When patients (and families) raise the alarm: Patient and family activated rapid response as a safety strategy for hospitals.

Patients and those close to them often have an intimate understanding of their condition and can participate in a broad range of clinical processes. During times of deterioration, their concerns might go unheard. Advocacy of family and friends can fulfil an important safety function and can support patients and healthcare professionals looking after them. If concerns by patients are not heard by the patient's primary team in hospital, patient and family activated rapid response systems allow patients and family members to alert critical care outreach teams directly. These types of systems are stipulated by regulators in Australia and in parts of the USA, and there are examples in the UK built around the 'Call for Concern' model championed by the Royal Berkshire Hospital. Implementation is not without its problems and requires a deep understanding of barriers and enablers. Empowering patients to escalate directly might help to change safety culture and have protective effects for patients and staff. Policy makers are urged to consider standardised regulation to aid implementation.

Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review.

BACKGROUND: Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas. OBJECTIVES: To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards. METHODS: We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE-CERQual. SEARCH STRATEGY: MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019. INCLUSION CRITERIA: Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care. RESULTS: We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE-CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment. CONCLUSION: This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative-clinician collaboration and the sharing of responsibility. RELEVANCE TO PRACTICE: These factors need to be addressed to promote more active partnerships when designing and implementing patient and family-initiated escalation of care interventions.

Co-design of a patient and family-initiated escalation of care intervention to detect and refer patient deterioration: Research protocol.

AIM: To co-design a patient and family-initiated intervention to improve the detection and escalation of patient deterioration on acute adult hospital wards in Northern Ireland and the Republic of Ireland. DESIGN: The design is a collective case study approach in an acute hospital in Northern Ireland and the Republic of Ireland using an adapted co-design approach and Medical Research Council framework guidelines. METHODS: Data will be collected from key stakeholders (patients, relatives, and healthcare professionals) using individual and focus group interviews and a review of patients' records. This will inform the development of a co-designed intervention and implementation strategy. The developed prototype will be further refined and optimized following a feedback session with stakeholders from each hospital site. This study was funded in February 2018 and Research Ethics Committee approval was granted in March 2019. DISCUSSION: This study will contribute to the growing knowledge base in relation to the interventions that improve the escalation of patient deterioration. It will also contribute to the intelligence, evidence and understanding of the role of patient and family participation in the detection and referral of clinical deterioration in acute adult hospital settings. IMPACT: There is an ongoing need to introduce systems or mechanisms in acute care hospital settings which allow patient or family members to have a greater role in escalating care when they are concerned about patient deterioration. To date there is limited evidence of rigorous studies examining this area and this study will use stakeholder engagement and involvement to co-design an intervention which will provide patients and families with a mechanism to address concerns which can be tested in practice.

Patient and family-initiated escalation of care: a qualitative systematic review protocol.

BACKGROUND: Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. This systematic review will address this gap. The aim of this review is to explore patients', relatives' and healthcare professionals' experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards. METHODS: We will search Medline, CINAHL, Embase and PsycINFO databases using free-text and MESH terms relating to deterioration, family-initiated rapid response, families, patients, healthcare staff, hospital and experiences. We will search grey literature and reference lists of included studies for further published and unpublished literature. All studies with a qualitative design or method will be included. Two reviewers will independently assess studies for eligibility, extract data and appraise the quality of included studies. Data will be synthesised using a thematic synthesis approach, and findings will be presented narratively. DISCUSSION: Patient- and family-initiated escalation of care schemes have been developed and implemented in several countries including the United States, the United Kingdom and Australia, but there is limited evidence regarding patients' or families' perceptions of deterioration or the barriers and facilitators to using these schemes in practice, particularly in acute adult areas. This systematic review will provide evidence for the development of a patient and family escalation of care scheme that can be tested in a feasibility study. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018106952.

The value of life story work for staff, people with dementia and family members.

