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Background: Competent clinical reasoning forms the foundation for effective and efficient clinical swallowing examination (CSE) and consequent dysphagia management decisions. While the nature of initial CSEs has been evaluated, it remains unclear how new information gathered by speech–language therapists (SLTs) throughout a patient's acute‐care journey is integrated into their initial clinical reasoning and management processes and used to review and revise initial management recommendations. Aims: To understand how SLTs' clinical reasoning and decision‐making regarding dysphagia assessment and management evolve as patients transition through acute hospital care from referral to discharge. Methods & Procedures: A longitudinal, qualitative approach was employed to gather information from two SLTs who managed six patients at a metropolitan acute‐care hospital. A retrospective 'think‐aloud' protocol was utilized to prompt SLTs regarding their clinical reasoning and decision‐making processes during initial and subsequent CSEs and patient interactions. Three types of concept maps were created based on these interviews: a descriptive concept map, a reasoning map and a hypothesis map. All concept maps were evaluated regarding their overall structure, facts gathered, types of reasoning engaged in (inductive versus deductive), types of hypotheses generated, and the diagnosis and management recommendations made following initial CSE and during subsequent dysphagia management. Outcomes & Results: Initial CSEs involved a rich process of fact‐gathering, that was predominantly led by inductive reasoning (hypothesis generation) and some application of deductive reasoning (hypothesis testing), with the primary aims of determining the presence of dysphagia and identifying the safest diet and fluid recommendations. During follow‐up assessments, SLTs engaged in increasingly more deductive testing of initial hypotheses, including fact‐gathering aimed at determining the tolerance of current diet and fluid recommendations or the suitability for diet and/or fluid upgrade and less inductive reasoning. Consistent with this aim, SLTs' hypotheses were focused primarily on airway protection and medical status during the follow‐up phase. Overall, both initial and follow‐up swallowing assessments were targeted primarily at identifying suitable management recommendations, and less so on identifying and formulating diagnoses. None of the patients presented with adverse respiratory and/or swallowing outcomes during admission and following discharge from speech pathology. Conclusions & Implications: Swallowing assessment and management across the acute‐care journey was observed as a high‐quality, patient‐centred process characterized by iterative cycles of inductive and deductive reasoning. This approach appears to maximize efficiency without compromising the quality of care. The outcomes of this research encourage further investigation and translation to tertiary and post‐professional education contexts as a clear understanding of the processes involved in reaching diagnoses and management recommendations can inform career‐long refinement of clinical skills. WHAT THIS PAPER ADDS: What is already known on the subject: SLTs' clinical reasoning processes during initial CSE employ iterative cycles of inductive and deductive reasoning, reflecting a patient‐centred assessment process. To date it is unknown how SLTs engage in clinical reasoning during follow‐up assessments of swallowing function, how they assess the appropriateness of initial management recommendations and how this relates to patient outcomes. What this paper adds to the existing knowledge: Our longitudinal evaluation of clinical reasoning and decision‐making patterns related to swallowing management in acute care demonstrated that SLTs tailored their processes to each patient's presentation. There was an emphasis on monitoring the suitability of the initial management recommendations and the potential for upgrade of diet or compensatory swallowing strategies. The iterative cycles of inductive and deductive reasoning reflect efficient decision‐making processes that maintain high‐quality clinical care within the acute environment. What are the potential or actual clinical implications of this work?: Employing efficient and high‐quality clinical reasoning is a hallmark of good dysphagia practice in maximizing positive patient outcomes. Developing approaches to understanding and making explicit clinical reasoning processes of experienced clinicians may assist SLTs of all developmental stages to provide high standards of care. [ABSTRACT FROM AUTHOR]

Introduction: The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. Methods: A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. Results: A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. Conclusion: The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in healthrelated quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program. [ABSTRACT FROM AUTHOR]

