 6-y retrospective cohort study of family satisfaction with critical care and decision-making in an Australian intensive care unit.

BACKGROUND: Partnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically. OBJECTIVE: The objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU). METHODS: A retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from "poor" (0) to "excellent" (100). RESULTS: In total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients' treatment in the ICU and appreciation for the care, skill, and professionalism of the staff. CONCLUSION: Very high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards.

Enteral nutrition feeding practices by intensive care nurses: A retrospective evaluation.

BACKGROUND: Enteral nutrition (EN) is an integral component of standard management of critically ill patients in intensive care. However, achieving adequate nutrition in this environment continues to present many challenges. DESIGN: A descriptive exploratory design using a retrospective review of medical records. AIMS AND OBJECTIVES: The aims of this study were to describe nursing practice associated with EN feeding and identify barriers to optimal nutritional delivery in the intensive care unit (ICU). METHODS: Patients admitted to a major Australian metropolitan health service ICU during a 6-month period, and who received EN for at least 72 hours, were eligible for inclusion. Documented text from patient medical records was analysed using content analysis. Numerical data were analysed using SPSS software (version 25.0). Descriptive and inferential statistics were calculated. RESULTS: A total of 150 patients were included in the study. The mean time from admission to EN commencement was 12.6 hours, with 59.3% commenced within 12 hours of admission. Only 9.3% of patients commenced EN at the target rate. Of the 150 patients, 24 (16%) received 80% of nutrition targets within 72 hours of admission. Patients who had EN commenced within 12 hours of admission and at the target rate were significantly more likely to achieve nutritional requirements (P = <.01). Patients who received an initial dietitian review within 24 hours of admission were more likely to achieve nutrition requirements (P = <.01). CONCLUSIONS: Commencing EN on time and meeting target volumes remains challenging in the ICU patient. Airway management, procedural requirements, and delayed dietitian review for prescribed hourly rate initiation provide barriers to optimal nutrition delivery to critically ill patients. Tackling these barriers may require interdisciplinary interventions. RELEVANCE TO CLINICAL PRACTICE: Providing adequate nutrition to critically ill patients is challenging. This study provides evidence that day's one and two are problematic to EN delivery; particularly concerning airway management, procedural requirements, and delayed dietitian review for prescribed hourly rate initiation. Highlighting the need for further research into these aspects of nutrition management.

Cultivating Value Co-Creation in Health System Research Comment on "Experience of Health Leadership in Partnering with University-Based Researchers in Canada - A Call to Re-imagine Research".

Partnerships have various purposes and exist in many configurations. Although there has been a refocusing in health system research on forming strategic partnerships between researchers and knowledge users (KUs) to maximise the relevance and uptake of research in practice; research knowledge frequently fails to reach KUs nor impact the community served. Whilst there have been many attempts to engage KUs, researchers and decision-makers often promote a top down approach that has lacked insight into KUs' specific needs and values. Bowen and colleagues uncovered a plethora of negative experiences from a group of Canadian health leaders involved in researcher partnerships. Their comments reflect their experiences seemingly at an earlier stage of a partnership so we were not surprised by their pessimism. However, our experience reflects an established research-health service partnership network where we collaborate and co-create for mutual benefit and with a shared purpose. The reason for its sustained success over several decades is the focus on co-creation of value between stakeholders. Re-imagining must prioritise a paradigm shift towards value co-creation if partnerships are to create opportunities for innovation, productivity and impact.

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

AIMS AND OBJECTIVES: To outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses. BACKGROUND: Medication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses' reporting behaviour and improve medication error reporting rates. DESIGN: Quasi-experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015-September 2016. One ward from each pair was randomised to either the intervention or control group. METHOD: Nurses within intervention wards received audit with feedback on a quarterly basis over a 12-month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one-page infographic poster, with content based on medication error data obtained from audits and the hospitals' risk management system (RiskMan). The primary outcome-rate of medication errors reported per month-was determined in both groups at pre-implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link. RESULTS: A nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre-implementation and implementation phases (80% increase). CONCLUSIONS: The audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses. RELEVANCE TO CLINICAL PRACTICE: Despite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.

