Breastfeeding Attitudes and Social Support Among Christian African Americans.

Purpose: To describe the breastfeeding attitudes and subjective norms of breastfeeding among African American Christians from the New England region. Study Design and Methods: A study was conducted using an online survey. Participants were recruited from four Christian churches in the New England region during the summer of 2021. Responses from direct questions about exclusive breastfeeding histories were tabulated. Open-ended question responses were analyzed using thematic analysis. Two results were merged to make the conclusions. Results: Participants (n = 101) aged 18-44 years (62.3%), college graduates (72.3%), and Catholics (71.4%) responded. Participants were willing to recommend six months of exclusive breastfeeding practice to relatives (89.9%) and friends/peers (87.9%) and support relatives (94.0%) and friends/peers (94.8%) to practice exclusive breastfeeding for 6 months. Breastfeeding attitude themes included beneficial and natural and receiving breastfeeding support. Subjective norms of breastfeeding themes included receiving support for breastfeeding; Christian leadership, teachings, and communal engagements; and gaps in Christian influence. Conclusion: The African American Christian community may be an emergent agent of breastfeeding social support for African American Christian women who chose to breastfeed. Health professionals should collaborate with African American Christian leadership to initiate programs to promote breastfeeding among African American Christian women in the United States.

Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis.

PURPOSE: The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada. MATERIAL AND METHODS: We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record. RESULTS: 44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events. CONCLUSIONS: An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

Occupational Injuries and Illnesses among Paramedicine Clinicians: Analyses of US Department of Labor Data (2010 - 2020).

OBJECTIVE: Paramedicine clinicians (PCs) in the United States (US) respond to 40 million calls for assistance every year. Their fatality rates are high and their rates of nonfatal injuries are higher than other emergency services personnel, and much higher than the average rate for all US workers. The objectives of this paper are to: describe current occupational injuries among PCs; determine changes in risks over time; and calculate differences in risks compared to other occupational groups. METHODS: This retrospective open cohort study of nonfatal injuries among PCs used 2010 through 2020 data from the US Department of Labor (DOL), Bureau of Labor Statistics; some data were unavailable for some years. The rates and relative risks (RRs) of injuries were calculated and compared against those of registered nurses (RNs), fire fighters (FFs), and all US workers. RESULTS: The annual average number of injuries was: 4,234 over-exertion and bodily reaction (eg, motion-related injuries); 3,935 sprains, strains, and tears; 2,000 back injuries; 580 transportation-related injuries; and over 400 violence-related injuries. In this cohort, women had an injury rate that was 50% higher than for men. In 2020, the overall rate of injuries among PCs was more than four-times higher, and the rate of back injuries more than seven-times higher than the national average for all US workers. The rate of violence-related injury was approximately six-times higher for PCs compared to all US workers, seven-times higher than the rate for FFs, and 60% higher than for RNs. The clinicians had a rate of transportation injuries that was 3.6-times higher than the national average for all workers and 2.3-times higher than for FFs. Their overall rate of cases varied between 290 per 10,000 workers in 2018 and 546 per 10,000 workers in 2022. CONCLUSIONS: Paramedicine clinicians are a critical component of the health, disaster, emergency services, and public health infrastructures, but they have risks that are different than other professionals.This analysis provides greater insight into the injuries and risks for these clinicians. The findings reveal the critical need for support for Emergency Medical Services (EMS)-specific research to develop evidence-based risk-reduction interventions. These risk-reduction efforts will require an enhanced data system that accurately and reliably tracks and identifies injuries and illnesses among PCs.

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models.

BACKGROUND: Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta. METHODS: We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis. RESULTS: Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible. INTERPRETATION: Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.

A Cohort Study of Occupational Fatalities among Paramedicine Clinicians: 2003 through 2020.

