Understanding the provision of goal-concordant care in the intensive care unit: A sequential two-phase qualitative descriptive study.

BACKGROUND: Goal-concordant care in intensive care is care that aligns with the patient's expressed goals, values, preferences and beliefs. Communication and shared decision-making are key to ensuring goal-concordant care. AIMS: The aims of his study were to explore (i) critical care clinicians' perspectives on how patient goals of care were communicated between clinicians, patients, and family in the intensive care unit; (ii) critical care nurses' role in this process; and (iii) how goals of care were used to guide care. METHOD: Sequential two-phase qualitative descriptive design. Data were collected from February to June 2022 in a level-3 intensive care unit in a private hospital in Melbourne, Australia. In Phase One, individual interviews were conducted with critical care nurse participants (n = 11). In Phase Two, the findings were presented to senior clinical leaders (n = 2) to build a more comprehensive understanding. Data were analysed using Braun and Clarke's six step reflexive thematic analysis. FINDINGS: There was poor consensus on the term 'goals of care', with some participants referring to daily treatment goals or treatment limitations and others to patients' wishes and expectations beyond the ICU. Critical care nurses perceived themselves as information brokers and patient advocates responsible for ensuring patient goals of care were respected, but engaging in goals-of-care conversations was challenging. A lack of role clarity, poor team communication, and inadequate processes to communicate patient goals impeded goal-concordant care. Senior clinical leaders affirmed these views, emphasising the need to utilise critical care nurses' insight for practical solutions to improve patient care. CONCLUSIONS: Clarity in both, the term 'goals of care' and the critical care nurses' role in these conversations, are the essential first steps to ensuring patients' values, preferences, and beliefs to guide shared-decision-making and goal-concordant care. Improved verbal and written communication that is inclusive of all members of the treating team is key to addressing these issues.

Use of Wearable Devices to Monitor Postoperative Activity following Cardiac Surgery. A Systematic Scoping Review.

AIM: There is an emerging trend of using wearable digital technology to monitor patient activity levels in acute care contexts. However, the overall extent and quality of evidence for their use in acute cardiac surgery care is unclear. The purpose of this systematic scoping review was to evaluate current literature regarding the use of wearable activity trackers/accelerometers to monitor patient activity levels in the first 30-days following cardiac surgery. METHOD: A systematic scoping review was conducted. A search of CINAHL and MEDLINE Complete databases identified all peer reviewed research evidence published in English between 2010 and 2023. Studies evaluating the use of wearable, technology in adults who had undergone coronary bypass graft surgery (CAGS), and/valve replacement (VR) were included. Study data was summarised thematically. RESULTS: A total of 853 citations were identified. Once duplicates were removed, 816 studies were screened by title and abstract, 54 full-text studies were assessed for eligibility and 11 studies included. Accelerometers were able to capture changing exercise and physical activity levels over an acute care admission. Device use was acceptable to clinicians and patients. Low activity levels in the early postoperative period were associated with longer length of stay and higher 30-day readmissions. CONCLUSION: Wearable devices are acceptable and feasible to use in acute care. Use of wearable activity trackers by acute cardiac patients may increase patient participation in exercise and identify more sedentary patients who are a greater risk of increased length of stay and hospital readmission.

Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study.

BACKGROUND: Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce. AIM: To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making. DESIGN: Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis. SETTING AND PARTICIPANTS: This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate. FINDINGS: Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation. CONCLUSION: Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns. IMPLICATIONS FOR CLINICAL PRACTICE: Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.

Australian health care workers experience of PPE related side-effects. A cross-sectional survey.

Introduction: Protection of health care workers (HCWs) is a fundamental aspect of an effective pandemic response. During the COVID-19 pandemic, frequency, and duration of Personal Protective Equipment (PPE) use increased. The experience of PPE-related side-effects has potential to contribute to decreased compliance resulting in breaches in infection prevention and increasing risk of HCW exposure. This study aims were to measure the frequency of PPE-related side-effects amongst HCW in Australia, and to establish if an increased frequency of adverse reactions was related to the significant increase in use and extended duration of time spent in PPE. Methods: A descriptive cross-sectional survey was used. Results: Of the 559 respondents the majority were female (83.7%), aged 31-45 years old (33.6%). A pre-existing skin condition was reported by 266 (47.6%). Frequency of PPE related side-effects were: pressure-related 401 (71.7%), skin 321 (57.4%) and respiratory 20 (3.6%). Surgical mask use was significantly associated with pre-exiting skin conditions (ß = 1.494 (SE 0.186), df (1), p < 0.001). Side effects to N95 respirator use was more commonly reported by staff working in COVID-19 high-risk areas (ß = 0.572 (SE 0.211), df (1), p = 0.007) independent of work duration (ß = -0.056 (SE 0.075), df (1), p = 0.456), and pre-existing skin conditions (ß = 1.272, (SE.198), df (1), p < 0.001). Conclusion: The COVID-19 pandemic has seen a significant increase in the use of PPE. While the preventative benefits of PPE are significant, adverse events related to PPE use are frequently reported by HCW. Findings in this study highlight the need for innovation in PPE design to maximize protection while decreasing adverse effects and maintaining adhere to use.

