Exploration of 'micro' level factors that affect the involvement of clinical pharmacists in interprofessional ward rounds in hospitals: Through the lens of social cognitive theory.

BACKGROUND: Macro and meso level factors that influence the participation by clinical pharmacists in ward rounds include pharmacy management culture, commitment to ward rounds and adequate time for ward rounds being included in workload models. The 'micro' level factors that affect the involvement of clinical pharmacists in ward rounds have not been widely explored. OBJECTIVE: Explore 'micro' level factors to gain insight into clinical pharmacists' participation in interprofessional ward rounds in inpatient settings through the lens of social cognitive theory. METHOD: A qualitative focused ethnographic study with five clinical pharmacists, four medical practitioners, one allied health professional and one nurse was conducted in three metropolitan hospitals in Southern Australia. Seven hours of semi-structured interview (n = 11) and 76-h of observations (n = 5) were conducted. A qualitative descriptive analysis was conducted (guided by Spradley) followed by reflexive thematic-analysis (according to Braun and Clarke's technique). RESULTS: Three micro level factors influencing clinical pharmacist participation in ward rounds are: (1) Cognitive mindset of clinical pharmacists, (2) Behavioural conduct of clinical pharmacists, and (3) Social rules of the ward. Clinical pharmacists that did not participate in ward round reconciled their moral distress by transferring information without clinical judgement or interpretation of the patient scenario to medical practitioners. Clinical pharmacists that did participate in ward rounds demonstrated credibility by making relevant recommendations with a holistic lens. This enabled clinical pharmacists to be perceived as trustworthy by medical practitioners. Positive experiences of participating in ward rounds contributed to their cognitive upward spiral of thoughts and emotions, fostering continued participation. CONCLUSION: Clinical pharmacists participate in ward rounds when they develop a positive mindset about ward round participation and perceive ward rounds as an enabler to the establishment of trusted professional relationships with medical practitioners. This trusted relationship creates an environment where the pharmacist develops confidence in making relevant recommendations.

Addressing Technical Failures in a Diabetic Retinopathy Screening Program.

Purpose: Diabetic retinopathy (DR) is a preventable cause of blindness detectable through screening using retinal digital photography. The Irish National Diabetic Retina Screening (DRS) programme, Diabetic RetinaScreen, provides free screening services to patients with diabetes from aged 12 years and older. A technical failure (TF) occurs when digital retinal imaging is ungradable, resulting in delays in the diagnosis and treatment of sight-threatening disease. Despite their impact, the causes of TFs, and indeed the utility of interventions to prevent them, have not been extensively examined. Aim: Primary analysis aimed to identify factors associated with TF. Secondary analysis examined a subset of cases, assessing patient data from five time points between 2019 and 2021 to identify photographer/patient factors associated with TF. Methods: Patient data from the DRS database for one provider were extracted for analysis between 2018 and 2022. Information on patient demographics, screening results, and other factors previously associated with TF were analyzed. Primary analysis involved using mixed-effects logistic regression models with nested patient-eye random effects. Secondary analysis reviewed a subset of cases in detail, checking for causes of TF. Results: The primary analysis included a total of 366,528 appointments from 104,407 patients over 5 years. Most patients had Type 2 diabetes (89.2%), and the overall TF rate was 4.9%. Diabetes type and duration, dilate pupil status, and the presence of lens artefacts on the camera were significantly associated with TF. The Secondary analysis identified the primary cause of TF was found to be optically dense cataracts, accounting for over half of the TFs. Conclusion: This study provides insight into the causes of TF within the Irish DRS program, highlighting cataracts as the primary contributing factor. The identification of patient-level factors associated with TF facilitates appropriate interventions that can be put in place to improve patient outcomes and minimize delays in treatment and diagnosis.

The Effect on Patients' Visual Acuity and Grade, Secondary to Non-Attendance at Treatment Centers, Post Referral from Diabetic RetinaScreen Ireland.

Background: Patient non-attendance following referral to hospital is a significant challenge, in particular, for persons with diabetes. Aim: We sought to determine the impact on both visual acuity and the subsequent follow-up retinopathy grade of patients when they fail to attend Diabetic Retinopathy Treatment (DRT) Centers following referral from Diabetic RetinaScreen (DRS). Methods: A retrospective analysis of patients discharged from DRT due to multiple consecutive missed appointments between January 2016 and June 2021. Patients discharged for non-attendance were compared with patients discharged from completed treatment. Results: Of the 24,945 NEC patients referred to DRT, 5900 (24%) and 9345 (37%) were discharged back to DRS due to non-attendance and completed treatment, respectively. Those discharged for non-attendance were younger (60.7 v 63.4, p < 0.001) and had higher proportions of males (67% v 63%, p < 0.001) and people with type 1 diabetes (27% v 18%, p < 0.001). After attending rescreening after discharge, those discharged for non-attendance were significantly more likely to have a worsening of DR grade (26% v 8%, p < 0.001). Conclusion: Despite being notified that further investigation (with possible treatment) was required post DRS, many diabetic patients failed to attend for further management of their eye care in DRT. These patients had worse visual outcomes compared to those that attended. Improved patient education and communication are required to mitigate against the consequences of non-attendance.

