Evaluating the process of practice enhancement for exclusive breastfeeding (PEEB): a participatory action research approach for clinical innovation.

BACKGROUND: Despite the known benefits of exclusive breastfeeding, global rates remain below recommended targets, with Ireland having one of the lowest rates in the world. This study explores the efficacy of Participatory Action Research (PAR) and Work-Based Learning Groups (WBLGs) to enhance breastfeeding practices within Irish healthcare settings from the perspective of WBLG participants and facilitators. METHODS: Employing a PAR approach, interdisciplinary healthcare professionals across maternity, primary, and community care settings (n = 94) participated in monthly WBLGs facilitated by three research and practice experts. These sessions, conducted over nine months (November 2021 - July 2022), focused on critical reflective and experiential learning to identify and understand existing breastfeeding culture and practices. Data were collected through participant feedback, facilitator notes, and reflective exercises, with analysis centered on participant engagement and the effectiveness of WBLGs. This approach facilitated a comprehensive understanding of breastfeeding support challenges and opportunities, leading to the development of actionable themes and strategies for practice improvement. RESULTS: Data analysis from WBLG participants led to the identification of five key themes: Empowerment, Ethos, Journey, Vision, and Personal Experience. These themes shaped the participants' meta-narrative, emphasising a journey of knowledge-building and empowerment for breastfeeding women and supporting staff, underlining the importance of teamwork and multidisciplinary approaches. The project team's evaluation highlighted four additional themes: Building Momentum, Balancing, Space Matters, and Being Present. These themes reflect the dynamics of the PAR process, highlighting the significance of creating a conducive environment for discussion, ensuring diverse engagement, and maintaining energy and focus to foster meaningful practice changes in breastfeeding support. CONCLUSION: This study highlights the potential of WBLGs and PAR to enhance the understanding and approach of healthcare professionals towards breastfeeding support. By fostering reflective and collaborative learning environments, the study has contributed to a deeper understanding of the challenges in breastfeeding support and identified key areas for improvement. The methodologies and themes identified hold promise to inform future practice and policy development in maternal and child health.

Laying the foundations for implementing Magnet principles in hospitals in Europe: A qualitative analysis.

BACKGROUND: Magnet hospitals, a concept developed in the U.S., have been associated with improved nurse recruitment and retention, and better patient outcomes. Magnet principles may be useful to address workforce challenges in European hospitals, but they have not been implemented or evaluated on a large scale in the European hospital context. OBJECTIVE: This study aims to explore the initial phase of implementing Magnet principles in 11 acute care hospitals in six European countries. The specific objectives of the study were to investigate the type of work that characterises the early phase of implementation and how implementation leaders engage with their context. METHODS: A multinational qualitative study was conducted, with data from 23 semi-structured, one-to-one interviews with implementation leaders in 11 acute care hospitals in six European countries. Thematic analyses guided the analysis of data. FINDINGS: Three themes of core work processes during the early phase of implementing Magnet principles in European hospitals were identified. The first theme, 'Creating space for Magnet', describes how work was directed towards creating both political and organisational space for the project. The second theme, 'Framing to fit: understanding and interpreting Magnet principles', describes the translational work to understand what the Magnet model entails and how it relates to the local hospital context. Finally, the third theme, 'Calibrating speed and dose', describes the strategic work of considering internal and external factors to adjust the process of implementation. CONCLUSIONS: The first phase of implementation was characterised by conceptual and relational work; translating the Magnet concepts, considering the fit into existing structures and practices and making space for Magnet in the local context. Understanding the local context played an important role in shaping and guiding the navigation of professional and organisational tensions. Hospitals employed diverse strategies to either emphasise or downplay the role of nurses and nursing to facilitate progress in the implementation.

Factors influencing communication partners of persons with severe/profound intellectual disability use of augmentative and alternative communication: an integrative review.