Narrative synthesis of the effectiveness and characteristics of heart failure disease self-management support programmes.

A deeper understanding of the key elements that should be included in heart failure (HF) disease self-management support (DSMS) programmes is crucial to enhance programme effectiveness and applicability to diverse settings. We investigated the characteristics and effectiveness of DSMS programmes designed to improve survival and decrease acute care readmissions for people with HF and determine the generalizability and applicability of the evidence to low- and middle-income countries (LMICs). A narrative meta-synthesis approach was used, and systematic reviews of randomized controlled trials (RCTs) of DSMS programmes were included. The Cochrane Database of Systematic Reviews, MEDLINE, and Embase were searched without language restriction and guided by the adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight high-quality systematic reviews were identified representing 250 studies, of which 138 were unique RCTs measuring the outcomes of interest. The findings revealed statistically significant reductions in HF readmissions [relative risk (RR) range 0.64-0.85, P < 0.5, five out of six reviews], all-cause readmissions (RR range 0.85-0.95, P < 0.5, five out of six reviews), and all-cause mortality (RR range 0.67-0.87, P < 0.5, five out of five reviews). Overall, 44.2% (n = 61) of RCTs reduced acute care readmission and improved survival. Studies were categorized according to intensity (low, moderate, moderate+, and high) based on the opportunity for immediate treatment of HF instability; 29.2% (14/48) of low-intensity, 63.6% (21/33) of moderate-intensity, 40% (6/15) of moderate+-intensity, and 47.6% (20/42) of high-intensity interventions were effective. Most effective programmes used moderate-intensity (39.4%, 48%, or 50%, respectively) or high-intensity (33.3%, 36%, and 43.7%, respectively) interventions. The majority of studies (90.6%) were conducted in high-income countries. Programmes that provided opportunities for early recognition and response to HF instability were more likely to reduce acute care readmission and enhance survival. Generalizability and applicability to LMICs are clearly limited. Tailoring HF DSMS programmes to accommodate cultural, resource, and environmental challenges requires careful consideration of intervention intensity, duration of follow-up, and feasibility in low-resource settings.

"Building the plane while flying it" Reflections on pandemic preparedness and response; an organisational case study.

BACKGROUND: The COVID-19 pandemic provided a unique opportunity to learn about acute health organisations experiences implementing a pandemic response plan in real-time. This study was conducted to explore organisational leader's perspectives and experience activating a COVID-19 pandemic response plan in their health service and the impact of this on service provision, clinicians, and consumers. METHODS: This study was conducted at a large metropolitan health service in Australia that provides acute, subacute, and residential aged care services. Semi-structured interviews were conducted with 12 key participants from the COVID-19 leadership team between November-January 2021/2022. A semi-structured interview guide was developed to explore how the health service developed a clinical governance structure, policy and procedures and experience when operationalising each element within the Hierarchy of Controls Framework. Thematic analysis was used to code data and identify themes. A cross-sectional survey of frontline healthcare workers on the impacts and perceptions of infection control practices during the COVID-19 pandemic, was also completed in 2021 with 559 responses. RESULTS: Twelve organisational leaders completed the semi-structured interviews. Key themes that emerged were: (1) Building the plane while flying it, (2) A unified communications strategy, (3) Clinicians fear 'my job is going to kill me', (4) Personal Protective Equipment (PPE) supply and demand, and (5) Maintaining a workforce. When surveyed, front-line healthcare workers responded positively overall about the health services pandemic response, in terms of communication, access to PPE, education, training, and availability of resources to provide a safe environment. CONCLUSION: Health service organisations were required to respond rapidly to meet service needs, including implementing a pandemic plan, developing a command structure and strategies to communicate and address the workforce needs. This study provides important insights for consideration when health service leaders are responding to future pandemics. Future pandemic plans should include detailed guidance for acute and long-term care providers in relation to organisational responsibilities, supply chain logistics and workforce preparation.