Disjunction, tension and dissonance within nursing pain care provision for the older hospitalized person: A focused ethnographic insight.

AIMS: This study presents an ethnographic insight into the older hospitalized persons' experiences on how nurses provide pain care provision. The older persons' perceptions of culturally mediated barriers and facilitators are presented. DESIGN: Focused ethnography. METHODS: Multi-site across eight acute care units within two tertiary referral hospitals on the east coast of Australia collected over a one-year period from 2014 to 2015. Semi-structured interviews (n = 12) of older persons (11 hr). Twenty-three (23) semi-structured interviews with nine (9) registered nurses (12 hr 38 min). Participant observation (1,041 hr) during day, night and evening shifts. RESULTS: The older person experienced disjunction within pain assessment by the reliance of nurses on objective measurement gained during functional task completion. Tension emerged during pain management when the older person was not included and/or options provided were not deemed effective. For some older persons this meant they undertook a decision to exclude their nurse from involvement in pain management. A thread woven throughout was a lack of communication, continuity of care and input from the older person. CONCLUSION: This study has implications for the provision of nursing care of the older hospitalized person. Dissonance within pain care provision for the older person occurs during episodes of missed pain care. Understanding and insight is gained into aspects of missed communication opportunities between nurses and the experiences of missed pain care of the older person.

Use of artificial intelligence and virtual reality within clinical simulation for nursing pain education: A scoping review.

OBJECTIVES: To explore and map the evidence for virtual reality and artificial intelligence in simulation for the provision of pain education for pre and post registration nurses. DESIGN: A scoping review of published and unpublished research from 2009 to 2019. DATA SOURCES: Nine electronic databases and hand-searching of reference lists. REVIEW METHODS: Studies were included if virtual reality or artificial intelligence interventions were used for education on pain care provision in nursing. Data were extracted and charted using an extraction tool and themes were explored using narrative analysis. RESULTS: The review process resulted in the inclusion of four published studies. All studies used mixed methods and used artificial intelligence within clinical simulations as an intervention. No studies using virtual reality for pain education met the inclusion criteria. Participants of three studies were undergraduate nursing students in universities and participants in the fourth study were registered nurses within a hospital. Outcomes measured were user acceptance of the technology and feasibility in all studies. The context was hospital located and focused on acute pain episodes, with one exception being sickle cell pain. Three studies had adult patients and the other pediatric patients. The exclusion of input from a patient perspective was notable, as was a lack of interdisciplinary involvement. CONCLUSION: Nurses are integral to the assessment and management of pain in many care settings requiring comprehensive communication and clinical skills. There is a paucity of research on the use of virtual reality or artificial intelligence in pain education for nurses. Current studies are preliminary in nature and/or pilot studies. Further empirical research, with robust design is required to inform nursing education, practice, and policy, thereby supporting the advancement of nursing pain education.

Technical and contextual barriers to oral care: New insights from intensive care unit nurses and health care professionals.

Oral care for intubated patients in the intensive care unit (ICU) is known to reduce bacterial colonization in oropharyngeal cavities decrease development of ventilator associated pneumonia (VAP) and the associated costs of managing this complication (1-4). Provision of oral hygiene by nurses is a fundamental aspect of care in the ICU (5). However, such a basic nursing activity can be devalued or rendered invisible by nurses when there is a greater emphasis on managing and maintaining biotechnology and/or a failure to underpin practice with research evidence that demonstrates the importance of fundamental care (5). A Canadian study by Dale and colleagues (6) to explore clinicians' knowledge of, and experiences with, delivering oral care in intubated patients is a timely reminder that the complexity of performing oral care in the ICU should not be underestimated or undervalued.

Development and Implementation of a Nurse-Led Model of Care Coordination to Provide Health-Sector Continuity of Care for People With Multimorbidity: Protocol for a Mixed Methods Study.

