Characterising the nature of clinical incidents reported across a tertiary health service: a retrospective audit.

Objective Reducing the number of adverse patient safety incidents (PSIs) requires careful monitoring and active management processes. However, there is limited information about the association between hospital settings and the type of PSI. The aims of this study were to describe the severity, nature and characteristics of PSIs from an analysis of their incidence and to assess the relationships between the type of PSI and its setting. Methods A retrospective audit of a clinical incident management system database was conducted for a tertiary health service in Australia with 620000 residents. Records of PSIs reported for patients between 1 July 2017 and 30 June 2018 with Safety Assessment Codes (SAC) of PSIs were extracted from the clinical incident management system and analysed using descriptive and inferential statistics. PSIs involving paediatrics, mental health and primary care were excluded. Results In all, 4385 eligible PSIs were analysed: 24 SAC1, 107 SAC2 and 4254 SAC3 incidents. Across reported PSIs, the most common incidents related to skin injury (28.6%), medication (23.2%), falls (19.9%) and clinical process (8.5%). Falls were reported significantly more often in the medical division (χ2=43.85, P<0.001), whereas skin injury incidents were reported significantly more often in the surgical division (χ2=22.56, P<0.001). Conclusions A better understanding of the nature of PSIs and where they occur may lead to more targeted quality improvement strategies. What is known about this topic? Improving patient safety requires effective safety learning systems, which include incident reporting and management processes. Although incident reporting systems typically underestimate the incidence of iatrogenic harm, they do provide valuable opportunities to improve the future safety of health care. What does this paper add? This study reports the extent and severity of different types of PSIs that typically occur in a large tertiary hospital in Australia. The most common types of incidents are skin injury, falls, medication errors and clinical process. There are empirical associations between the type of PSI and clinical division (medical, surgical). What are the implications for practitioners? A greater understanding of the types of PSI and the settings in which they occur may inform the development of more targeted quality improvement strategies that potentially reduce their incidence.

Factors influencing hand hygiene practice of nursing students: A descriptive, mixed-methods study.

Developing nursing students' knowledge and practice of infection prevention and control (IPC) is fundamental to safe healthcare. A two-phase descriptive, mixed-method study conducted within a Bachelor of Nursing program at an Australian university aimed to explore: (i) theoretical knowledge of IPC, highlighting hand hygiene, of nursing students and; (ii) nursing students' and clinical facilitators' perceptions of factors influencing these practices during clinical placement. Phase One utilised an anonymous validated questionnaire assessing students' knowledge; identifying variables influencing students' IPC practices, subjected to descriptive and inferential analysis. Phase Two were semi-structured interviews exploring clinical facilitators' experiences/perceptions of students during clinical placement, analysed thematically. Students' demonstrated satisfactory knowledge of IPC in their second and third year, but clinical facilitators perceived that. students lacked awareness of the importance of these practices. Five themes arose from the interviews: (i) understanding workplace culture; (ii) students' modelling local behaviour; (iii) enhancing and consolidating knowledge for practice; (iv) adjusting to practice reality and; (v) accessing additional hand hygiene resources. Factors specific to workplace setting and culture were perceived to influence nursing students' socialisation. Future practice/education strategies could address these factors by ensuring students receive adequate supervision during clinical placement, and having strong advocates/role models present in the workplace.

A new model of patient-centred care for general practitioners: results of an integrative review.

BACKGROUND: GPs providing patient-centred care (PCC) is embedded in international health care policies due to its positive impact on patients and potential to lower health care costs. However, what is currently known about GP-delivered PCC is unknown. OBJECTIVE: To synthesize literature investigating GP-delivered PCC and address 'what is currently known about GP-delivered PCC?' METHOD: A systematic literature search was conducted between June and July 2018. Eligible articles were empirical, full-text studies published in English between January 2003 and July 2018, related to at least three of the four dimensions of PCC described by Hudon et al. (2011), and related to preventative, acute, and/or chronic care by GPs. Following screening, full-text articles were independently assessed for inclusion by two investigators. Data were extracted and quality assessed by two researchers. Findings on PCC were analysed thematically (meta-synthesis). RESULTS: Thirty medium- to high-quality studies met the inclusions criteria. Included studies utilized varied designs, with the most frequent being quantitative, cross-sectional. A theoretical model of PCC was synthesized from included studies and contained four major components: (i) understanding the whole person, (ii) finding common ground, (iii) experiencing time and (iv) aiming for positive outcomes. Harms of PCC were rarely reported. CONCLUSIONS: Four overarching theoretical components of PCC relate to elements of the consultation and experience of time. These components can be used to inform the development of toolkits to support GPs and general practice organizations in pursuit of PCC as well as tools to measure patient-centredness.