INTRODUCTION/STUDY OBJECTIVES: Emergency medical technicians (EMTs) and paramedics respond to 40 million calls for assistance every year in the United States; these paramedicine clinicians are a critical component of the nation's health care, disaster response, public safety, and public health systems. The study objective is to identify the risks of occupational fatalities among paramedicine clinicians working in the United States. METHODS: To determine fatality rates and relative risks, this cohort study focused on 2003 through 2020 data of individuals classified as EMTs and paramedics by the United States Department of Labor (DOL). Data provided by the DOL and accessed through its website were used for the analyses. The DOL classifies EMTs and paramedics who have the job title of fire fighter as fire fighters and so they were not included in this analysis. It is unknown how many paramedicine clinicians employed by hospitals, police departments, or other agencies are classified as health workers, police officers, or other and were not included in this analysis. RESULTS: An average of 206,000 paramedicine clinicians per year were employed in the United States during the study period; approximately one-third were women. Thirty percent (30%) were employed by local governments. Of the 204 total fatalities, 153 (75%) were transportation-related incidents. Over one-half of the 204 cases were classified as "multiple traumatic injuries and disorders." The fatality rate for men was three-times higher than for women (95% confidence interval [CI], 1.4 to 6.3). The fatality rate for paramedicine clinicians was eight-times higher than the rate for other health care practitioners (95% CI, 5.8 to 10.1) and 60% higher than the rate for all United States workers (95% CI, 1.24 to 2.04). CONCLUSIONS: Approximately 11 paramedicine clinicians are documented as dying every year. The highest risk is from transportation-related events. However, the methods used by the DOL for tracking occupational fatalities means that many cases among paramedicine clinicians are not included. A better data system, and paramedicine clinician-specific research, are needed to inform the development and implementation of evidence-based interventions to prevent occupational fatalities. Research, and the resulting evidence-based interventions, are needed to meet what should be the ultimate goal of zero occupational fatalities for paramedicine clinicians in the United States and internationally.

Disparities in 6 Month Exclusive Breastfeeding in Ghana, Africa: A Scoping Review.

BACKGROUND: Exclusive breastfeeding practice for 6 months is a critical global public health goal. In 2020, only 44% of infants globally, 31% in Central and West Africa, and 43% in Ghana, were exclusively breastfed for the first 6 months of life. RESEARCH AIM: To critically evaluate disparities in exclusive breastfeeding practice for 6 months in Ghana. METHODS: The scoping review was guided by Arksey and O'Malley's (2005) six-stage scoping review process. The online databases of American Psychological Association PsychInfo (APA PsychInfo), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Scopus were searched with keywords inclusive of Ghana, exclusive breastfeeding, breastfeeding, infant feeding, lactation, lactating, and exclusive. Eligibility criteria included full-text, peer-reviewed research articles written in the English language without limitation to specific years. Data were analyzed thematically. RESULTS: Initially, 317 records were identified, and 15 full-text articles were eligible for the scoping review. Four main themes emerged as disparities in exclusive breastfeeding practice in Ghana. The themes were healthcare (prenatal clinic visits, delivery place, exclusive breastfeeding knowledge), personal (maternal age, Human Immunodeficiency Virus status, parity, type of delivery, breast problem), employment (unemployed, formal, or informal sector worker), and sociocultural (ethnicity/region, family support, religious beliefs, cultural practices). CONCLUSION: Disparities in exclusive breastfeeding in Ghana warrant the collaborative efforts of stakeholders for successful mitigation. Future researchers should explore the role of religion and sociocultural practices to protect, promote, and support 6 months of exclusive breastfeeding in Ghana.

Breastfeeding Social Support Among African American Women in the United States: A Meta-Ethnography.

BACKGROUND: In the United States, there are racial disparities in 6 months of exclusive breastfeeding. Only, 25.8% of American infants were breastfed for the first 180 days of life, with African American infants least (19.8%) exclusively breastfed in 2018. PURPOSE: The meta-ethnography explored the breastfeeding support for African American women in the United States. DATA SOURCES: The online databases of American Psychological Association, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Scopus were searched with key words, and the search was not limited by the year of publication. STUDY SELECTION: The inclusion criteria for the study selection entailed all qualitative studies conducted on breastfeeding support among self-identified African American women in the United States, written in English language, peer reviewed, or dissertation. The initial search produced 905 articles of which 8 met the eligibility criteria. DATA EXTRACTION: Data extraction and analysis were guided by Noblit and Hare's (1988) meta-ethnography approach. The analysis process was completed by a team of researchers, inclusive of breastfeeding experts. RESULTS: Five overarching themes emerged including trustworthy information; early postpartum support by key influencers; maternal culture; tangible resources, and Black mothers' empowerment. IMPLICATIONS FOR PRACTICE AND RESEARCH: Social support is a major determinant for the initiation and continuation of breastfeeding among African American women in the United States. Future longitudinal studies are warranted to explore the social support of breastfeeding among African American women in the United States.