Handheld Computer Devices to Support Clinical Decision-making in Acute Nursing Practice: Systematic Scoping Review.

BACKGROUND: Nursing care is increasingly supported by computerized information systems and decision support aids. Since the advent of handheld computer devices (HCDs), there has been limited exploration of their use in nursing practice. OBJECTIVE: The study aimed to understand the professional and clinical impacts of the use of mobile health apps in nursing to assist clinical decision-making in acute care settings. The study also aimed to explore the scope of published research and identify key nomenclature with respect to research in this emerging field within nursing practice. METHODS: This scoping review involved a tripartite search of electronic databases (CINAHL, Embase, MEDLINE, and Google Scholar) using preliminary, broad, and comprehensive search terms. The included studies were hand searched for additional citations. Two researchers independently screened the studies for inclusion and appraised quality using structured critical appraisal tools. RESULTS: Of the 2309 unique studies screened, 28 (1.21%) were included in the final analyses: randomized controlled trials (n=3, 11%) and quasi-experimental (n=9, 32%), observational (n=10, 36%), mixed methods (n=2, 7%), qualitative descriptive (n=2, 7%), and diagnostic accuracy (n=2, 7%) studies. Studies investigated the impact of HCDs on nursing decisions (n=12, 43%); the effectiveness, safety, and quality of care (n=9, 32%); and HCD usability, uptake, and acceptance (n=14, 50%) and were judged to contain moderate-to-high risk of bias. The terminology used to describe HCDs was heterogenous across studies, comprising 24 unique descriptors and 17 individual concepts that reflected 3 discrete technology platforms ("PDA technology," "Smartphone/tablet technology," and "Health care-specific technology"). Study findings varied, as did the range of decision-making modalities targeted by HCD interventions. Interventions varied according to the level of clinician versus algorithmic judgment: unstructured clinical judgment, structured clinical judgment, and computerized algorithmic judgment. CONCLUSIONS: The extant literature is varied but suggests that HCDs can be used effectively to support aspects of acute nursing care. However, there is a dearth of high-level evidence regarding this phenomenon and studies exploring the degree to which HCD implementation may affect acute nursing care delivery workflow. Additional targeted research using rigorous experimental designs is needed in this emerging field to determine the true potential of HCDs in optimizing acute nursing care.

Obstructive sleep apnea, chronic obstructive pulmonary disease and hypertensive microvascular disease: a cross-sectional observational cohort study.

Hypertensive microvascular disease is associated with an increased risk of diastolic heart failure, vascular dementia and progressive renal impairment. This study examined whether individuals with obstructive sleep apnoea (OSA) had more retinal hypertensive microvascular disease than those with chronic obstructive pulmonary disease (COPD) and hospital controls. This was a single-centre, cross-sectional, observational study of participants recruited consecutively from a general respiratory clinic and a general medical clinic. OSA was diagnosed on overnight polysomnography study (apnoea:hypopnoea index ≥ 5), and controls with COPD had a forced expiratory volume/forced vital capacity (forced expiratory ratio) < 70%. Individuals with both OSA and COPD were excluded. Hospital controls had no COPD on respiratory function testing and no OSA on specialist physician questioning. Study participants completed a medical questionnaire, and underwent resting BP measurement, and retinal photography with a non-mydriatic camera. Images were deidentified and graded for microvascular retinopathy (Wong and Mitchell classification), and arteriole and venular calibre using a semiautomated method at a grading centre. Individuals with OSA (n = 79) demonstrated a trend to a higher mean arterial pressure than other hospital patients (n = 143) (89.2 ± 8.9 mmHg, p = 0.02), and more microvascular retinopathy (p < 0.001), and narrower retinal arterioles (134.2 ± 15.9 µm and 148.0 ± 16.2 µm respectively, p < 0.01). Microvascular retinopathy and arteriolar narrowing were still more common in OSA than hospital controls, after adjusting for age, BMI, mean arterial pressure, smoking history and dyslipidaemia (p < 0.01, p < 0.01, respectively). Individuals with OSA demonstrated a trend to a higher mean arterial pressure than those with COPD (n = 132, 93.2 ± 12.2 mmHg and 89.7 ± 12.8 mmHg respectively, p = 0.07), and more microvascular retinopathy (p = 0.0001) and narrower arterioles (134.2 ± 15.9 and 152.3 ± 16.8, p < 0.01). Individuals with OSA alone had more systemic microvascular disease than those with COPD alone or other hospital patients without OSA and COPD, despite being younger in age.