PURPOSE: To present a synthesis of evidence related to the factors influencing communication partners' use of augmentative and alternative communication with persons with severe/profound intellectual disability. MATERIALS AND METHODS: An integrative review guided by five steps; problem identification, literature search, data evaluation, data analysis and presentation was undertaken. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, nine databases were searched, 1,342 studies were screened against the eligibility criteria, and 15 studies underwent thematic analysis. RESULTS: Two themes emerged; (1) Achieving Meaningful Communication and (2) Communication Partners' Preparedness to Use Augmentative and Alternative Communication. Achieving meaningful communication was central to communication partners' use of augmentative and alternative communication and was two-fold. It involved identifying the persons' communication methods and encouraging them to communicate. Communication partners' preparedness also influenced their use of augmentative and alternative communication. This preparedness was impacted by communication partners' preconceived thoughts about and knowledge of augmentative and alternative communication, nurturing their belief in augmentative and alternative communication, and the interpersonal dynamic between network members. CONCLUSION: Communication partners' use of augmentative and alternative communication is influenced by multiple and complex factors. The findings contribute to the knowledge of the potential factors to be considered to prepare communication partners to use augmentative and alternative communication.

Multiple, complex factors influence communication partners of persons with severe/profound intellectual disability use of augmentative and alternative communication (AAC), which include communication partners' beliefs, attitudes, expectations, knowledge and resources such as training, support and time.To offer individuals with severe/profound intellectual disability opportunities to communicate, communication partners need to recognise their attempts and thus, their ability. Continuously being sensitive to the individuals' communication methods, whilst being cognisant that these methods can change may enhance communication partners' awareness and understanding of the individuals' communication attempts.Communication partners' need to feel prepared to use AAC. To feel prepared, they need to be aware of the potential benefits that AAC can offer the interaction and the long-term outcomes, develop their knowledge, and be surrounded by a supportive team dynamic.

Advanced nurse and midwife practitioners' experience of interprofessional collaboration when implementing evidence-based practice into routine care: An interpretative phenomenological analysis.

AIM: To understand advanced nurse and midwife practitioners' experience of interprofessional collaboration in implementing evidence-based practice into routine care. DESIGN: A qualitative interpretative phenomenological analysis. METHODS: A purposeful sample of 10 Registered Advanced Nurse and Midwife Practitioners from a range of practice settings in the Republic of Ireland participated in semi-structured interviews over a 10-month timeframe. Interviews were transcribed verbatim and data were analysed using a multi-stage approach in line with guidance for interpretative phenomenological analysis. RESULTS: Six superordinate themes emerged: Understanding of advanced practice; 'Treated as an equal and as a "nurse"'; Nursing management support; 'A voice to implement anything new'; Confidence and Emotional intelligence. These factors impacted interprofessional relationships and the extent to which advanced practitioners could implement evidence-based practice. CONCLUSION: There is scope to improve advanced practitioners' ability to collaborate with the interprofessional team in implementing evidence-based practice into routine care. IMPACT AND IMPLICATIONS: The study findings demonstrate that enhancing understanding of the advanced practice role; increasing organizational support for advanced practitioners and augmenting specific practitioner skills and attributes will increase their ability to collaborate effectively and implement evidence-based practice. Supporting advanced practitioners in this important aspect of their role will positively influence health outcomes for patients. CONTRIBUTION TO THE WIDER GLOBAL CLINICAL COMMUNITY: As numbers of both nurse and midwife practitioners increase globally, this study provides timely evidence from a range of practice settings to guide the design of education programmes and policies governing advanced practice. Study recommendations have broad applicability to all healthcare professionals who are engaged in implementing evidence-based practice into routine care. REPORTING METHOD: Consolidated criteria for reporting qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Teaching strategies for shared decision-making within the context of evidence-based healthcare practice: A scoping review.