BACKGROUND: Innovative strategies are required to reduce care fragmentation for people with multimorbidity. Coordinated models of health care delivery need to be adopted to deliver consumer-centered continuity of care. Nurse-led services have emerged over the past 20 years as evidence-based structured models of care delivery, providing a range of positive and coordinated health care outcomes. Although nurse-led services are effective in a range of clinical settings, strategies to improve continuity of care across the secondary and primary health care sectors for people with multimorbidity have not been examined. OBJECTIVE: To implement a nurse-led model of care coordination from a multidisciplinary outpatient setting and provide continuity of care between the secondary and primary health care sectors for people with multimorbidity. METHODS: This action research mixed methods study will have two phases. Phase 1 includes a systematic review, stakeholder forums, and validation workshop to collaboratively develop a model of care for a nurse-led care coordination service. Phase 2, through a series of iterative action research cycles, will implement a nurse-led model of care coordination in a multidisciplinary outpatient setting. Three to five iterative action research cycles will allow the model to be refined and further developed with multiple data collection points throughout. RESULTS: Pilot implementation of the model of care coordination commenced in October 2018. Formal study recruitment commenced in May 2019 and the intervention and follow-up phases are ongoing. The results of the data analysis are expected to be available by March 2020. CONCLUSIONS: Nursing, clinician, and patient outcomes and experiences with the nurse-led model of care coordination will provide a template to improve continuity of care between the secondary and primary health care systems. The model template may provide a future pathway for implementation of nurse-led services both nationally and internationally. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15006.

Experiences of the older hospitalised person on nursing pain care: An ethnographic insight.

AIMS AND OBJECTIVES: To present an ethnographic insight into the older hospitalised person (those aged over 65 years) perceptions and experiences of pain care provision by nurses in acute care. BACKGROUND: Pain care provision by nurses remains less than optimal for the older hospitalised person despite numerous evidence-based guidelines. There is a paucity of research providing input from the experiences of the older hospitalised person in relation to their perspectives of pain care provision by nurses in acute care. Pain care research needs more involvement from those older persons with documented diagnoses of dementia, delirium or cognitive impairment, and intellectual disabilities and those in their end stage of palliation. DESIGN: A focused ethnographic study. The consolidated criteria for reporting qualitative research (COREQ) were used to report the findings of this study. METHODS: A focused ethnographic study was conducted in 8 acute care units within 2 large tertiary referral hospitals on the east coast of Australia. Consisting of semi-structured interviews (n = 12) of cognitively intact older persons (11 hr). Twenty-three (23) semi-structured interviews with nine (9) RN participants (12 hr and 38 min). Participant observation period totalled 1,041 hr. RESULTS: The older persons' experiences of receiving pain care were based on a formulaic assessment process focusing on intensity of pain and pain management options provided often lacked their input. The older persons often did not perceive their pain care provision as being of benefit to themselves. The nurses lacked insight and understanding on the nature of pain for the older person. CONCLUSION: Understanding was gained into how the older persons' pain care was hampered due to the lack of appropriate, and meaningful pain care provision and provides insight into why the older hospitalised person continues to experience a less than optimal experience. RELEVANCE TO CLINICAL PRACTICE: Older hospitalised persons can gain continuity of pain care when nurses negotiate with them to repattern or restructure their nursing routines for pain care provision. Older people need inclusion into pain care decisions. All vulnerable older persons require nurses to use an evidence-based pain assessment tool.

Efficacy of the use of evidence-based algorithmic guidelines in the acute care setting for pain assessment and management in older people: a critical review of the literature.

AIM: The aim of the literature review was to identify all examples of primary research using an algorithmic approach for the implementation of a clinical practice guideline relating to pain assessment and/or management within acute care, with a specific focus on older people. DESIGN: Critical literature review. DATA SOURCES: Inclusion criteria were; English language publications within the past 13 years; peer reviewed; research conducted within a hospital; about adult inpatients. Exclusion criteria; research located outside of a hospital context; quality improvement studies; rehabilitation studies and literature reviews. REVIEW METHODS: Critical appraisal of the literature by using a qualitative interpretation of a translational approach. The literature was thematically mapped according to the criteria of credibility, transferability, plausibility and applicability. RESULTS: No clinical practice guideline was found that directly related to both assessment and management of pain using an algorithm in acute care for older people. Five studies were found to have relevance and were critically evaluated. CONCLUSION: A critique of the literature shows that an algorithmic approach is feasible for translation into a clinical practice guideline for assessment and management of pain in older people within the acute care setting. IMPLICATIONS FOR PRACTICE: Implementation of any algorithmic approach requires consideration of the environment, culture and availability of resources.