Development and psychometric testing of a patient-reported inventory to measure patient-centred care in dietetic practice.

To develop and psychometrically test a conceptually grounded patient-reported inventory to measure patient-centred care (PCC) in dietetics. Development of the inventory involved conducting a literature search and selecting previously validated scales to reflect the conceptual model of PCC that was developed by the research team. Next, a cross-sectional survey of patients attending individual consultations with Accredited Practicing Dietitians working in primary care was undertaken. To evaluate the factor structure of the inventory, exploratory factor analysis was performed using principal component analysis. Cronbach's α, inter-item correlations and corrected-item total correlations were computed to test the internal consistency reliability. A total of 133 patients completed the survey. Five factors were extracted, accounting for 78.4% of the variance. All items demonstrated significant loadings (i.e. ≥0.45) and most items had significant loadings on only one factor. High Cronbach's α values (ranging 0.87-0.97), inter-item correlations (0.46-0.89) and corrected item-total correlations (0.61-0.90) indicated good internal consistency of the inventory, but also potential item redundancy. This study provides the first patient-reported measure of PCC in dietetic practice, which has promising preliminary validity and reliability. With further testing, there is potential for this inventory to be used in future dietetic practice, research and education.

Improving Nutrition Care, Delivery, and Intakes Among Hospitalised Patients: A Mixed Methods, Integrated Knowledge Translation Study.

Malnutrition is a common and complex problem in hospitals. This study used an integrated knowledge translation approach to develop, implement, and evaluate a multifaceted, tailored intervention to improve nutrition care, delivery, and intake among acute medical inpatients. This observational, pre-post study was conducted in a medical ward at a public hospital in Australia. The intervention was co-developed with key stakeholders and targeted three levels: individuals (nutrition intake magnets at patient bedsides), the ward (multidisciplinary hospital staff training), and the organisation (foodservice system changes). Observational data were collected pre- and post-intervention on patient demographics, food intakes, and the mealtime environment. Data were entered into SPSS and analysed using descriptive and inferential statistics. Ethical approval was gained through the hospital and university ethics committees. A total of 207 patients were observed; 116 pre- and 91 post-intervention. After intervention implementation, patients' mean energy and protein intakes (in proportion to their estimated requirements) were significantly higher and the number of patients eating adequately doubled (p < 0.05). In summary, a multifaceted, pragmatic intervention, tailored to the study context and developed and implemented alongside hospital staff and patients, seemed to be effective in improving nutrition practices and patient nutrition intakes on an acute medical ward.

Reprint of: Patient participation in nursing bedside handover: A systematic mixed-methods review.