Aim: This paper reports the findings of a sub-sample of interviews from a larger study designed to explore the attitudes of health care workers towards older people in that acute care setting.The discussion in this paper focuses only on interviews with nurses and their negative attitudes towards older people in their care. Background: As Australia's ageing population continues to grow exponentially, their demand for hospital care also increases. Many nurses in the acute care setting have had little, if any, specialist education in the care of older people and therefore do not understand the extent of their needs. Coupled with the lack of specialist knowledge is the low status of older person care in this setting. Many nurses prefer to care for younger patients with acute illnesses that are curable (Nay 1993 in Nay & Garratt 2004: 61). As with the population at large, health care professionals hold negative views about old age and this is reflected in their attitudes. Method: The findings presented in this paper focus on data analysed from in depth interviews with nurses. As a prompt to discussions, nurses were presented with scenarios that exemplified both positive and negative attitudes to care. However, much of what was discussed in interviews focused on negative attitudes. Interviews with medical and allied health staff will be reported in a separate paper. Results: The analysis of data with nurses reveals two themes and subthemes. 'Marginalisation and oppression of the older person' shows the ways in which nurses perceive older people are relegated to a lower status in the acute care setting, how this is 'contagious' and how 'lack of time' for care for older people is problematic and has become their 'catchcry'.'Stereotyping the older person' depicts some of the ways in which this evolves, for example, through 'Chinese Whispers' (UsingEnglish.com 2006), but has become part of the ageist culture. [ABSTRACT FROM AUTHOR]

This study aimed to describe how occupational therapists working in acute care settings in Australia assess cognitive function in patients with TBI, the influences on assessment choice, and clinician perceptions of performance-based assessment. An online survey was completed by 81 occupational therapists. The most common method of cognitive assessment was reported as non-standardized observation of functional tasks (94.7%), followed by carer-report / self-report (93%). Despite their being positive perceptions of performance-based assessment there was limited use in practice. Assessment use was impacted by practical and organizational constraints including access to assessment resources, time and the built environment in acute care. [ABSTRACT FROM AUTHOR]

Objectives: To examine in a sample of nurses working in acute-care wards, self-reported perceptions of the: 1) patient; family; nurse; doctor; and health system-related barriers to the provision of optimal end-of-life care to people who are dying in hospital; and 2) five barriers which, if removed, would lead to the greatest improvements in hospital-based end-of-life care. Background: Nurses play a central role in caring for dying patients and can offer a unique perspective about the factors that impact the quality of end-oflife care delivered in hospitals. Study design and methods: Two hundred and fifteen registered and enrolled nurses from three metropolitan and three rural hospitals across three health services completed a questionnaire-based, cross-sectional study between April 2016 and June 2017. Results: Nurses perceive that doctors continue to treat for too long (79% ranked as a large barrier); families have unrealistic expectations about a patient's prognosis (73%); junior doctors are unwilling to alter the decision of senior doctors (67%); doctors do not adequately explain the dying process (66%); and doctors have inadequate training in end-of-life care (66%). Nurses indicated that doctors reducing the length of active treatment and families having a more realistic expectation about life-expectancy would lead to the greatest improvement in end-oflife care in hospitals. Discussion: In this study of nurses working in a wide range of acute care settings across rural and metropolitan locations, substantial barriers to the provision of high-quality end-of-life care were perceived across all facets of healthcare provision. Important barriers included the continuation of potentially futile treatment, inadequacy of symptom control, and poor communication between doctors, patients and their families. Conclusion: Nurses perceive a range of patient; family; provider; and health system-related challenges to the provision of optimal end-of-life care in hospital. Findings highlight potential areas for improvement as part of a coordinated approach to optimising the provision of end-of-life care in hospitals. Future goals should include larger-scale, longitudinal studies across various states and territories to inform the development of interventions that can help to address the identified gaps in service provision. Implications for research, policy, and practice: This study has highlighted the need to involve all stakeholders when designing interventions to improve end-of-life care. Nurses can provide valuable insight into the factors that can make the greatest impact in improving care provision. It suggests that the provision of high-quality end-oflife care in hospitals is complex, and that there is substantial overlap between items nurses perceive to be barriers in each of the five domains of care provision. To achieve sustainable improvement in the quality of end-of-life care provided in hospitals, a multi-factorial, and collegial, approach to designing interventions will be needed. What is already known about the topic? • End-of-life care is increasingly being provided in hospital settings. • Nurses are an important source of information and support for dying patients and their families. • Few studies have explored nurses' perceptions of the barriers to the provision of high-quality end-oflife care across all domains of healthcare provision. What this paper adds: • Important barriers include continuation of potentially futile treatment, adequacy of symptom control, and poor communication between doctors, patients, and their families. • Findings can support the design of more effective intervention strategies to mitigate identified barriers and achieve improvements in the quality of end-of-life care delivered in hospital. [ABSTRACT FROM AUTHOR]