Prevalence of chronic obstructive pulmonary disease and chronic bronchitis in eight countries: a systematic review and meta-analysis.

Objective: To estimate the prevalence of chronic obstructive pulmonary disease (COPD) and chronic bronchitis in eight countries in South Asia through a systematic review and meta-analysis. Methods: We searched MEDLINE® Complete, Web of Science, Embase®, Scopus, CINAHL and reference lists of screened studies for research on the prevalence of COPD and chronic bronchitis in South Asian countries published between January 1990 and February 2021. We used standardized diagnostic criteria for definitions of COPD and chronic bronchitis. Two reviewers undertook study screening, full-text review, quality appraisal and data extraction. Findings: Of 1529 studies retrieved, 43 met the inclusion criteria: 32 provided data from India; four from Bangladesh; three from Nepal; two from Pakistan; and two from both India and Sri Lanka. Twenty-six studies used standardized diagnostic definitions and 19 were included in the meta-analysis. The estimated pooled prevalence of COPD was 11.1% (95% confidence interval, CI: 7.4-14.8%), using the Global Initiative for Chronic Obstructive Lung Disease fixed criteria and 8.0% (95% CI: 5.6-10.4%) using the lower limit of normal criteria. The prevalence of COPD was highest in north India (19.4%) and Bangladesh (13.5%) and in men. The estimated pooled prevalence of chronic bronchitis was 5.0% (95% CI: 4.1-6.0%) in India and 3.6% (95% CI: 3.1-4.0%) in Pakistan. Conclusion: Included countries have a high prevalence of COPD although it varied by geographical area and study characteristics. Future research in South Asia should use standardized diagnostic criteria to examine the contribution of setting-specific risk factors to inform prevention and control strategies.

Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: a cluster randomised controlled trial.

BACKGROUND: People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care. OBJECTIVE: The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia. DESIGN: Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside. SUBJECTS & SETTING: One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff. METHODS: Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence. Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes. RESULTS: At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified. CONCLUSION: This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257 . Registered 14 December 2018.

Impact of Pain on Postoperative Recovery and Participation in Care Following Knee Arthroplasty Surgery: A Qualitative Descriptive Study.

BACKGROUND: Patient participation in care is key to optimising postsurgical outcomes and the quality of acute care delivery. AIMS: This study explored patient perceptions of the impact of pain on acute recovery following Total Knee Arthroplasty (TKA), and barriers and facilitators to participating in pain management. DESIGN: An exploratory-descriptive qualitative study involving semi-structured interviews. SETTINGS: A private-sector health service. PARTICIPANTS/SUBJECTS: Participants were adults undergoing TKA allocated to the control ward of a cluster randomised controlled trial who received standard care. METHODS: To allow adequate opportunity for participation in their care, interview and pain data were collected on postoperative Day 3. Acute pain was assessed using an 11-point Numerical Rating Scale (NRS). Interviews were analysed using combined qualitative thematic analysis and quantitative content analysis. RESULTS: Overall, 120 patients, 69 females (50.4%) and 68 males, were interviewed (mean age = 66.8 years, stadard deviation [SD] = 8.5). Most reported severe (NRS 7-10), day 3 pain (n = 76, 63.3%). Two themes emerged from interviews: (1) participants' postoperative pain experience; and (2) participation in postoperative pain management was limited. Pain experience was characterised by variation in pain and its qualities, having uncontrolled pain and distress, and influence from preoperative expectations. Patient participation was characterized by reliance upon prior staff instruction, barriers from limited knowledge, inconsistent promotion of non-pharmacologic strategies, and suboptimal clinician-patient communication. Regular analgesia was identified to facilitate participation. CONCLUSIONS: Despite the known benefits of patient participation in pain management, gaps remain in providing patients with the knowledge and opportunity to take an active role in their recovery. Interventions to overcome identified barriers need to be developed and evaluated.

Healthcare providers' experiences with advance care planning and goals of patient care medical treatment orders in residential aged care facilities: an explanatory descriptive study.