BACKGROUND: Numerous reviews of nursing handover have been undertaken, but none have focused on the patient's role. OBJECTIVES: To explore how patient participation in nursing shift-to-shift bedside handover can be enacted. DESIGN: Systematic mixed- methods review. DATA SOURCES: Three search strategies were undertaken in July-August 2016: database searching, backwards citation searching and forward citation searching. To be included, papers had to either be research or quality improvement (QI) projects focusing on the patient role. Fifty-four articles were retrieved, including 21 studies and 25 QI projects. REVIEW METHODS: Screening, data extraction and quality appraisal was undertaken systematically by two reviewers. Research studies and QI projects were synthesised separately using thematic synthesis, then the results of this synthesis were combined using a mixed-method synthesis table. RESULTS: Segregated synthesis of research of patients' perceptions revealed two contrasting categories; patient-centred handover and nurse-centred handover. Segregated synthesis of research of nurses' perceptions included three categories: viewing the patient as an information resource; dealing with confidential and sensitive information; and enabling patient participation. The segregated synthesis of QI projects included two categories: nurse barriers to enacting patient participation in bedside handover; and involving patients in beside handover. Once segregated findings were configured, we discovered that the patient's role in bedside handover involves contributing clinical information related to their care or progress, which may influence patient safety. Barriers related to nurses' discomfort encouraging patient participation and worries for sharing confidential and sensitive information. The way nurses approach patients, and how patient-centred they are, constitute further potential barriers. Strategies to improve patient participation in handover include training nurses, making handovers predictable for patients and increasing the interpersonal approach during handover. CONCLUSIONS: Using research and QI projects allowed diverse findings to expand each other and identify gaps between research and heuristic knowledge. Our review showed the tension between standardising handovers and making them predictable for patient participation, while promoting tailored and flexible handovers. Further investigation of this issue is required, to understand how to train nurses to achieve this and prepare patients to do this. Many barriers and strategies identified were from QI projects and the nurse perspective, thus caution interpreting results is required. We recommend steps be taken in the future to ensure high quality QI projects.

How Effective Are Dietitians in Weight Management? A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Effective, evidence-based strategies to prevent and treat obesity are urgently required. Dietitians have provided individualized weight management counselling for decades, yet evidence of the effectiveness of this intervention has never been synthesized. The aim of this study was to examine the effectiveness of individualized nutrition care for weight management provided by dietitians to adults in comparison to minimal or no intervention. Databases (Cochrane, CINAHL plus, MedLine ovid, ProQuest family health, PubMed, Scopus) were searched for terms analogous with patient, dietetics and consultation with no date restrictions. The search yielded 5796 unique articles, with 14 randomized controlled trials meeting inclusion criteria. The risk of bias for the included studies ranged from unclear to high. Six studies found a significant intervention effect for the dietitian consultation, and a further four found significant positive change for both the intervention and control groups. Data were synthesized through random effects meta-analysis from five studies (n = 1598) with weight loss as the outcome, and from four studies (n = 1224) with Body Mass Index (BMI) decrease as the outcome. Groups receiving the dietitian intervention lost an additional 1.03 kg (95% CI:-1.40; -0.66, p < 0.0001) of weight and 0.43 kg/m2 (95% CI:-0.59, -0.26; p < 0.0001) of BMI than those receiving usual care. Heterogeneity was low for both weight loss and BMI, with the pooled means varying from 1.26 to -0.93 kg and -0.4 kg/m² for weight and BMI, respectively, with the removal of single studies. This study is the first to synthesize evidence on the effectiveness of individualized nutrition care delivered by a dietitian. Well-controlled studies that include cost-effectiveness measures are needed to strengthen the evidence base.

Effectiveness of dietetic consultation for lowering blood lipid levels in the management of cardiovascular disease risk: A systematic review and meta-analysis of randomised controlled trials.

AIM: Evidence of the effectiveness of dietetic consultation for the management of cardiovascular disease (CVD) risk factors has not been previously synthesised. A systematic review and four meta-analyses evaluated the effectiveness of dietetic consultation for lowering blood lipid levels in high-risk individuals in primary health-care settings. METHODS: Of the 4860 records identified, 10 eligible randomised controlled trials (RCTs, n = 1530) were evaluated for reporting blood lipid outcomes following dietetic consultation (DN)-defined as at least one exclusive individual face-to-face consultation with a dietitian and comparators (C)-defined as no nutrition intervention or usual or minimal care provided by physicians and/or nurses. RESULTS: DN groups were effective for lowering blood lipid levels across nine studies reporting total cholesterol (TC) and LDL; and across five of six studies reporting triglycerides (TG). Between-group differences were not consistently assessed, with significance levels reported in four studies all in favour of DN, P < 0.05. Meta-analyses for TC and LDL (seven studies) confirmed DN and C groups were equally effective, P > 0.05; and for TG (six studies) DN groups were significantly more effective than C groups, P < 0.05). CONCLUSIONS: This review provides RCT evidence that dietetic counselling is effective for lowering TG levels and at least as effective as usual and minimal care for improving cholesterol levels in high-risk individuals in primary health care. However, more adequate reporting of methods and greater consistency in timing interventions and data collection will enhance the quality of the evidence and increase confidence in the health benefits of dietetic counselling for the management of CVD risk.