Background: Older people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. This paper examines the effects of the ACE service on RACF residents' transfer to hospital using a controlled pre-post design.Methods: Four intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors.Results: Residents had a mean age of 86 years. ED presentations ranged between 16 and 211 visits/100 RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR = 1.17, p = 0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 min (p = 0.0575), and was 40 % less likely to be admitted to hospital, . The latter was highly significant (p = 0.0012).Conclusions: Transfers to ED and admission to hospital are common for residents of RACFs. This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders.Trial Registration: The Australian New Zealand Clinical Trials Registration number is ACTRN12616000588493 It was registered on 6(th) May 2016. [ABSTRACT FROM AUTHOR]

Predischarge occupational therapy home assessments are routinely performed with older adults in Europe, Australia and North America. Their primary aim is to facilitate a timely and safe discharge from hospital. However, there is a lack of published research on this topic, especially studies exploring occupational therapists' perceptions of home assessments. The paper aims to redress this by describing occupational therapists' perceptions of predischarge occupational therapy home assessments with older adults in acute care. All occupational therapists who undertook home assessments in an acute care hospital with older adults during the duration of the study period were invited to complete a reflective diary. In total, 15 reflective diaries were completed by six therapists. The data were analysed using thematic content analysis. The findings suggest that home assessments were carried out because of mobility or environmental concerns. Satisfaction and dissatisfaction with the outcome of the home assessment were related to the incidents that occurred during the assessment. Some of the occupational therapists' anxieties were related to the older adults' level of functioning or ill health, and the older adults' own concerns did have an impact upon the therapists' expectations of the home assessment process. [ABSTRACT FROM AUTHOR]

walsh a.m., edwards h.e., courtney m.d., wilson j.e.&monaghan s.j. (2005) Journal of Advanced Nursing49(5), 453–464Fever management: paediatric nurses’ knowledge, attitudes and influencing factorsThis paper describes Australian paediatric nurses’ knowledge of and attitudes toward fever and its management and the predictors of their intentions to administer paracetamol to a febrile child.Despite evidence-based support for the beneficial effects of fever over the past three decades, health professionals’ negative attitudes toward fever and their reliance on antipyretics to reduce it have persisted and continue to be reported in the literature.A self-report questionnaire was used. An instrument was developed, piloted by test–retest and revised prior to data collection. Fifty-one paediatric nurses working in medical wards of a metropolitan paediatric hospital in Australia participated.Nurses’ mean knowledge score about the physiology of fever, general fever management and antipyretics was 62%, which was not as high as expected. Participants reported positive attitudes toward the benefits of fever, the necessity for its reduction in children with pre-existing cardiac or respiratory conditions and towards regular antipyretic administration masking the infective process. Negative attitudes included disbelief that temperature is often unrelated to illness severity. Conflicting attitudes toward febrile convulsions were highlighted by beliefs that antipyretic therapy prevents these and that antipyretics do not prevent initial febrile convulsions. Predictors of intentions to administer paracetamol were beliefs about the effectiveness of paracetamol and nurses’ beliefs about the expectations of others in relation to paracetamol administration. Nurses reported strong intentions to administer paracetamol to the next febrile child they cared for. Limitations of the study include the use of a nurse manager for recruitment and collecting the data at only one site.Fever management is an integral aspect of paediatric nursing. For its consistent rational management, nurses must have appropriate knowledge and positive attitudes. This highlights the need for continuing education in fever management. [ABSTRACT FROM AUTHOR]

Objective. This study describes how a model of early rehabilitation ('in-reach rehabilitation') can be integrated into acute care provision for hospitalised patients with high rehabilitation needs. This pragmatic evaluation aimed to assess service impact on home discharge rates from acute care. Methods. An integrated early rehabilitation service was implemented at a tertiary teaching hospital in Sydney, Australia. Eligible patients were screened, placed on a waitlist, and treated in order of debility (six to eight patients concurrently). Routine data were collected and compared between those who received an in-reach rehabilitation program, and controls who remained on waitlist. Results. From December 2021 to September 2022, 229 patients were identified as suitable for in-reach rehabilitation; of whom 100 received an in-reach program and the remaining 129 were waitlist controls. Patients who received in-reach rehabilitation achieved a significantly higher rate of discharge home from acute care compared to waitlist controls (46.0% vs 24.0%, P = 0.002) and lower rates of transfer to subacute inpatient rehabilitation (43.0% vs 62.0%). This was despite in-reach patients having high functional care needs (60% needed assistance from ≥two people to mobilise) and complex medical needs (median hospital length of stay 44.5 days, IQR 27.8-66.0). Conclusions. It is feasible to deliver in-reach rehabilitation to hospitalised patients with heterogeneous diagnoses who have high rehabilitation needs. The rate of discharge home directly from acute wards is higher among those patients who received early in-reach rehabilitation compared to those on a waitlist. [ABSTRACT FROM AUTHOR]