Implementing a Psychiatric Behaviours of Concern emergency team in an acute inpatient psychiatry unit: Staff perspectives.

Behaviours of concern including aggression are widespread in mental health inpatient settings. Restrictive interventions such as restraint and seclusion can cause additional trauma to already traumatized patients. To decrease use of these interventions in an acute psychiatric unit in Melbourne, Australia, a Psychiatric Behaviours of Concern (Psy-BOC) response team was introduced. In a Psy-BOC call, senior medical, nursing, and allied health staff respond to escalating behavioural situations to work with the primary treating team to implement clinical interventions of least restrictive practice. Here, we present qualitative findings reporting staff response to Psy-BOC. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ). Twenty-four staff participated in five focus groups. Four themes were identified: Identifying behavioural deterioration, responding to behaviours of concern, staff reactions, and barriers. Although staff were skilled in recognizing and de-escalating behaviours of concern, patients were secluded when heightened risk was perceived. The adoption of Psy-BOC was met with some resistance to the cultural change required to adopt this new model. Increased awareness, early identification of behaviours of concern, and pressure from management resulted in reductions in restrictive interventions. Management of patients with drug-induced psychosis without restraint presented specific difficulties. The ward setting was challenging, offering no break-out spaces for patients, and few comfortable areas. Some staff appreciated the advice and expertise of the Psy-Boc team, others felt disempowered and undermined. Improving leadership, staff education, support and collaboration, and including frontline staff in refining the process could enhance the Psy-BOC response and increase safety for all.

Examining subacute nurses' roles in a changing healthcare context.

AIMS AND OBJECTIVES: To explore and describe nurses' role in the rehabilitation and care of patients in one subacute care facility in Melbourne, Australia. BACKGROUND: The role of nurses in subacute care and within the rehabilitation team is evolving and remains unclear. DESIGN: Mixed methods. METHODS: Fourteen nurses from seven rehabilitation and geriatric evaluation and management wards in one subacute facility in Melbourne, Australia, were observed in practice for two hours and then interviewed. Activities were recorded electronically. Interviews were audio-recorded and transcribed. Data were analysed using content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ). RESULTS: Three main themes are as follows: (a) Nurses as rehabilitators; (b) Teamwork in rehabilitation; and (c) The changing context of subacute care. Nurses prioritised patient personal and clinical care above other responsibilities. They were largely excluded from team decision-making because clinical responsibilities precluded them from attending team meetings. Unsuitable buildings, increased patient acuity and time constraints were further challenges. CONCLUSIONS: Nurses have a multifaceted role in patient rehabilitation that is poorly understood. An evaluation of the nursing role within the interdisciplinary team, skills and processes of care may increase understanding, and improve communication and relationships between disciplines potentially benefiting patients. Role clarity and differentiation in nursing skills are required within the nursing workforce. RELEVANCE TO CLINICAL PRACTICE: Nurses have a unique role in both clinical care and rehabilitation of patients, and as part of the interdisciplinary team. Respectful professional relationships need fostering within the interdisciplinary team to achieve optimal patient outcomes. The way that team meetings and decision-making occur in the subacute wards requires adjustment to ensure that the valuable contribution of nurses, both to the interdisciplinary team and to the rehabilitation of patients, is used and acknowledged to improve patient care.

Engaging patients and families in communication across transitions of care: An integrative review.

OBJECTIVE: To determine the current evidence about patient and family engagement in communication with health professionals during transitions of care to, within and from acute care settings. METHODS: An integrative review using seven international databases was conducted for 2003-2017. Forty eligible studies were analysed and synthesised using framework synthesis. RESULTS: Four themes: 1) Partnering in care: patients and families should be partners in decision-making and care; 2) Augmenting communication during transitions: intrinsic and extrinsic factors supported transition communication between patients, families and health professionals; 3) Impeding information exchange: the difficulties faced by patients and families taking an active role in transition; and 4) Outcomes of communication during transitions: reported experiences for patients, families and health professionals. CONCLUSION: While attitudes towards engaging patients and family in transition communication in acute settings are generally positive, current practices are variable. Structural supports for practice are not always present. PRACTICE IMPLICATIONS: Organisational strategies to improve communication must incorporate an understanding of patient needs. A structured approach which considers timing, privacy, location and appropriateness for patients and families is needed. Communication training is required for patients, families and health professionals. Health professionals must respect a patient's right to be informed by regularly communicating.