BACKGROUND: Advance care planning (ACP) is a process by which people communicate their healthcare preferences and values, planning for a time when they are unable to voice them. Within residential aged care facilities (RACF), both the completion and the clarity of ACP documents are varied and, internationally, medical treatment orders have been used to address these issues. AIMS: In this study, goals of patient care (GOPC) medical treatment orders were introduced alongside usual ACP in three RACF to improve healthcare decision-making for residents. This study explored the experiences of RACF healthcare providers with ACP and GOPC medical treatment orders. METHODS: The study used an explanatory descriptive approach. Within three RACF where the GOPC medical treatment orders had been introduced, focus groups and interviews with healthcare providers were performed. The transcribed interviews were analysed thematically. RESULTS: Healthcare providers not only reported support for ACP and GOPC but also discussed many problematic issues. Analysis of the data identified four main themes: enablers, barriers, resident autonomy and advance documentation (ACP and GOPC). CONCLUSION: Healthcare providers identified ACP and GOPC as positive tools for assisting with medical decision-making for residents. Although barriers exist in completion and activation of plans, healthcare providers described them as progressing resident-centred care. Willingness to follow ACP instructions was reported to be reduced by lack of trust by clinicians. Families were also reported to change their views from those documented in family-completed ACP, attributed to poor understanding of their purpose. Participants reported that GOPC led to clearer documentation of residents' medical treatment plans rather than relying on ACP documents alone.

Australian and Danish nurses' and midwives' wellbeing during COVID-19: A comparison study.

Background: Most investigations of nurses' and midwives' psychological wellbeing during the COVID-19 pandemic have been conducted in a single setting. Aim: To assess and compare the psychological wellbeing of nurses and midwives in Australia and Denmark during the COVID-19 pandemic. Methods: Nurses and midwives employed at four metropolitan health services in Australia and one in Denmark completed an anonymous online survey, which assessed depression, anxiety, and stress symptoms (The Depression, Anxiety and Stress Scale - 21 Items (DASS-21)), and sociodemographic and employment factors. Findings: Completed surveys were received from 3001 nurses and midwives (1611 Australian and 1390 Danish). Overall, approximately one in seven of the nurses and midwives surveyed reported moderate to extremely severe levels of depression (n = 399, 13.5%), anxiety (n = 381, 12.9%) and stress (n = 394, 13.4%). Australian nurses' and midwives' scores on all DASS-21 subscales were significantly higher (representing higher levels of depression, anxiety and stress) than the scores for the Danish nurses and midwives. Fewer years of clinical experience, living in Australia and being employed on a part-time basis were significantly associated with higher levels of psychological distress. Discussion: A considerable proportion of nurses and midwives experienced distress during the COVID-19 pandemic; however, the proportion and severity varied by country. Australian nurses and midwives experienced higher levels of distress than their Danish colleagues. Conclusion: Nurses and midwives working in countries with relatively low numbers of COVID-19 cases and deaths are also likely to experience psychological distress. Nurses and midwives would benefit from targeted country-specific support and wellbeing initiatives.

An evaluation of interventions to improve outcomes for hospitalized patients in isolation: A systematic review.

BACKGROUND: Isolation is effective in preventing transmission of infectious disease. However, it has been shown to have negative effects including increased anxiety and poor physical outcomes. OBJECTIVES: To summarize the effects of interventions to improve safety and outcomes for patients in isolation DESIGN: Systematic review (PROSPERO protocol registration - CRD42020222779). SETTING: Acute hospital PARTICIPANTS: Intervention studies including patients in preventative or protective isolation in a single room. METHODS: MEDLINE, Global Health, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Excerpta Medica database were searched from 1996-October 2020. Two independent reviewers screened references and assessed risk of bias. One reviewer extracted data and was checked by another. Main outcomes were Quality of Life and mortality. RESULTS: We identified 16,698 references and included 6 studies with different study designs. Average age ranged from 4-71 years. Samples sizes were small (range 10-49 participants) apart from one non-randomized controlled trial including >600 participants. Interventions were music therapy (n = 3), psychological counseling (n = 2) and exercise training (n = 1). One study reporting on Quality of Life and found no change after exercise. None of the studies reported on mortality. Due to heterogeneous results no meta-analyses were performed. CONCLUSIONS: There is a lack of high-quality evidence for effective comprehensive interventions to manage adverse effects associated with isolation. Future studies should investigate the effect of multi-component interventions using rigorous methods to improve outcomes for hospitalized isolated patients.