Objectives. To describe current and planned processes and outcome measures to address implementation of the six end-of-life actions in the National Safety and Quality Health Service (NSQHS) Standards (2nd edn) and explore associated barriers and enablers. Methods. This study used an exploratory mixed methods national survey of acute healthcare facilities between September 2018 and March 2019. This study involved public and private facilities (N = 765) that provided end-of-life care, which are required to be accredited to the NSQHS Standards. Participants include those responsible for reporting implementation of end-of-life care actions at a facility providing end-of-life care. Participants were asked what processes and outcome measures were implemented or being planned to address the end-of-life care actions, and the associated barriers and enablers. Results. Fifty respondents (6.5% response rate) from across Australia contributed data, reporting greater confidence in addressing Actions 5.16: Clinicians have access to Specialist Palliative Care Services; 5.17: Advance care plans can be received from patients and stored in medical records; and 5.18: Supervision and support is available for workforce providing end-of-life care. Barriers associated with the actions that were the most challenging to address included: competing clinical priorities, and insufficient resources to provide best practice end-of-life care; and the burdensome nature of conducting audits. Enablers included: (1) local, jurisdictional, and national strategic plans and policies; (2) support from Specialist Palliative Care Services; (3) access to resources and data; (4) standardised approaches to implementation and measuring outcomes; and (5) clinician, consumer and community engagement and education on end-of-life care. Conclusion. Enablers and barriers in implementing the six end-of-life care actions were identified. Respondents reported that high-level support and direction, system-wide approaches, practical clinical support, and widespread community and clinician engagement would enable their facility to better address the end-of-life actions. [ABSTRACT FROM AUTHOR]

Aim: To examine self‐reported exposure and experiences of negative workplace behaviour and ways of coping of nursing staff before and after educational workshops. Design: A Quasi‐experimental design. Method/Setting/Participants: Data were collected pre‐ /postworkshops using a structured questionnaire. Nurses (N = 230) from 12 units in four regional acute care hospitals were invited to complete a pre‐intervention survey. Educational workshops were then implemented by the organization at two of the hospitals, after which, follow‐up surveys were undertaken. Results: There were 74 responses in the pre‐intervention and 56 responses in the postintervention time period. There were 111 participants who attended the educational intervention, 20% (n = 22) completed the follow‐up survey. Participants were more likely exposed to work‐related bullying acts and they used problem‐focused coping strategies and sought social support as a way of coping when exposed to the negative behaviours. Overall, there was a decrease in both bullying and incivility experienced by participants; however, our findings were unable to establish that a statistically significant difference was made due to the implementation of the intervention. Study Registration: Australian New Zealand Clinical Trials Registry (Registration No. ACTRN12618002007213; December 14, 2018). [ABSTRACT FROM AUTHOR]

Aim: To provide an estimate of the numbers of medication errors and adverse drug reactions that occur along a person's journey through their hospital stay in Australia. Methods: A search of databases and online resources was undertaken to identify published literature on medication safety in the acute care setting in Australia from 2008 to 2013. Data on the rates of adverse drug reactions and medication errors associated with hospitalization was extracted from the published studies. This evidence was synthesized with evidence from previous reviews of medication safety in the acute care setting in Australia conducted in 2002 and 2008. Results: Findings from the Australian literature across the two previous reviews of medication safety and the present review indicate the proportion of all hospital admissions that are medication-related is between 2 and 3%. Studies assessing medication errors on admission to hospital suggest there may be an overall rate of two errors for every three patients at the time of admission to hospital. Large studies examining the rates of prescribing errors in major Australian teaching hospitals give insight into the rates of prescription error and suggest that prescription error rates of up to one error per patient occur in the hospital system. The best available evidence from more recent research suggests that errors (excluding errors of timing) occur in around 9% of medication administrations in hospital. At hospital discharge, errors in medication documentation in discharge summaries may occur at a rate of up to two errors per patient. Conclusions: Medication safety in the various stages of the patient journey through acute care in Australia continues to be a significant problem. However, the extent of medication-related problems in acute care needs to be interpreted within the context of increasingly complex health care. There are an estimated 230 000 medication-related hospital admissions occurring per year. This suggests an annual cost of medication-related admissions of AU$1.2 billion. [ABSTRACT FROM AUTHOR]