OBJECTIVE: To describe the nature of teaching Shared Decision Making (SDM) within the context of Evidence Based Practice (EBP) to support development of contemporaneous EBP education programmes for healthcare learners. METHODS: A scoping review following the Joanna Briggs Institute (JBI) guidance was conducted with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) used to guide reporting. RESULTS: The narrative overview of 23 studies provides insight into the 'what' and 'how' of teaching SDM within the context of EBP education. A minority of studies explicitly and concurrently incorporated EBP and SDM in terms of how programme content was organised. Teaching strategies most often used regardless of learner cohort or setting included didactic, face-to-face lectures, together with role-play/modelling, small group workshops and video recordings. Programme evaluation outcomes predominantly focused on participant reactions to training and participant learning. CONCLUSION: While a disconnect between EBP and SDM remains evident in healthcare programmes, increased recognition by educators to actively facilitate this interdependent relationship is emerging. PRACTICE IMPLICATIONS: Intentionally structuring learning activities in a manner which demonstrates the relevance and interdependence of SDM and EBP may mitigate 'learning silos' and enhance learners' abilities to make connections required in practice.

Communication partners experiences of communicating with adults with severe/profound intellectual disability through augmentative and alternative communication: A mixed methods systematic review.

People with severe/profound intellectual disability experience challenges in communicating and require their communication partners to adapt to their means of communication. Augmentative and Alternative Communication (AAC) is recognised as a potential means to meet their communication needs. Interventions need to be aimed at both the individual and their communication partners. We conducted a mixed methods systematic review of the literature to synthesise evidence on communication partners experience of communicating with adults with severe/profound intellectual disability through AAC. Eight publications met the inclusion criteria, they underwent thematic synthesis where four themes emerged. A shared commitment to communication partnership is fundamental for the effective and efficient use of AAC. However, there was a disconnect between communication partners perceptions of their roles and responsibilities. This review prompts further research to explore communication partners perceptions of their roles and responsibilities in the use of AAC with people with severe/profound intellectual disabilities.

Evaluating the use of participatory action research to implement evidence-based guidance on dementia palliative care in long-term care settings: A creative hermeneutic analysis.

BACKGROUND: Dementia affects a large proportion of society and places a significant burden on older people and healthcare systems internationally. Managing symptoms at the end of life for people with dementia is complex. Participatory action research can offer an approach that helps to encourage implementation of evidence-based practices in long-term care settings. METHODS: Three evidence-based guidance documents (pain assessment and management, medication management, nutrition and hydration management) were introduced in three long-term care settings for older people. Data generated from work-based learning groups were analysed using a critical hermeneutic approach to explore the use of participatory action research to support the implementation of guidance documents in these settings. RESULTS: Engagement and Facilitation emerged as key factors which both enabled and hindered the PAR processes at each study site. CONCLUSIONS: This study adds to the body of knowledge that emphasises the value of participatory action research in enabling practice change. It further identifies key practice development approaches that are necessary to enable a PAR approach to occur in care settings for older people with dementia. The study highlights the need to ensure that dedicated attention is paid to strategies that facilitate key transformations in clinical practice.

Determining the need for a breast cancer awareness educational intervention for women with mild/moderate levels of intellectual disability: A qualitative descriptive study.

OBJECTIVE: Following a review of the existing body of literature, this study aimed to explore the need for a breast cancer awareness intervention specifically targeted at women with mild/moderate levels of intellectual disability (ID) and provide perspectives on the preferred processes and content underpinning an intervention. METHODS: A qualitative, descriptive design using semi-structured, individual (n = 5) and focus group (n = 5) interviews were used to engage with a non-probability, purposive sample of key stakeholders (n = 25) including women with mild/moderate levels of ID, caregivers and healthcare professionals. Data were analysed using qualitative content analysis. RESULTS: Findings highlighted that an educational intervention should focus on breast awareness as opposed to breast cancer awareness. Additionally, findings identified that a combined breast awareness and healthy living intervention could be effective. However, the intervention needs to have a multimodal, hands-on, person-centred approach to learning which is underpinned by theory. Furthermore, integrating the caregivers and healthcare professionals into the intervention is recommended. CONCLUSION: Findings from this study provide a foundation for developing and implementing a theoretically underpinned, multimodal, breast awareness and healthy living educational intervention for women with mild/moderate levels of ID.

