Identifying and prioritising future interventions with stakeholders to improve paediatric urgent care pathways in Scotland, UK: a mixed-methods study.

OBJECTIVES: To identify and prioritise interventions, from the perspectives of parents and health professionals, which may be alternatives to current unscheduled paediatric urgent care pathways. DESIGN: FLAMINGO (FLow of AdMissions in chIldren and youNG peOple) is a sequential mixed-methods study, with public and patient involvement (PPI) throughout. Data linkage for urgent admissions and three referral sources: emergency department, out of hours service and general practice, was followed by qualitative interviews with parents and professionals. Findings were presented and discussed at a stakeholder intervention prioritisation event. SETTING: National Health Service in Scotland, UK. PARTICIPANTS: Quantitative data: children with urgent medical admission to hospital from 2015 to 2017. Qualitative interviews: parents and health professionals with experiences of urgent short stay hospital admissions of children. PPI engagement was conducted with nine parent-toddler groups and a university-based PPI advisory group. Stakeholder event: parents, health professionals and representatives from Scottish Government, academia, charities and PPI attended. RESULTS: Data for 171 039 admissions which included 92 229 short stay admissions were analysed and 48 health professionals and 21 parents were interviewed. The stakeholder event included 7 parents, 12 health professionals and 28 other stakeholders. Analysis and synthesis of all data identified seven interventions which were prioritised at the stakeholder event: (1) addressing gaps in acute paediatric skills of health professionals working in community settings; (2) assessment and observation of acutely unwell children in community settings; (3) creation of holistic children's 'hubs'; (4) adoption of 'hospital at home' models; and three specialised care pathways for subgroups of children; (5) convulsions; (6) being aged <2 years old; and (7) wheeze/bronchiolitis. Stakeholders prioritised interventions 1, 2 and 3; these could be combined into a whole population intervention. Barriers to progressing these include resources, staffing and rurality. CONCLUSIONS: Health professionals and families want future interventions that are patient-centred, community-based and aligned to outcomes that matter to them.

Regional variations in short stay urgent paediatric hospital admissions: a sequential mixed-methods approach exploring differences through data linkage and qualitative interviews.

OBJECTIVES: The aim of this sequential mixed-methods study was to describe and understand how paediatric short stay admission (SSA) rates vary across Health Board regions of Scotland. DESIGN: Exploratory sequential mixed-methods study. Routinely acquired data for the annual (per capita) SSA to hospital were compared across the 11 regions. Five diverse regions with different SSA per capita formed cases for qualitative interviews with health professionals and parents to explore how care pathways, service features and geography may influence decisions to admit. SETTING: Scotland. PARTICIPANTS: All children admitted to hospital 2015-2017. Healthcare staff (n=48) and parents (n=15) were interviewed. RESULTS: Of 171 039 urgent hospital admissions, 92 229 were SSAs, with a fivefold variation between 14 and 69/1000 children/year across regions. SSAs were higher for children in the most deprived compared with the least deprived communities. When expressed as a ratio of highest to lowest SSA/1000 children/year for diagnosed conditions between regions, the ratio was highest (10.1) for upper respiratory tract infection and lowest (2.8) for convulsions. Readmissions varied between 0.80 and 2.52/1000/year, with regions reporting higher SSA rates more likely to report higher readmission rates (r=0.70, p=0.016, n=11). Proximity and ease of access to services, local differences in service structure and configuration, national policy directives and disparities in how an SSA is defined were recognised by interviewees as explaining the observed regional variations in SSAs. Socioeconomic deprivation was seldom spontaneously raised by professionals when reflecting on reasons to refer or admit a child. Instead, greater emphasis was placed on the wider social circumstances and parents' capacity to cope with and manage their child's illness at home. CONCLUSION: SSA rates for children vary quantitatively by region, condition and area deprivation and our interviews identify reasons for this. These findings can usefully inform future care pathway interventions.

Registered Nurses' and nursing students' perspectives on moral distress and its effects: A mixed-methods systematic review and thematic synthesis.