Background: Nurses' harm prevention practices during the admission of older persons to hospital have important consequences for patient safety, preventable patient harm and length of hospital stay. Novel solutions are needed to assist nurses to balance complexity, high workload burden and patient safety during admission processes. Aim: Explore the nurses' experiences of harm prevention practices during the admission of an older person to the hospital. Design: A multi‐method qualitative study informed by frameworks of behaviour change and human‐centred co‐design. Methods: The purposive sample included 44 nurses, 5 clinicians from other disciplines and 3 consumers recruited from five general medicine wards across three hospitals of a large public health service in metropolitan Melbourne, Australia. Data were collected over 12 h of naturalistic observations of nurses during eight patient admissions, and during four participatory human‐centred co‐design workshops between August 2019 and January 2020. Observation, field notes and workshop artefact data were integrated for qualitative content and thematic analysis. Results: Analysis revealed a 5‐step journey map, with a temporal logic, that captured nurses' experiences, as well as the enablers and barriers to harm prevention practices when admitting an older person to the hospital. The consensus was reached on three priority features to assist nurses to implement harm prevention practices when they admit an older person to the hospital: (1) prioritize important care; (2) tailor care to the individual and (3) see the big picture for the patient. Conclusion: The novel research approach identified five steps in nurses' activities and harm prevention practices during admission of an older person to the hospital, and key features for a solution to assist nurses to keep patients safe. The findings provide the foundation for further research to develop interventions to assist nurses to manage high workloads during this complex activity. [ABSTRACT FROM AUTHOR]

Objective: The longer-term impact of injury is increasingly recognized, but the early phases of recovery are less well understood. The best tools to measure early recovery of mobility and physical function following traumatic injury are unclear. The purpose of this study was to assess the clinical utility, validity, reliability, and responsiveness of 4 mobility and physical function measures in patients following traumatic injury. Methods: In this cohort, measurement-focused study (n = 100), the modified Iowa Level of Assistance Score, Acute Care Index of Function, Activity Measure for Post-Acute Care "6 Clicks" short forms, and Functional Independence Measure were completed during first and last physical therapy sessions. Clinical utility and floor and ceiling effects were documented. Known-groups validity (early vs late in admission and by discharge destination), predictive validity (using 6-month postinjury outcomes data), and responsiveness were established. Interrater reliability was assessed in 30 patients with stable mobility and function. Results: Participants had a median age of 52 years (interquartile range = 33–68 years), and 68% were male. The modified Iowa Level of Assistance Score, Acute Care Index of Function, and "6 Clicks" short forms were quick to administer (an extra median time of 30 seconds–1 minute), but the Functional Independence Measure took much longer (extra median time of 5 minutes). At the last physical therapy session, ceiling effects were present for all measures except the Functional Independence Measure (18%–33% of participants). All had strong known-groups validity (early vs late in admission and by discharge destination). All were responsive (effect sizes >1.0) and had excellent interrater reliability (intraclass correlation coefficients = 0.79–0.94). Conclusion: All 4 measures were reliable, valid, and responsive; however, their clinical utility varied, and ceiling effects were common at physical therapy discharge. Impact: This study is an important step toward evidence-based measurement in acute trauma physical therapy care. It provides critical information to guide assessment of mobility and physical function in acute trauma physical therapy, which may facilitate benchmarking across different hospitals and trauma centers and further progress the science and practice of physical therapy following traumatic injury. [ABSTRACT FROM AUTHOR]

Background: Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia.Methods: A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers.Discussion: The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives.Trial Registration: The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry ( ACTRN12620000507987 , registered 23/04/2020). [ABSTRACT FROM AUTHOR]