Implementation of evidence-based guidance for dementia palliative care using participatory action research: examining implementation through the Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: The importance of providing evidence-based palliative care for people with dementia is increasingly acknowledged as important for patient outcomes. In Ireland, evidence-based guidance has been developed in order to address key features of dementia palliative care, including the management of pain, medications and hydration and nutrition. The aim of this study was to identify and explore the factors affecting the implementation of evidence-based guidance on dementia palliative care. METHODS: The Consolidated Framework for Implementation (CFIR) guided a mixed-method pre-post study. One guidance document pertaining to the management of pain, medication or hydration and nutrition was implemented in three long-term care facilities. Participatory action research in the form of work-based learning groups was used to implement the guidance, drawing on a situational analysis (pre-implementation). Staff questionnaires and audits were conducted pre- and post-implementation while champion interviews were also conducted post-implementation. RESULTS: Features of the guidance, the inner setting components such as readiness to change, and the process of implementation were most frequently identified as impacting implementation. Components of the outer setting, such as external policy incentives and individual characteristics, featured less commonly. Data from qualitative interviews revealed that the guidance was perceived as advantageous or complimentary to previous care provided. Within the inner setting, leadership and support from other colleagues facilitated implementation. However, limited availability of other healthcare professionals to assist with carrying out guidance actions presented a barrier in some facilities. The external facilitators of the work-based learning groups (WBLGs) were perceived as experienced and encouraged active participation and reflection on practices. Despite the challenge of releasing staff to attend the WBLGs, quantitative data demonstrated reduced staff de-motivation amongst those who did attend was noted post-implementation (pre-Mdn = 19.50 versus post-Mdn = 22.00, U = 497.00, p = 0.07). CONCLUSIONS: A situational analysis informed by the CFIR framework in conjunction with a participatory action research approach helped to advance the implementation of the guidance. The progress of implementation depended on the extent to which evidence-based care was previously being implemented at each site. Post-implementation analysis using CFIR identified challenges to address in future projects such as staff cover and timing of training to facilitate attendance for staff with different working hours. Facilitators included multidisciplinary engagement with the intervention and champions at each site to support the implementation process.

Symptom burden and functional performance in patients with chronic obstructive pulmonary disease.

BACKGROUND: The burden of COPD is growing, and it is one of the leading disease burdens worldwide. Studies on symptom burden as a multidimensional concept in COPD and functional performance are lacking, and little is known about the effect of multiple symptoms and symptom burden on functional performance. METHODS: A descriptive, cross-sectional correlational survey design was used. The Memorial Symptom Assessment Scale (MSAS) and the Functional Performance Inventory-Short Form (FPI-SF) were used to measure the symptom burden and functional performance. Data were analyzed using descriptive and inferential statistics. Participants (n = 214) were recruited from the respiratory outpatient clinic in one of the teaching hospitals in Ireland. RESULTS: Patients with COPD, regardless of classification, experienced significant physical and psychological symptom burden. A total of 20 symptoms were negatively correlated with overall functional performance, indicating a high symptom burden for those symptoms was associated with low overall functional performance. A statistically significant negative correlation between physical symptom burden, psychological symptom burden, total symptom burden, and functional performance was found. CONCLUSION: Patients with COPD experience a significant symptom burden and low functional performance. Decreased functional performance was not related only to a single burdensome symptom, but may also be related to the contribution of several physical/psychological burdensome symptoms, or both. Assessment and management of these symptoms are essential and imply that alleviating these symptoms' burden may promote improved functional performance. This study supported the growing body of evidence of the need for patients with advanced COPD to receive palliative care.

Patient-reported experiences of consultation with an advanced nurse practitioner: Factor structure and reliability analysis of the patient enablement and satisfaction survey.