AIM: To examine Registered Nurses (RNs') and nursing students' perspectives on factors contributing to moral distress and the effects on their health, well-being and professional and career intentions. DESIGN: Joanna Briggs Institute mixed-methods systematic review and thematic synthesis. Registered in Prospero (Redacted). METHODS: Five databases were searched on 5 May 2021 for studies published in English since January 2010. Methodological quality assessment was conducted in parallel with data extraction. RESULTS: Searches yielded 2343 hits. Seventy-seven articles were included. Most were correlational design and used convenience sampling. Studies were mainly from North America and Asia and situated in intensive and critical care settings. There were common, consistent sources of moral distress across continents, specialities and settings. Factors related to perceived inability or failure to enact moral agency and responsibility in moral events at individual, team and structural levels generated distress. Moral distress had a negative effect on RNs health and psychological well-being. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution to this systematic review.

Wearable activity trackers for nurses' health: A qualitative acceptability study.

AIM: To assess the practical, social and ethical acceptability of the use of a POLAR® H7 chest-strap wearable device to influence health behaviours among pre-registered nurses. DESIGN: Qualitative acceptability study including a simulated test of use reported using COREQ guidelines. METHODS: Pre-registered nurses simulated nine nursing tasks while wearing the chest strap in a clinical simulation facility in a Scottish university in 2016. Focus groups and semi-structured interviews were conducted to assess technology acceptance with participants who did and did not participate in the simulated nursing tasks. Focus groups and interviews were transcribed and analysed thematically guided by a theoretical model of technology acceptance. RESULTS: Pre-registered nurses thought the use of chest-strap devices to monitor their own health in real-time was acceptable. However, participants shared that it was important that the use of technology was inclusive and supportive of nurses' health and cautioned against misuse of data from wearable devices for individual performance management or stigmatisation.

Competencies and standards in nurse education: The irresolvable tensions.

This paper explores the inherent contradiction between the purpose of nurse education - to produce critical thinking, autonomous and accountable future nurses - and the prescription of standards and competencies to realize this goal. Drawing on examples from the United Kingdom's Nursing and Midwifery Council's (NMC) 'Future Nurse' standards, we argue that standards and competencies offer little more than a veneer of protection to the public and that, fundamentally, educational approaches based on 'dot point' formulations are antithetical to conditions in which genuinely critical-thinking, autonomous and accountable practitioners can develop. The purpose of this paper is to raise debate about the hegemony of competencies and standards. For the sake of academic health and the future of the nursing profession, the ubiquity of competency-based education must be critiqued and challenged.

Effects of student-led drama on nursing students' attitudes to interprofessional working and nursing advocacy: A pre-test post-test educational intervention study.

BACKGROUND: Nursing educators need to equip students to work in interprofessional teams and advocate for patients in increasingly integrated health and social care settings. Drama-based education has been used in nursing to help students understand complex concepts and practices, including communication, empathy, and patient safety. However, few studies have evaluated drama-based education to promote understanding of interprofessional care and advocacy, and none have involved student-led drama where students create dramatic performances to support learning. OBJECTIVES: To examine the effects of student-led drama on student nurses' attitudes to interprofessional working and advocacy. DESIGN: Pre-test post-test educational intervention study. SETTINGS: Public university in Scotland. PARTICIPANTS: 400 undergraduate student nurses enrolled on a 15-week module focussed on health and social care integration and interprofessional working. METHODS: Students completed paper questionnaires at the start (n = 274, response rate: 80.1 %) and end (n = 175, 63.9 %) of the module. Outcome measures were the validated Attitudes Towards Healthcare Teams Scale (ATHCTS) and Protective Nursing Advocacy Scale (PNAS). Change in mean ATHCTS and PNAS scores were assessed using paired samples t-tests, with Cohen's d to estimate effect size. RESULTS: ATHCTS scores significantly increased from 3.87 to 4.19 (p < 0.001, d = 0.52). PNAS scores increased from 3.58 to 3.81 (p < 0.001, d = 0.79), with significant improvements in the 'acting as an advocate' (4.18 to 4.51, p < 0.001, d = 0.81) and 'environmental and educational influences' subscales (3.79 to 4.13, p < 0.001, d = 0.75). Statements focussed on promoting holistic, dignified care and enabling health professionals to be responsive to emotional and financial needs of patients, showed greatest change. CONCLUSIONS: Education based on plays created and performed by student nurses led to significant improvements in student nurses' attitudes towards interprofessional working and nursing advocacy. Student-led drama should be embedded in nursing curricula to enable students to understand the realities and complexities of health and social care integration and interprofessional working.