A comparison of patients' and dietitians' perceptions of patient-centred care: A cross-sectional survey.

AIM: The aim of this study was to compare patients' and dietitians' perceptions of patient-centred care (PCC) in dietetic practice. METHODS: Participants were as follows: (a) adult patients who had attended ≥1 individual dietetic consultation with an Accredited Practicing Dietitian (APD) working in primary care; and (b) APDs with experience working in primary care. A cross-sectional survey was undertaken using a patient- and dietitian-reported inventory to measure PCC in dietetic practice. The inventory comprised of five previously validated scales: The Communication Assessment Tool; the 9-item Shared Decision-Making Questionnaire; the Patient-Doctor Depth of Relationship Scale; the Schmidt Perception of Nursing Care Scale-Seeing the Individual Patient sub-scale; and the Person-Centred Practice Inventory-Staff -Providing Holistic Care sub-scale. Descriptive statistics were used to analyse participant characteristics and to compute total scores for the five scales. The Mann-Whitney U test was used to compare median scores between patients and dietitians. RESULTS: One-hundred and thirty-three patients and 180 dietitians completed the survey. Patients reported significantly higher scores compared to dietitians for "shared decision-making" (P = 0.004), but significantly lower scores for "providing holistic and individualized care" (P = 0.005), "knowing the patient/dietitian" (P = 0.001) and "caring patient-dietitian relationships" (P =0.009). CONCLUSION: This study highlighted potentially important differences between patients' and dietitians' perceptions of PCC and identified key aspects of dietetic care requiring practice improvements. Strategies are needed to bridge gaps between dietitians' and patients' perceptions and enhance PCC in dietetic practice. These findings suggest that dietitians should focus on individualizing nutrition care, gaining a holistic understanding of their patients and knowing/understanding each patient.

Patient participation in nursing bedside handover: A systematic mixed-methods review.

BACKGROUND: Numerous reviews of nursing handover have been undertaken, but none have focused on the patients' role. OBJECTIVES: To explore how patient participation in nursing shift-to-shift bedside handover can be enacted. DESIGN: Systematic mixed- methods review. DATA SOURCES: Three search strategies were undertaken in July-August 2016: database searching, backwards citation searching and forward citation searching. To be included, papers had to either be research or quality improvement (QI) projects focusing on the patient role. Fifty-four articles were retrieved, including 21 studies and 25 QI projects. REVIEW METHODS: Screening, data extraction and quality appraisal was undertaken systematically by two reviewers. Research studies and QI projects were synthesised separately using thematic synthesis, then the results of this synthesis were combined using a mixed-method synthesis table. RESULTS: Segregated synthesis of research of patients' perceptions revealed two contrasting categories; patient-centred handover and nurse-centred handover. Segregated synthesis of research of nurses' perceptions included three categories: viewing the patient as an information resource; dealing with confidential and sensitive information; and enabling patient participation. The segregated synthesis of QI projects included two categories: nurse barrier to enacting patient participation in bedside handover; and involving patients in beside handover. Once segregated findings were configured, we discovered that the patient's role in bedside handover involves contributing clinical information related to their care or progress, which may influence patient safety. Barriers related to nurses' concerns for the consequences of encouraging patient participation, worries for sharing confidential and sensitive information and feeling hesitant in changing their handover methods. The way nurses approach patients, and how patient-centred they are, constitute further potential barriers. Strategies to improve patient participation in handover include training nurses, making handovers predictable for patients and involving both patients and nurses throughout the change process. CONCLUSIONS: Using research and QI projects allowed diverse findings to expand each other and identify gaps between research and heuristic knowledge. Our review showed the tension between standardising handovers and making them predictable for patient participation, while promoting tailored and flexible handovers. Further investigation of this issue is required, to understand how to train nurses and patient views. Many barriers and strategies identified were from QI projects and the nurse perspective, thus caution interpreting results is required. We recommend steps be taken in the future to ensure high quality QI projects.