Identifying the core components of a nursing home hospital avoidance programme.

BACKGROUND: Nursing home hospital avoidance programmes have contributed to a reduction in unnecessary emergency transfers but a description of the core components of the programmes has not been forthcoming. A well-operationalised health-care programme requires clarity around core components to evaluate and replicate the programme. Core components are the essential functions and principles that must be implemented to produce expected outcomes. OBJECTIVES: To identify the core components of a nursing home hospital avoidance programme by assessing how the core components identified at one nursing home (Site One) translated to a second nursing home (Site Two). METHODS: Data collected during the programme's implementation at Site Two were reviewed for evidence of how the core components named at Site One were implemented at Site Two and to determine if any additional core components were evident. The preliminary updated core components were then shared with seven evaluators familiar with the hospital avoidance programme for consensus. RESULTS: The updated core components were agreed to include the following: Decision Support Tools, Advanced Clinical Skills Training, Specialist Clinical Support and Collaboration, Facility Policy and Procedures, Family and Care Recipient Education and Engagement, Culture of Staff Readiness, Supportive Executive and Facility Management. CONCLUSION: This study launches a discussion on the need to identify hospital avoidance programme core components, while providing valuable insight into how Site One core programme components, such as resources, education and training, clinical and facility support, translated to Site Two, and why modifications and additions, such as incorporating the programme into facility policy, family education and executive support were necessary, and the ramifications of those changes. The next step is to take the eight core component categories and undertake a rigorous fidelity assessment as part of formal process evaluation where the components can be critiqued and measured across multiple nursing home sites. The core components can then be used as evidence-based building blocks for developing, implementing and evaluating nursing home hospital avoidance programmes.

Comparison of the Management and Short-Term Outcomes between Patients with Advanced Cancer and Other End-of-Life Conditions Presenting to Two Canadian Emergency Departments.

Background: An increasing number of patients with end-of-life (EOL) conditions, particularly those with advanced cancer, are presenting to the emergency department (ED). Objectives: To assess the characteristics, management and short-term outcomes of ED patients with advanced cancer compared to patients with other EOL conditions. Methodology/Design: A secondary analysis of a prospective cohort study. Setting/Participants: Volunteer emergency physicians in two Canadian EDs identified presentations for advanced cancer and other EOL conditions with the aid of a modified screening tool March-August 2018. Results: Among the 663 presentations by patients with EOL conditions, 272 (41%) presented with advanced cancer. The majority of presentations for advanced cancer (81%) or other EOL conditions (77%) were by patients with unmet palliative care (PC) needs. Patients with advanced cancer were significantly less likely to have active goals of care (GOC) documented on their charts (53% vs. 75%; p < 0.001). While no significant differences were found between the groups, the majority of presentations involved imaging, investigations, consultations, and hospitalization. Presentations for advanced cancer were more likely to receive a postdischarge referral (38% vs. 23%; p < 0.001). Referrals to PC consultations or postdischarge referrals were infrequent. Regression analysis found that patients with advanced cancer were associated with shorter length of stay (LOS). Conclusions: The majority of presentations for advanced cancer or other EOL conditions involved significant resource use. Patients with cancer experienced shorter LOS; however, had less documentation of GOC and gaps in referrals to PC services were identified. Interventions should be explored to promote early GOC discussions and PC referrals in this patient group.

Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study.

BACKGROUND: Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process. METHODS: We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis. RESULTS: Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians. INTERPRETATION: These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs.