AIM: The aim was to analyse the psychometric properties of a patient-reported-experience measure, the Patient Enablement and Satisfaction Survey (PESS), when used to evaluate the care provided by Advanced Nurse Practitioners (ANPs) in terms of factor structure and internal consistency. The PESS is a 20-item, patient-completed data collection tool that was originally developed to measure patient experience and enablement following consultation with nurses in general practice. DESIGN: Cross-sectional survey; validity and reliability analysis. METHODS: The sample in this study consisted of 178 patients who consulted with 26 ANPs working in four different specialities. Data were collected between June and December 2019. An exploratory factor analysis of the PESS was conducted to determine convergent validity which was supported by parallel analysis and the traditional Kaiser criterion. The internal consistency of individual PESS items was determined via Cronbach's alpha, McDonald's omega, the Average Variance Extracted tests and item-subscale/total score correlations. RESULTS: A three-factor structure (PESS-ANP) was found through exploratory factor analysis and this was supported by parallel analysis, the traditional Kaiser criterion and the percentage of variance explained criterion. A high degree of internal consistency was reported across all factors. One question was omitted from the analysis ('Overall Satisfaction') following the identification of problematic cross-loadings. The three factor solution was identified as: patient satisfaction, quality of care provision and patient enablement. CONCLUSION: The findings of this study propose a three-factor model that is sufficiently reliable for analysing the experience and enablement of patients following consultation with an ANP. IMPACT: Increasingly, patient-reported experience measures are being used to evaluate patients' experience of receiving care from a healthcare professional. The PESS was identified to be reliable in evaluating the experience of patients who receive care from an ANP while a three-factor structure was proposed that can capture specific attributes of this care.

Nurse Practitioners' Implementation of Evidence-Based Practice Into Routine Care: A Scoping Review.

BACKGROUND: Implementation of evidence-based practice (EBP) is essential for ensuring high-quality health care at minimum cost. Although all nurses have a responsibility to implement EBP at an individual patient level, nurse practitioners (NPs) as clinical leaders have additional responsibilities in leading and collaborating with transdisciplinary teams to implement EBP across patient groups and embed practice change into routine care. AIM: To explore the factors affecting the implementation of EBP into routine care by NPs. Specifically, to examine NP beliefs, levels of EBP implementation, and barriers and enablers to EBP implementation into routine care. METHODS: A scoping review was conducted using the Arksey and O'Malley (International Journal of Social Research Methodology, 8, 2005, 19) framework. The electronic databases CINAHL, Medline, and PsycINFO were searched for studies published between 2009 and 2018 along with gray literature and reference lists of included articles. Abstracts and studies were screened using predefined eligibility criteria. Data extraction was undertaken using a standardized framework and data synthesis completed. RESULTS: Seven studies were included in the review. Findings indicated NPs valued EBP and believed it to be important in standardizing patient care. NPs' implementation of EBP was found to be relatively low overall. It was not possible to fully determine the extent to which NPs implemented EBP into routine care. NPs experienced similar barriers to EBP implementation as do nurse generalists such as lack of time, lack of EBP competence, lack of support from colleagues and managers, and inadequate resources. In particular, NPs identified collaborative practice issues as factors affecting EBP implementation. Identified barriers included physician-driven practice and the need to maintain professional and political boundaries. Supportive collaborative relationships and having professional confidence were identified facilitators. LINKING EVIDENCE TO ACTION: An exploration of NPs' experience of interprofessional collaboration when implementing EBP into routine care is needed to identify requirements for support in this area.

Defining breast cancer awareness and identifying barriers to breast cancer awareness for women with an intellectual disability: A review of the literature.

INTRODUCTION: Incidence rates for developing breast cancer are similar for women regardless of intellectual ability. However, women with an intellectual disability present with advanced breast cancers, which often have a poor prognosis. METHOD: A structured narrative review of the literature was performed to explore the concepts of breast awareness and breast cancer awareness and subsequently, identify barriers to breast cancer awareness encountered by women with an intellectual disability. RESULTS: A total of 22 studies involving people with varying levels of intellectual disability informed this review. The barriers to breast cancer awareness encountered by women with an intellectual disability include: lack of their understanding, the role of the carer and literacy issues. CONCLUSION: Identifying the barriers to breast cancer awareness for women with an intellectual disability will help to facilitate breast cancer awareness which has the potential to result in better long-term outcomes through an early diagnosis of breast cancer.