Challenges to self-isolation among contacts of cases of COVID-19: a national telephone survey in Wales.

BACKGROUND: Self-isolation is challenging and adherence is dependent on a range of psychological, social and economic factors. We aimed to identify the challenges experienced by contacts of coronavirus disease 2019 (COVID-19) cases to better target support and minimize the harms of self-isolation. METHODS: The Contact Adherence Behavioural Insights Study (CABINS) was a 15-minute telephone survey conducted with confirmed contacts of COVID-19 (N = 2027), identified through the NHS Wales Test Trace Protect (TTP) database. RESULTS: Younger people (aged 18-29 years) were three times more likely to report mental health concerns (adjusted odds ratio [aOR]: 3.16, 95% confidence interval [CI]: 2.05-4.86) and two times more likely to report loneliness (aOR: 1.96, CI: 1.37-2.81) compared to people aged over 60 years. Women were 1.5 times more likely to experience mental health concerns (aOR: 1.51, 95% CI: 1.20-1.92) compared to men. People with high levels of income precarity were eight times more likely to report financial challenges (aOR: 7.73, CI: 5.10-11.74) and three times more likely to report mental health concerns than their more financially secure counterparts (aOR: 3.08, CI: 2.22-4.28). CONCLUSION: Self-isolation is particularly challenging for younger people, women and those with precarious incomes. Providing enhanced support is required to minimize the harms of self-isolation.

Seeking Good Work in the COVID-19 Recovery: Shifting Priorities and Employment Choices Among Workers.

OBJECTIVE: Disruption to working lives spurred by the COVID-19 pandemic may shape people's preferences for future employment. We aimed to identify the components of work prioritized by a UK sample and the employment changes they had considered since the start of the COVID-19 pandemic. METHODS: A nationally representative longitudinal household survey was conducted in Wales at two time points between 2020 and 2021. RESULTS: Those in poorer health prioritized flexibility and were more likely to consider retiring. Those with limiting preexisting conditions or low mental well-being were more likely to consider becoming self-employed. Those experiencing financial insecurity (including those with high wage precarity or those furloughed) were more likely to consider retraining, becoming self-employed, or securing permanent employment. CONCLUSIONS: Ensuring flexible, secure, and autonomous work is accessible for individuals facing greater employment-related insecurity may be key.

Short stay hospital admissions for an acutely unwell child: A qualitative study of outcomes that matter to parents and professionals.

BACKGROUND: Numbers of urgent short stay admissions (SSAs) of children to UK hospitals are rising rapidly. This paper reports on experiences of SSAs from the perspective of parents accessing urgent care for their acutely unwell child and of health professionals referring, caring for, or admitting children. METHODS: A qualitative interview study was conducted by a multi-disciplinary team with patient and public involvement (PPI) to explore contextual factors relating to SSAs and better understand pre-hospital urgent care pathways. Purposive sampling of Health Board areas in Scotland, health professionals with experience of paediatric urgent care pathways and parents with experience of a SSA for their acutely unwell child was undertaken to ensure maximal variation in characteristics such as deprivation, urban-rural and hospital structure. Interviews took place between Dec 2019 and Mar 2021 and thematic framework analysis was applied. RESULTS: Twenty-one parents and forty-eight health professionals were interviewed. In the context of an urgent SSA, the themes were centred around shared outcomes of care that matter. The main outcome which was common to both parents and health professionals was the importance of preserving the child's safety. Additional shared outcomes by parents and health professionals were a desire to reduce worries and uncertainty about the illness trajectory, and provide reassurance with sufficient time, space and personnel to undertake a period of skilled observation to assess and manage the acutely unwell child. Parents wanted easy access to urgent care and, preferably, with input from paediatric-trained staff. Healthcare professionals considered that it was important to reduce the number of children admitted to hospital where safe and appropriate to do so. CONCLUSIONS: The shared outcomes of care between parents and health professionals emphasises the potential merit of adopting a partnership approach in identifying, developing and testing interventions to improve the acceptability, safety, efficiency, and cost-effectiveness of urgent care pathways between home and hospital.