Factors influencing self-reported adherence to standard precautions among Thai nursing students: A cross sectional study.

AIM: This study explored nursing students' compliance with standard precautions (SPs) and attitudes to SPs in Thailand, to identify factors that may increase adherence to SPs and infection prevention and control best practice. BACKGROUND: In the context of high rates of healthcare associated infections as in Thailand, effective strategies to promote high levels of clinician adherence to SPs is a priority. Nursing students are one group of healthcare workers who play a vital role in caring for patients and constitute the future nursing workforce. DESIGN: A cross-sectional survey design was used. METHODS: A self-reported survey comprising the Compliance with Standard Precautions Scale and the Factors Influencing Adherence to Standard Precautions Scale were distributed to nursing students as a Thai paper-based survey. RESULTS: A total of '533 second' to fourth year nursing students from a tertiary nursing school in Bangkok, Thailand completed the survey. The average nursing student compliance to SPs was 68.5%. Most (91.2%) reported only using water for handwashing and 57.2% reported reuse of surgical masks. The fourth-year students had higher compliance (M=3.90, SD=1.12) on the 'prevention of cross infection from person-to-person' dimension while second-year students reported higher compliance on the 'disposal of sharps' (M=2.67, SD=0.57) dimension. 'Contextual Cues' was identified as the factor (M=3.41, SD=0.40) that had the greatest influence on adherence and 'Practice Culture' (M=1.84, SD=0.66) and 'Justification' (M = 1.35, SD.68 had the lowest influence. Fourth year students identified 'Leadership' (M=2.90, SD=0.49) as an important influence on adherence to SPs. CONCLUSIONS: To increase nursing students' adherence there needs to be greater emphasis on the importance of SPs in theoretical sessions and regular monitoring and feedback on hand hygiene performance and personal protective equipment use while students are on placements. More visible organizational leadership and promotion of high levels of adherence to SPs may assist students to translate their theoretical knowledge into practice.

Increased retinal venular calibre in acute infections.

Population-based studies have demonstrated that increased retinal venular calibre is a risk factor for cardiac disease, cardiac events and stroke. Venular dilatation also occurs with diabetes, obesity, dyslipidemia and autoimmune disease where it is attributed to inflammation. This study examined whether the inflammation associated with infections also affected microvascular calibre. Participants with infections and CRP levels  > 100 mg/L were recruited from the medical wards of a teaching hospital and assisted to complete a demographic and vascular risk factor questionnaire, and to undergo non-mydriatic retinal photography (Canon CR5-45NM, Japan). They were then treated with appropriate antibiotics, and underwent repeat retinal imaging when their CRP levels had fallen to less than 100 mg/L. Retinal images were examined for arteriole and venular calibre using validated semi-automated software based on Knudtson's modification of the Parr-Hubbard formula (IVAN, U Wisconsin). Differences in inflammatory markers and calibre were examined using the paired t-test for continuous variables. Determinants of calibre were calculated from multiple linear regression analysis. Forty-one participants with respiratory (27, 66%), urinary (6, 15%), skin (5, 12%), or miscellaneous (3, 7%) infections were studied. After antibiotic treatment, participants' mean CRP levels fell from 172.9 ± 68.4 mg/L to 42.2 ± 28.2 mg/L (p < 0.0001) and mean neutrophil counts fell from 9 ± 4 × 109/L to 6 ± 3 × 109/L (p < 0.0001). The participants' mean venular calibre (CRVE) decreased from 240.9 ± 26.9 MU to 233.4 ± 23.5 MU (p = 0.0017) but arteriolar calibre (CRAE) was unchanged (156.9 ± 15.2 MU and 156.2 ± 16.0 MU, p = 0.84). Thirteen additional participants with infections had a CRP > 100 mg/L that persisted at review (199.2 ± 59.0 and 159.4 ± 40.7 mg/L, p = 0.055). Their CRAE and CRVE were not different before and after antibiotic treatment (p = 0.96, p = 0.78). Hospital inpatients with severe infections had retinal venular calibre that decreased as their infections resolved and CRP levels fell after antibiotic treatment. The changes in venular calibre with intercurrent infections may confound retinal vascular assessments of, for example, blood pressure control and cardiac risk.