Aims and Objectives: To critically appraise relevant literature on the lived experiences of registered nurses caring for adults with intellectual disability in the acute care setting in Australia to determine current knowledge and gaps in the literature. Background: People with intellectual disability have the right to the highest attainable health care the same as everyone else. However, inequities still exist in the delivery of health care across the globe, including Australia that result in poorer health outcomes for this population group. Part of the problem is a lack of understanding of the complexities of ID care due to an absence of ID specific content in undergraduate curricula. Design: Integrative literature review. Methods: Electronic databases were searched for relevant empirical and theoretical literature. Additional articles were found by reviewing reference lists of selected articles resulting in ten articles for review. Selected articles were critically appraised using JBI critical appraisal tools. Data were analysed using comparative thematic analysis. PRISMA checklist completed the review. Results: Two main themes emerged from the data that informed the gap in knowledge: (a) Defining nursing practice; and (b) Confidence to practice. Conclusions: There was limited qualitative research published on the topic. International studies revealed that a lack of understanding of the ID condition due to inadequate education left registered nurses feeling underprepared, unsupported and struggling to provide optimal care. No studies were located on the phenomenon within the Australian context. A study exploring the lived experiences of RNs in Australia is needed to offer a deeper understanding of the phenomenon that will help inform practice. Relevance to practice: Including ID care in national undergraduate and postgraduate nursing curricula must become a nursing educational and professional priority to support nurses more fully in their practice to ensure patients with ID receive the highest attainable standard of nursing care. [ABSTRACT FROM AUTHOR]

The purpose of this research is to determine the impact of working during the early stage of the COVID‐19 pandemic on the well‐being of staff at one 600‐bed acute hospital in metropolitan Melbourne, Australia. This exploratory study is part of a larger mixed methods survey project, reporting the qualitative data from an on‐line survey of clinical staff working at one acute hospital between April 16th and May 13th, 2020 during the COVID‐19 pandemic. Responses to five free‐text questions were analysed using inductive content analysis. 321 medical, nursing, allied health and non‐clinical staff responded to the survey. Respondents reported anxiety, fear and uncertainty related to the pandemic, from the perspectives of work, home, family and community. They reported feeling confused by inconsistent messages received from government, hospital executive, managers and media. Seven themes were identified: (i) worrying about patient care, (ii) changed working conditions, (iii) working in the changed hospital environment, (iv) impact of the pandemic, (v) personal isolation and uncertainty, (vi) leadership and management and (vii) additional support needed for staff. Despite the pandemic being comparatively well‐controlled in Australia, all disciplines reported a high degree of anticipatory anxiety. Staff working in healthcare require both managerial and psychological support to minimise anxiety and promote well‐being and resilience in order to deal with the health crisis. Regular unambiguous communication directing the way forward is crucial. [ABSTRACT FROM AUTHOR]

Background: It is essential to evaluate the ways in which practice changes are implemented and received in and across contexts, identifying barriers and enablers, and mechanisms for enhancing success. Aim: To provide insights into the experiences of clinicians in implementing a multifaceted bundled urinary catheter care intervention in four acute care hospitals in New South Wales, Australia. Methods: The catheter care bundle was implemented using a pre‐ and postintervention study design. The intervention was implemented in all adult inpatient wards, emergency departments and operating theatres of four hospitals. The bundle consisted of an integrated set of evidence‐based practices to assist clinicians in making better informed decisions related to catheter insertion, care and removal practices. Focus groups at each participating hospital evaluated the implementation processes from the clinicians' perspective, identifying barriers and enablers to successful implementation. Results: Eight focus groups were held with 35 participants. Four key inter‐related themes were identified: early and sustained engagement with key stakeholders; good planning but remaining flexible; managing the burden of practice change; and adopting and sustaining practice change. These themes capture and highlight the complexity and the challenges associated with implementation of the practice change across contexts and the project timeline. Conclusion: It is imperative to understand the challenges associated with complex practice change and ways in which implementation can be optimised. This study identified barriers and enablers experienced by staff implementing the bundled intervention. The themes encapsulate factors central to success of practice change within the complex, multilayered healthcare environment. Relevance to clinical practice: Key challenges highlight the need for forward planning, strategic engagement of key players, continuing monitoring and feedback together with adequate resourcing tailored to result in sustainable normalisation of the intervention over time. The COREQ checklist for qualitative studies has been used in reporting this study. [ABSTRACT FROM AUTHOR]