INTRODUCTION: This study examined emergency department (ED) presentations of patients with end of life (EOL) conditions and patients having met and unmet palliative care needs were compared. METHODS: Presentations for EOL conditions were prospectively identified and screened for palliative care needs. Descriptive data were reported as proportions, means or medians. Bi-variable analysis for dichotomous and continuous variables were performed by chi-squared and T-tests (p≤0.01), respectively. A multivariable logistic regression model identified factors associated with having unmet palliative needs and reported adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Overall, 663 presentations for EOL conditions were identified; 518 (78%) involved patients with unmet palliative care needs. Presentations by patients with unmet palliative needs were more likely to involve consultations (80% vs. 67%, p = 0.001) and result in hospitalization (69% vs. 51%, p<0.001) compared to patients whose palliative needs were met. Patients with unmet palliative care needs were more likely to have previous ED visits (73% unmet vs. 48% met; p<0.001). While medication, procedures, investigations and imaging ordering were high across all patients with EOL conditions, there were no significant differences between the groups. Consultations with palliative specialists in the ED (6% unmet vs. 1% met) and following discharge (29% unmet vs. 18% met) were similarly uncommon. Patients having two or more EOL conditions (aOR = 2.41; 95% CI: 1.16, 5.00), requiring hospitalization (aOR = 1.93; 95% CI: 1.30, 2.87), and dying during the ED visit (aOR = 2.15; 95% CI: 1.02, 4.53) were strongly associated with having unmet palliative care needs. CONCLUSIONS: Most ED presentations for EOL conditions were made by patients with unmet palliative care needs, who were significantly more likely to require consultation, hospitalization, and to die. Referrals to palliative care services during and after the ED visit were infrequent, indicating important opportunities to promote these services.

An Assessment of the Management of Patients with Advanced End-Stage Illness in the Emergency Department: An Observational Cohort Study.

Background: Presentations to the emergency department (ED) by patients with end-of-life (EOL) conditions for their acute care needs are common. Objectives: The objective of this study was to identify and describe the ED management across presentations to the ED for EOL conditions. Design: Prospective observational cohort study. Settings/Subjects: Emergency physicians in two Canadian ED's were asked to identify presentations by adult patients with EOL conditions using a modified screening tool. Measurements: Patient characteristics and ED management for each presentation were collected through chart review by trained research assistants. Descriptive analyses were conducted as appropriate and bivariate comparisons of dichotomous and continuous variables were completed using χ2 tests and using t test or Wilcoxon rank-sum test, respectively. Results: Physicians identified 663 ED presentations for EOL conditions, with advanced cancer (41%), dementia (23%), and chronic obstructive pulmonary disease (16%) being the most common EOL conditions. The majority of presentations involved consultations (77%), hospitalization (65%), and numerous investigations (97%), including blood work (97%) and imaging (92%). The majority of patients with EOL conditions had a history of ED visits (68%). Using a modified screening tool, 78% of presentations involved patients with unmet palliative care needs, but only 1% of presentations involved a palliative consultation or admission to a palliative care unit. Conclusion: Presentations to the ED for EOL conditions involve significant ED resources; however, only a handful of patients are referred to palliative services. Patients with EOL conditions are appropriate targets for palliative services and community support outside the ED.

Black/African American Breastfeeding Experience: Cultural, Sociological, and Health Dimensions Through an Equity Lens.

Background: Disparities in breastfeeding (BF) continue to be a public health challenge, as currently only 42% of infants in the world and 25.6% of infants in the United States are exclusively breastfed for the first 6 months of life. In 2019, the infants least likely to be exclusively breastfed at 6 months are African Americans (AA) (17.2%). Materials and Methods: A scoping review of the literature was undertaken by using Arksey and O'Malley's six-stage framework to determine key themes of AA women's experience BF through an equity lens. Electronic databases of CINAHL and PubMed were searched for peer-reviewed, full-text articles written in the English language within the past 5 years by using the terms BF, AA, Black, sociological, cultural, equity, health, attitude, exposure, initiation, continuation, barriers, and facilitators. Results: Initially, 497 articles were identified, and 26 peer-reviewed articles met the eligibility criteria. Through an equity lens, three main themes emerged, which summarized AA women's BF experience: cultural (family, peers and community support; misconceptions; personal factors), sociological (prejudices, racism, home environment; financial status; sexuality issues; BF role models; employment policies), and health dimensions (family involvement; timely and honest information from staff; baby-friendly hospital initiatives; postnatal follow-up; special supplemental nutrition program for women, infants, and children). Conclusion: For AA women, exclusively BF is beset with diverse cultural, health, and sociological challenges. Multifaceted approaches are needed for successful resolution of BF challenges to bridge the racial gap in BF in the United States. Future studies may explore interventions targeted to modifiable barriers to improve BF outcomes.