Dementia is a term used to describe a collection of symptoms that include problems with memory, self-care, reasoning and communication. Care interventions that focus on preserving people's dignity and identity are therefore essential. Using Driscoll's reflective model to guide critical thinking, this article reflects on the use of one intervention, namely life story work, to promote person-centred care for people with dementia. It explores the value or effect of life story work for healthcare staff, the person with dementia and family members. It also highlights best practice guidelines that are useful to consider to promote its optimal success as an intervention in dementia care, for example, instigating it early in the dementia journey and embedding it in a supportive culture. It is important to highlight to nursing students the many positive aspects of incorporating life story work into practice.

An evaluation of a critical care course for undergraduate nursing students.

AIM: The aim of this paper was to evaluate a 2-day critical care course (CCC) delivered to a cohort of adult branch nursing students. BACKGROUND: In today's health care system there is an increase in the number of critically ill patients being cared for in a ward environment. As a result, nurses require the knowledge and skills to effectively manage this patient group. Skills such as prompt recognition of the sick patient, effective communication and performing basic management care skills are necessary. METHODS: The CCC was provided to final year adult branch nursing students (n = 182) within a university in the UK. On completion of the course, participants were invited to undertake a Likert scale questionnaire. The questionnaire also contained a free response section to elicit qualitative information. Quantitative data were analysed using SPSS version 17.0 and descriptive statistics produced. Qualitative responses were analysed thematically. RESULTS: There was a 73.7% (n = 135) response rate. Overall, there was a positive evaluation of the course. Students (89.6%; n = 121) reported a perceived increase in confidence when caring for critically ill patients following the course and 88.2% (n = 119) felt that their knowledge and skills had improved at the end of the 2-day course. CONCLUSION: This study supports the implementation of critical care training for undergraduate nursing students. There are implications for the development of specific modules, aiming to improve undergraduate nursing students' recognition, assessment and management of the critically ill patient. RELEVANCE TO CLINICAL PRACTICE: There is a shortage of critical care practice placements for undergraduate nursing students. It is essential that an undergraduate curriculum incorporates critical care teaching so that critical care skills are evident at the point of registration.

Acute cardiogenic pulmonary oedema: reflecting on the management of an intensive care unit patient.

AIM: The aim of this paper is to reflect upon the management interventions of non-invasive ventilation (NIV) and diuretic therapy that were implemented for a patient admitted to an intensive care unit (ICU) with acute cardiogenic pulmonary oedema. BACKGROUND: Acute pulmonary oedema is a serious and life-threatening complication of acute heart failure, particularly if this results from an ischaemic event. Statistics highlight that of those patients treated for acute cardiogenic pulmonary oedema, approximately only one third were alive after 1 year. Many of these patients will require intensive care management in order to restore homeostasis. It is therefore imperative that nurses understand the condition and the relevant management of it in order to maximize the already poor prognosis. RESULTS: Using Driscoll's (2000) reflective model to guide critical thinking, this paper reflects on the management of one patient who was admitted to ICU with acute cardiogenic pulmonary oedema as a result of heart failure. Although there are many aspects of patient management that can be explored, specific care interventions that this patient received in relation to NIV and diuretic therapy will be considered. The evidence base for their use, together with the relevant nursing management issues, and patient implications will be critically analysed and outlined. CONCLUSIONS: This paper identifies that standard therapy for acute cardiogenic pulmonary oedema is largely supportive and aimed at promoting gaseous exchange. It also highlights that nurses have a key role in ensuring that these essential treatments are as efficacious as possible. RELEVANCE TO CLINICAL PRACTICE: By using a reflective analysis approach, this paper highlights how reflecting on practice improves knowledge and understanding of the use of NIV and diuretic therapy interventions and should facilitate nurses working in ICU to become more competent in ensuring that the treatment provided for acute cardiogenic pulmonary oedema is as successful as possible.