Background: Bronchiolitis is the most common reason for infants under one year of age to be hospitalised. Despite management being well defined with high quality evidence of no efficacy for salbutamol, adrenaline, glucocorticoids, antibiotics or chest x-rays, substantial variation in practice occurs. Understanding factors that influence practice variation is vital in order to tailor knowledge translation interventions to improve practice. This study explores factors influencing the uptake of five evidence-based guideline recommendations using the Theoretical Domains Framework.Methods: Semi-structured interviews were undertaken with clinicians in emergency departments and paediatric inpatient areas across Australia and New Zealand exploring current practice, and factors that influence this, based on the Theoretical Domains Framework. Interview transcripts were coded using thematic content analysis.Results: Between July and October 2016, 20 clinicians (12 doctors, 8 nurses) were interviewed. Most clinicians believed chest x-rays were not indicated and caused radiation exposure (beliefs about consequences). However, in practice their decisions were influenced by concerns about misdiagnosis, severity of illness, lack of experience (knowledge) and confidence in managing infants with bronchiolitis (skills), and parental pressure influencing practice (social influences). Some senior clinicians believed trialling salbutamol might be of benefit for some infants (beliefs about consequences) but others strongly discounted this, believing salbutamol to be ineffective, with high quality evidence supporting this (knowledge). Most were concerned about antibiotic resistance and did not believe in antibiotic use in infants with bronchiolitis (beliefs about consequences) but experienced pressure from parents to prescribe (social influences). Glucocorticoid use was generally believed to be of no benefit (knowledge) with concerns surrounding frequency of use in primary care, and parental pressure (social influences). Nurse's reinforced evidence-based management of bronchiolitis with junior clinicians (social/professional role and identity). Regular turnover of medical staff, a lack of 'paediatric confident' nurses and doctors, reduced senior medical coverage after hours, and time pressure in emergency departments were factors influencing practice (environmental context and resources).Conclusions: Factors influencing the management of infants with bronchiolitis in the acute care period were identified using the Theoretical Domains Framework. These factors will inform the development of tailored knowledge translation interventions. [ABSTRACT FROM AUTHOR]

Background: Health Professionals are required to balance care practices against patient risk to optimise safety. Communicating clinical risk with the patient requires confidence. Objective: The objective was to explore health professionals understanding and confidence of patient-centred communication during conversations of risk prevention. Design: An exploratory study was conducted. Methods: Nurses, physiotherapists and social workers in a metropolitan hospital in Sydney (New South Wales, Australia) completed face to face interviews (n = 16) regarding person-centred communication and clinical risk. Results: The sample was predominately female and had been a health profession for 11.5 years (mean). Six key themes were generated including: Perceptions of person-centred communication; Preparing for person-centred communication and Understanding and prioritising conversations about preventable clinical risk. Conclusions: Person-centred communication was embedded in clinical practice; the 'patient voice' was considered central. Clinical risk was a priority. Education to improve communication was highlighted as a way to enhance person-centred communication. [ABSTRACT FROM AUTHOR]

Aims and objectives: To present an ethnographic insight into the older hospitalised person (those aged over 65 years) perceptions and experiences of pain care provision by nurses in acute care. Background: Pain care provision by nurses remains less than optimal for the older hospitalised person despite numerous evidence‐based guidelines. There is a paucity of research providing input from the experiences of the older hospitalised person in relation to their perspectives of pain care provision by nurses in acute care. Pain care research needs more involvement from those older persons with documented diagnoses of dementia, delirium or cognitive impairment, and intellectual disabilities and those in their end stage of palliation. Design: A focused ethnographic study. The consolidated criteria for reporting qualitative research (COREQ) were used to report the findings of this study. Methods: A focused ethnographic study was conducted in 8 acute care units within 2 large tertiary referral hospitals on the east coast of Australia. Consisting of semi‐structured interviews (n = 12) of cognitively intact older persons (11 hr). Twenty‐three (23) semi‐structured interviews with nine (9) RN participants (12 hr and 38 min). Participant observation period totalled 1,041 hr. Results: The older persons' experiences of receiving pain care were based on a formulaic assessment process focusing on intensity of pain and pain management options provided often lacked their input. The older persons often did not perceive their pain care provision as being of benefit to themselves. The nurses lacked insight and understanding on the nature of pain for the older person. Conclusion: Understanding was gained into how the older persons' pain care was hampered due to the lack of appropriate, and meaningful pain care provision and provides insight into why the older hospitalised person continues to experience a less than optimal experience. Relevance to clinical practice: Older hospitalised persons can gain continuity of pain care when nurses negotiate with them to repattern or restructure their nursing routines for pain care provision. Older people need inclusion into pain care decisions. All vulnerable older persons require nurses to use an evidence‐based pain assessment tool. [ABSTRACT FROM AUTHOR]