Exploring staff perceptions of organ donation after circulatory death.

BACKGROUND AND OBJECTIVE: Solid organ donation remains low in Australia; however, donation after circulatory death (DCD) bolsters rates and is associated with good short- and long-term clinical outcomes among recipients, especially in lung and kidney recipients. However, its reintroduction is met with resistance within hospitals. The aim of the present study was to develop a greater understanding of DCD perceptions among staff involved. METHODS: This descriptive exploratory study incorporated open-ended and scaled questions with intensive care staff at a public tertiary teaching hospital in Australia. Interviews were digitally recorded and transcribed verbatim before thematic analysis. Quantitative responses were assessed using a 10-point Likert scale. RESULTS: Twelve participants were interviewed. Responses to the Likert scale questions were averaged. Donation after brain death was unanimously accepted (average = 10.0), whereas DCD acceptance was lower but remained supported (average = 8.8). Interview responses generated five themes, each containing subthemes. Respondents had concerns with DCD where perceptions existed that DCD would increase family distress, from either timeframes not being met or logistical delays. A second major source of concern stemmed from personal conflict relating to their role. There was difficulty transitioning from primarily sustaining life or facilitating palliation alone to advocating for DCD, especially where there was perceived potential for deviations from standard palliation in analgesia, sedation, and investigations. Overall, concerns were overcome by reliance on a supportive work environment, rationalisation of concerns over time, and reliance on protocols. CONCLUSIONS: Supportive leadership within the hospital's intensive care unit meant DCD occurred with minimal institutional resistance. However, some individual concerns surrounding DCD were identified. These may be present and amplified in other centres. More study is required in centres where institutional resistance to DCD is identified so that DCD may be further promoted to expand the donor pool.

The perspective of allied health staff on the role of nurses in subacute care.

AIMS AND OBJECTIVES: To explore allied health staff perceptions on the role of nurses in subacute care wards. BACKGROUND: A consequence of earlier discharge from acute hospitals is higher acuity of patients in subacute care. The impact on nurses' roles and required skill mix remains unknown. In the same way, nurses' integration into the rehabilitation team is ambiguous. DESIGN: Descriptive qualitative inquiry. METHODS: Semistructured interviews conducted with 14 allied health staff from one subacute care facility in Melbourne, Australia. Interviews were audio-recorded and transcribed verbatim. Analysis using the framework approach. RESULTS: Three main themes were evident: (a) the changing context of care: patient acuity, rapid patient discharge and out-dated buildings influenced care; (b) generalist as opposed to specialist rehabilitation nurses: a divide between traditional nursing roles of clinical and personal care and a specialist rehabilitation role; and (c) interdisciplinary relations and communication demonstrated lack of respect for nurses and integrating holistic care into everyday routines. CONCLUSIONS: Allied health staff had limited understanding of nurses' role in subacute care, and expectations varied. Power relationships appeared to hamper teamwork. Failure to include nurses in team discussions and decision-making could hinder patient outcomes. Progressing patients to levels of independence involves both integrating rehabilitation into activities of daily living with nurses and therapy-based sessions. Promotion of the incorporation of nursing input into patient rehabilitation is needed with both nurses and allied health staff. RELEVANCE TO CLINICAL PRACTICE: Lack of understanding of the nurses' role contributes to lack of respect for the nursing contribution to rehabilitation. Nurses have a key role in rehabilitation sometimes impeded by poor teamwork with allied health staff. Processes in subacute care wards need examination to facilitate more effective team practices inclusive of nurses. Progressing patients' independence in rehabilitation units involves activities of daily living with nurses as much as therapy-based sessions.