Podcasts and videostreaming: Useful tools to facilitate learning of pathophysiology in undergraduate nurse education?

Nurses require an understanding of pathophysiological processes to support safe practice in the clinical area. A review of the literature indicates that nursing students have traditionally found this to be a challenging element of the course. The increasing availability of newer technology in higher education such as videostreaming and podcasting provides the opportunity to utilise a variety of approaches to cater for a wider range of learning styles. In view of this, lecturers developed multimedia resources to incorporate into a pathophysiology module. An evaluation of students' views on the use of ICT to facilitate understanding of pathophysiology was undertaken. The majority of students appeared to welcome the incorporation of alternative teaching approaches into the module. Interestingly despite the opportunities which technology offers to enhance learning many of the students also highlighted the importance of maintaining significant face-to-face contact with lecturers. This supports the findings of the literature which indicates that students find hybrid learning strategies that combine traditional teaching with more innovative methods particularly beneficial.

Addressing medication errors--The role of undergraduate nurse education.

Medication errors are a persistent problem in today's National Health Service (NHS). Many factors contribute to drug incidents occurring, from the initial prescription stage through to administration and arise from both individual and system failures. The literature identifies the multi-disciplinary nature of the problem and highlights the important contribution that nurses make with regards to ensuring medication safety. However limited evidence exists in the literature regarding the extent to which the current content of undergraduate pharmacology education prepares nurses for their role in the prevention of errors. The report "Building a safer NHS for patients-improving medication safety" [Department of Health, 2004. Building a Safer NHS for Patients: Improving Medication Safety. The Stationary Office, London] concludes that it is now imperative that undergraduate education should emphasise the issue of medication safety. An educational initiative was therefore introduced to address this problem. A "Medication Safety Day" which focused on the causes of medication errors was implemented to highlight how and why drug incidents may occur. This initiative recognises that nurse education should not only ensure adequate theoretical knowledge of pharmacology but should also equip students with an awareness of how many diverse factors may contribute to the occurrence of medication errors.

Relocation stress in critical care: a review of the literature.

1. Transfer to the ward following a period in intensive care may cause stress for patients. 2. A review of the literature reveals that this phenomenon has been described in a number of different ways, such as transfer stress, transfer anxiety, translocation syndrome and, more recently, relocation stress. 3. This paper reviews the various concepts before arriving at a more operational definition of the phenomenon. 4. It attempts to reveal what causes this phenomenon and to what extent it exists. 5. Patients' responses to transfer are identified and the physical and psychological problems that have been associated with discharge from intensive care are discussed. 6. Lists of interventions that the literature suggests may reduce or prevent this phenomenon from occurring are reviewed. 7. Recommendations for practice development and further research are made.

Leaving the intensive care unit: a phenomenological study of the patients' experience.

Discharge from intensive care (ICU), is said to pose difficulties for patients; a phenomenon referred to as "relocation stress". However, this phenomenon has not been fully examined, particularly from the critical care patients' perspective. This study, therefore, explored the lived experience of transfer from ICU to the ward. Phenomenology, based on the interpretative Heideggerian approach was used to guide the study. A purposive sample of six participants was selected. Open interviews were used to collect data. Participants were interviewed twice; once in ICU, prior to transfer, and once in the ward following transfer. The findings revealed that pre-transfer, participants were mainly accepting of their impending transfer. Participants discussed a desire for normality and identified that leaving the ICU staff was the most negative component of transfer. In the post-transfer period, findings revealed mixed feelings regarding the actual transfer. Participants were still suffering from physical complaints, which led to feelings of despondency. Differences between ICU and the ward were also highlighted. Finally, the enormity of the ICU experience appeared to have an impact post-transfer. The results of this study indicate that transfer from ICU can be problematic for some individuals. However, caution is required regarding the use of the nursing diagnosis of relocation stress without obtaining an individual perspective on experiences. Recommendations include the need for greater continuity of care for those recovering from critical illness.