Symptom burden in patients with chronic obstructive pulmonary disease.

BACKGROUND: There is now a growing body of evidence to suggest that patients with chronic disease experience their symptoms as a burden. Although symptoms are a principal focus for diagnosis and treatment of chronic obstructive pulmonary disease (COPD), there has been little research to date on symptom burden with reference to frequency, severity, and distress of symptoms. METHODS: A descriptive, cross-sectional survey design was used. Symptom burden was measured using the Memorial Symptom Assessment Scale (MSAS). A sample of 214 patients with COPD, recruited from one of the major teaching hospitals in Ireland. RESULTS: Patients experienced a median of 13 symptoms. Patients with 'very severe' COPD experienced the greatest number, with a median of 15 symptoms, followed by those with 'severe' COPD, with a median of 14 symptoms. Patients with 'mild' and 'moderate' COPD reported a median of 10 symptoms each. The most burdensome symptoms were shortness of breath, lack of energy, difficulty sleeping, worrying, dry mouth, feeling nervous, and feeling irritable. Total symptom burden was found to be low. Patients with 'very severe' COPD had the greatest symptom burden, followed by those with 'severe', 'moderate', and 'mild' COPD. Symptom burden was higher for psychological symptoms, with a mean score of 1.60 compared to the physical symptoms (mean = 0.87). CONCLUSION: Patients with COPD experience a remarkably high number of symptoms, and significant symptom burden of both physical and psychological symptoms. There is a need for early assessment and management of both physical and psychological symptoms in all patients with COPD.

Building capacity: getting evidence-based practice into healthcare professional curricula.

Fostering a culture of clinical effectiveness in healthcare is crucial to achieving optimum outcomes for patients. Evidence-based practice (EBP) is a cornerstone of clinical effectiveness. An EBP capacity-building project commenced in Ireland in 2016, in collaboration with the Centre of Evidence-Based Medicine in Oxford. A key part of this project, reported here, was the development of a competency framework for education in EBP and clinical effectiveness to ensure responsiveness of education standards and curricula of healthcare professionals in this area. METHODS: Following a review of national and international reports, professional guidance documents and empirical literature pertaining to clinical effectiveness education (CEE), a preliminary competency framework was developed. Stakeholder consultations were conducted over a 6-month period, which consisted of 13 focus groups (n=45) and included representatives from clinical practice, higher education and professional training sectors, regulator/accrediting bodies, the Department of Health (Ireland) and patient/service user groups. RESULTS: An overarching interprofessional competency framework for CEE was proposed and included the following domains: EBP, quality improvement processes, implementation strategies and collaborative practice: a total of 16 competencies and 60 indicators. CONCLUSION: A competency framework for CEE for health and social care professionals is presented. It is intended that this framework will provide guidance to healthcare educators and regulators in the construction and revision of curricula, learning outcomes, teaching and assessment strategies, and graduate/clinician attributes.

An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review.

OBJECTIVES: Patients are unintentionally, yet frequently, harmed in situations that are deemed preventable. Incident reporting systems help prevent harm, yet there is considerable variability in how patient safety incidents are reported. This may lead to inconsistent or unnecessary patterns of incident reporting and failures to identify serious patient safety incidents. This systematic review aims to describe international approaches in relation to defining serious reportable patient safety incidents. METHODS: Multiple electronic and gray literature databases were searched for articles published between 2009 and 2019. Empirical studies, reviews, national reports, and policies were included. A narrative synthesis was conducted because of study heterogeneity. RESULTS: A total of 50 articles were included. There was wide variation in the terminology used to represent serious reportable patient safety incidents. Several countries defined a specific subset of incidents, which are considered sufficiently serious, yet preventable if appropriate safety measures are taken. Terms such as "never events," "serious reportable events," or "always review and report" were used. The following dimensions were identified to define a serious reportable patient safety incident: (1) incidents being largely preventable; (2) having the potential for significant learning; (3) causing serious harm or have the potential to cause serious harm; (4) being identifiable, measurable, and feasible for inclusion in an incident reporting system; and (5) running the risk of recurrence. CONCLUSIONS: Variations in terminology and reporting systems between countries might contribute to missed opportunities for learning. International standardized definitions and blame-free reporting systems would enable comparison and international learning to enhance patient safety.