The effectiveness and cost effectiveness of a hospital avoidance program in a residential aged care facility: a prospective cohort study and modelled decision analysis.

BACKGROUND: Residential aged care facility residents experience high rates of hospital admissions which are stressful, costly and often preventable. The EDDIE program is a hospital avoidance initiative designed to enable nursing and care staff to detect, refer and quickly respond to early signals of a deteriorating resident. The program was implemented in a 96-bed residential aged care facility in regional Australia. METHODS: A prospective pre-post cohort study design was used to collect data on costs of program delivery, hospital admission rates and length of stay for the 12 months prior to, and following, the intervention. A Markov decision model was developed to synthesize study data with published literature in order to estimate the cost-effectiveness of the program. Quality adjusted life years (QALYs) were adopted as the measure of effectiveness. RESULTS: The EDDIE program was associated with a 19% reduction in annual hospital admissions and a 31% reduction in the average length of stay. The cost-effectiveness analysis found the program to be both more effective and less costly than usual care, with 0.06 QALYs gained and $249,000 health system costs saved in a modelled cohort of 96 residents. A probabilistic sensitivity analysis estimated that there was an 86% probability that the program was cost-effective after taking the uncertainty of the model inputs into account. CONCLUSIONS: This study provides promising evidence for the effectiveness and cost-effectiveness of a nurse led, early intervention program in preventing unnecessary hospital admissions within a residential aged care facility. Further research in multi-site randomised studies is needed to confirm the generalisability of these results.

From symptom to cancer diagnosis: Perspectives of patients and family members in Alberta, Canada.

BACKGROUND: Significant intervals from the identification of suspicious symptoms to a definitive diagnosis of cancer are common. Streamlining pathways to diagnosis may increase survival, quality of life post-treatment, and patient experience. Discussions of pathways to diagnosis from the perspective of patients and family members are crucial to advancing cancer diagnosis. AIM: To examine the perspectives of a group of patients with cancer and family members in Alberta, Canada, on factors associated with timelines to diagnosis and overall experience. METHODS: A qualitative approach was used. In-depth, semi-structured interviews with patients with cancer (n = 18) and patient relatives (n = 5) were conducted and subjected to a thematic analysis. FINDINGS: Participants struggled emotionally in the diagnostic period. Relevant to their experience were: potentially avoidable delays, concerns about health status, and misunderstood investigation process. Participants emphasized the importance of their active involvement in the care process, and had unmet supportive care needs. CONCLUSION: Psychosocial supports available to potential cancer patients and their families are minimal, and may be important for improved experiences before diagnosis. Access to other patients' lived experiences with the diagnostic process and with cancer, and an enhanced supportive role of family doctors might help improve experiences for patients and families in the interval before receiving a diagnosis of cancer, which may have a significant impact on wellbeing.

International Survey of Violence Against EMS Personnel: Physical Violence Report.