Inter-rater reliability and predictive accuracy of the Shkuratova Assessment of Falls-risk in Rehabilitation (SAFER) tool.

Despite the recognised importance of falls prevention in rehabilitation settings, there is limited research focusing on falls risk assessment tools designed to guide both patient screening and therapy. This study evaluated the predictive accuracy and inter-rater reliability of the Shkuratova Assessment of Falls-risk in Rehabilitation settings (SAFER) tool. The study was conducted at a subacute rehabilitation facility in Australia. Patient assessments were performed on admission to subacute care by trained physiotherapists, and the incidence of falls was documented prospectively. Of the 147 patients, 45 had at least one fall and were compared to 102 who had no falls. The inter-rater reliability of the SAFER tool when used by trained physiotherapists was high with the level of agreement for individual items ranging from 74 to 99%. Thirty-two (76%) patients who experienced a fall during their admission and 46 (44%) who did not fall were identified as having a high falls-risk. Using a SAFER tool cut-off of 12/26: sensitivity is 69%, specificity is 66%, area under the curve 0.71 (95% confidence interval: 0.62-0.80). The high negative predictive values at a range of cut-offs provided strong evidence that patients identified as having a low falls-risk were unlikely to experience a fall. Performing a comprehensive assessment of specific deficits in gait, balance and mobility on admission provided a streamlined approach to identification of patients who would benefit from tailored falls prevention interventions.

Pre-registration nursing and occupational therapy students' experience of interprofessional simulation training designed to develop communication and team-work skills: A mixed methods study.

To bridge the gap between university and the clinical environment, the university where this study was conducted incorporated interprofessional simulation sessions into the curricula for pre-registration nursing and occupational therapy students. The purpose of the study was to evaluate the effectiveness of simulation training to support the development of students' interprofessional communication and teamwork skills. Study participants were first-year students. A mixed methods study design was used that included: (1) a cross-sectional survey, (using the Interprofessional Education Collaborative Competency Self-Assessment tool), before and after the simulation session; and (2) two focus groups with students and one with academic staff. A total of 91 students and 5 staff participated. All students increased their self-perceived skills in interprofessional interactions. Two major themes were identified: 'Communication and Teamwork', with four sub-themes, (1) 'Significance of Communication in teamwork'; (2) 'Learning about, from and with each other'; (3) 'Professional role identification and collaborative practice'; and (4) 'Clinical leadership facilitated collaboration' and 'Lessons learnt from the simulation session', with three subthemes: (1) 'enhanced preparation for clinical placement'; (2) 'the experience of interacting with a simulated patient'; and (3) 'holistic patient care'. The results from the study demonstrated that interprofessional simulation sessions are an effective approach to introducing and developing collaborative clinical practice.

Diagnostic Accuracy of a Two-Stage Sequential Screening Strategy Implemented by Community Health Workers (CHWs) to Identify Individuals with COPD in Rural India.

PURPOSE: Undiagnosed Chronic Obstructive Pulmonary Disease (COPD) results in high morbidity, disability and mortality in India. Effective strategies for active COPD screening in community settings are needed to increase early identification, risk reduction and timely management. The objective of this study was to test the diagnostic accuracy of a sequential two-step screening strategy to detect COPD, implemented by community health workers (CHWs), among adults aged ≥40 years in a rural area of North India. PATIENTS AND METHODS: Trained CHWs screened all consenting (n=3256) eligible adults in two villages using the Lung Function Questionnaire (LFQ) to assess their COPD risk and conducted pocket spirometry on 268 randomly selected (132 with high risk ie LFQ score ≤18 and 136 with low risk ie LFQ score >18) individuals. Subsequently, trained researchers conducted post-bronchodilator spirometry on these randomly selected individuals using a diagnostic quality spirometer and confirmed the COPD diagnosis according to the Global Initiative for Obstructive Lung Disease (GOLD) criteria (FEV1/FVC ratio <0.7). RESULTS: This strategy of using LFQ followed by pocket spirometry was sensitive (78.6%) and specific (78.8%), with a positive predictive value of 66% and negative predictive value of 88%. It could accurately detect 67% of GOLD Stage 1, 78% of GOLD Stage 2, 82% of GOLD Stage 3 and 100% of GOLD Stage 4 individuals with airflow limitation. CONCLUSION: COPD can be accurately detected by trained CHWs using a simple sequential screening strategy. This can potentially contribute to accurate assessment of COPD and thus its effective management in low-resource settings.