Ethical frameworks for quality improvement activities: an analysis of international practice.

PURPOSE: To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems. DATA SOURCES: We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries. STUDY SELECTION: National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada. DATA EXTRACTION: Data were extracted from 19 documents using an a priori framework developed from the published literature. RESULTS: We organized data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review but requires proportionate review or organizational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement. CONCLUSION: Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organizations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics.

Advance care planning in COPD: guidance development for healthcare professionals.

OBJECTIVES: To examine current practices, attitudes and levels of confidence related to advance care planning (ACP) in patients with chronic obstructive pulmonary disease (COPD) among healthcare professionals working in Ireland. This will inform future clinical guidance development. METHODS: A cross-sectional survey of healthcare professionals. RESULTS: There were 143 participants (109 general practitioners, 25 nurses, 7 physiotherapists and 2 consultant physicians). The majority (82%, n=117) cared for patients with COPD weekly, but only 23% (n=33) had initiated ACP with a patient with COPD over the previous 6 months. Overall, 59% (n=85) answered ≥6 of 8 general knowledge questions correctly. Participants demonstrated positive attitudes towards ACP (mean score 3.6/5.0), but confidence levels were low (2.2/4.0). Most thought ACP was appropriate for patients with severe or very severe COPD (71%, n=101%, and 91%, n=130, respectively) but were unsure or felt that it was not appropriate for those with mild-moderate COPD. However, almost all participants (97%, n=139) stated that if a patient expressed a desire to have ACP discussions, they would comply. Topics most likely to be discussed related to diagnosis and treatment options. Death and end-of-life issues were rarely discussed. The death of a family member or friend and participation in support groups were identified as new 'triggers' for initiating ACP. CONCLUSIONS: Targeted education to improve general knowledge and confidence levels among healthcare professionals, together with initiatives to increase public awareness of ACP so that patients themselves might be more inclined to start the discussion, may help increase the uptake of ACP for this patient group.

The development and psychometric testing of the Perinatal Infant Care Social Support (PICSS) instrument.

BACKGROUND: Social support facilitates a woman's transition to motherhood. This major developmental transition can be stressful as it includes adaptation of self as well as learning new infant care practice skills. Although a number of instruments have been developed to measure social support, none have been developed or underpinned by theory in the context of perinatal infant care practices. AIM: To develop a reliable and valid instrument to measure social support for new mothers in the perinatal period. METHODS: Phase 1 involved the development of instrument structure and content. Constructs to be measured were defined through an analysis of relevant theoretical and empirical literature. Phase 2 established the psychometric properties of the functional domain of the PICSS. Exploratory factor analyses and principal Component Analyses were undertaken with a sample of first-time mothers (n = 371) from postnatal wards of a large maternity hospital. Item reduction and Cronbach's alpha reliability tests were performed. The structural social support domain was not amenable to psychometric testing. RESULTS: Exploratory Factor Analyses and Principal Component Analyses of the functional domain resulted in a logically coherent 19-item, two-factor solution. The first factor 'Supporting Presence' has nine items (Cronbach's alpha = 0.90) and the second factor 'Practical Support' has ten items (Cronbach's alpha = 0.86). CONCLUSIONS: The PICSS is a coherent and valid measure of social support for new mothers in the postnatal period in the context of infant care practices.