IntroductionEach year, Emergency Medical Services (EMS) personnel respond to over 30 million calls for assistance in the United States alone. These EMS personnel have a rate of occupational fatality comparable to firefighters and police, and a rate of non-fatal injuries that is higher than the rates for police and firefighters and much higher than the national average for all workers. In Australia, no occupational group has a higher injury or fatality rate than EMS personnel. Emergency Medical Services personnel in the US have a rate of occupational violence injuries that is about 22-times higher than the average for all workers. On average, more than one EMS provider in the US is killed every year in an act of violence.Hypothesis/ObjectiveThe objective of this epidemiological study was to identify the risks and factors associated with work-related physical violence against EMS personnel internationally. METHODS: An online survey, based on a tool developed by the World Health Organization (WHO; Geneva, Switzerland), collected responses from April through November 2016. RESULTS: There were 1,778 EMS personnel respondents from 13 countries; 69% were male and 54% were married. Around 55% described their primary EMS work location as "urban." Approximately 68% described their employer as a "public provider." The majority of respondents were from the US.When asked "Have you ever been physically attacked while on-duty?" 761 (65%) of the 1,172 who answered the question answered "Yes." In almost 10% (67) of those incidents, the perpetrator used a weapon. Approximately 90% of the perpetrators were patients and around five percent were patient family members. The influence of alcohol and drugs was prevalent. Overall, men experienced more assaults than women, and younger workers experienced more assaults than older workers. CONCLUSIONS: In order to develop and implement measures to increase safety, EMS personnel must be involved with the research and implementation process. Furthermore, EMS agencies must work with university researchers to quantify agency-level risks and to develop, test, and implement interventions in such a way that they can be reliably evaluated and the results published in peer-reviewed journals. MaguireBJ, BrowneM, O'NeillBJ, DealyMT, ClareD, O'MearaP. International survey of violence against EMS personnel: physical violence report. Prehosp Disaster Med. 2018;33(5):526-531.

Preventing EMS workplace violence: A mixed-methods analysis of insights from assaulted medics.

OBJECTIVE: To describe measures that assaulted EMS personnel believe will help prevent violence against EMS personnel. METHODS: This mixed- methods study includes a thematic analysis and directed content analysis of one survey question that asked the victims of workplace violence how the incident might have been prevented. RESULTS: Of 1778 survey respondents, 633 reported being assaulted in the previous 12 months; 203 of them believed the incident could have been prevented and 193 of them (95%) answered this question. Six themes were identified using Haddon's Matrix as a framework. The themes included: Human factors, including specialized training related to specific populations and de-escalation techniques as well as improved situational awareness; Equipment factors, such as restraint equipment and resources; and, Operational and environment factors, including advanced warning systems. Persons who could have prevented the violence were identified as police, self, other professionals, partners and dispatchers. Restraints and training were suggested as violence-prevention tools and methods CONCLUSIONS: This is the first international study from the perspective of victimized EMS personnel, to report on ways that violence could be prevented. Ambulance agencies should consider these suggestions and work with researchers to evaluate risks at the agency level and to develop, implement and test interventions to reduce the risks of violence against EMS personnel. These teams should work together to both form an evidence-base for prevention and to publish findings so that EMS medical directors, administrators and professionals around the world can learn from each experience.

Nursing staff intentions towards managing deteriorating health in nursing homes: A convergent parallel mixed-methods study using the theory of planned behaviour.

AIMS AND OBJECTIVES: To predict the factors that are most important in explaining nursing staff intentions towards early detection of the deteriorating health of a resident and providing subacute care in the nursing home setting. BACKGROUND: Nursing staff play a pivotal role in managing the deteriorating resident and determining whether the resident needs to be transferred to hospital or remain in the nursing home; however, there is a dearth of literature that explains the factors that influence their intentions. This information is needed to underpin hospital avoidance programs that aim to enhance nursing confidence and skills in this area. DESIGN: A convergent parallel mixed-methods study, using the theory of planned behaviour as a framework. METHODS: Surveys and focus groups were conducted with nursing staff (n = 75) at a 94-bed nursing home at two points in time, prior to and following the implementation of a hospital avoidance program. The quantitative and qualitative data were analysed separately and merged during final analysis. RESULTS: Nursing staff had strong intentions, a positive attitude that became significantly more positive with the hospital avoidance program in place, and a reasonable sense of control; however, the influence of important referents was the strongest predictor of intention towards managing residents with deteriorating health. Support from a hospital avoidance program empowered staff and increased confidence to intervene. CONCLUSION: The theory of planned behaviour served as an effective framework for identifying the strong influence referents had on nursing staff intentions around managing residents with deteriorating health. Although nursing staff had a reasonable sense of control over this area of their work, they believed they benefitted from a hospital avoidance program initiated by the nursing home. RELEVANCE TO CLINICAL PRACTICE: Managers implementing hospital avoidance programs should consider the role of referents, appraise the known barriers and facilitators and take steps to identify those unique to their local situation. All levels of nursing staff play a role in preventing hospitalisation and should be consulted in the design, implementation and evaluation of any hospital avoidance strategies.