Aims and objectives: To explore the context and culture of nursing surveillance on an acute care ward. Background: Prevention of patient deterioration is primarily a nursing responsibility in hospital. Registered nurses make judgements and act on emerging threats to patient safety through a process of nursing surveillance. Organisational factors that weaken nursing surveillance capacity on general wards increase the need for patient rescue at the end point of clinical deterioration with poorer outcomes. Yet little is known about cultures that enable and sustain ward nursing surveillance for patient safety. Design: Workplace observations and semistructured interviews using a critical lens as the first stage of a larger emancipatory practice development project. Methods: Researcher immersion including 96 hr of nonparticipant observation with 12 semistructured interviews during July–August 2017. This study adhered to the COREQ guidelines. Results: We offer a metaphor of nursing surveillance as the threads that support the very fabric of acute care nursing work. These hidden threads enable nurses to weave the tapestry of care that keeps patients safe. This tapestry is vulnerable to internal and external forces, which weaken the structure, putting patients and staff at risk. Conclusion: Understanding local context is essential to supporting practice change. This workplace observation challenges us to find ways to creatively engage nurses with the underlying cultural and systems issues that so often remain hidden from view in the deteriorating patient literature. Relevance to clinical practice: Building cultural values that strengthen nursing surveillance is a prerequisite for safe and effective hospital care. As such, practice‐based research that empowers frontline nurses and teams to develop person‐centred workplace cultures can hold the key to unlocking sustainable improvements in patient safety. [ABSTRACT FROM AUTHOR]

Aims and objectives: (a) Describe the co‐development of a point‐of‐care App to promote uptake of best practice recommendations and consolidate nurses' knowledge for managing symptoms of neurocognitive disorders. (b) Report acceptability, usability and feasibility of the App to nurses for patient care in hospital. Background: Strategies used in hospitals to reduce symptoms, risk of harm, or complications of behavioural and psychological symptoms associated with neurocognitive disorders are frequently inconsistent with best practice recommendations. Design: Three‐stage, mixed‐methods, process and outcome evaluation. Methods: The App was co‐developed with experts, nurse end‐users and a consumer. Evaluation data were collected from a convenience sample of nurses observed during delivery of 80.5 hr of care to 38 patients; the App (n = 32 patients); and individual and focus group interviews with nurses (n = 25). Reporting adhered to an adapted STROBE checklist. Results: The App included three components: cognition and risk assessment; tailored evidence‐based strategies; and monitoring and evaluation of effectiveness. Observation data captured nurses using the App with 44.7% (n = 17) of eligible inpatients. Cognitive screening was completed at least once for each patient, with 146 risk assessments recorded. Interview data indicated the App's acceptability was enhanced by familiarity and perceived benefits, but hindered by perceived increases in workload, inconsistent use, pressure to use the App and resistance to change. Feasibility and usability were enhanced by easy navigation, and clear and useful content, but hindered by unclear expectations, unfamiliarity and device‐related factors. Conclusions: The App provided an evidence‐based tool that was, overall, considered feasible and acceptable to support best practice. Findings provide guidance to enhance usability for future implementation. Relevance to clinical practice: Co‐development using best evidence and key stakeholders enabled creation of a novel, feasible and acceptable technology. Real‐time access to assessment tools and tailored knowledge supported nurses' clinical decision‐making; workload and unfamiliarity were barriers to use. [ABSTRACT FROM AUTHOR]

Aims and objectives: To test the mnemonic Have you SCAND MMe Please? as a framework to audit nursing care to prevent harms common to older inpatients. Background: It is not known if acute hospital care comprehensively addresses eight interrelated factors that contribute to preventable harms common in older hospitalised patients. Design: Retrospective audit of medical records. Methods: A random selection of 400 medical records of inpatients over 65 years of age with an unplanned admission of longer than 72 hr in acute medical wards at four hospitals in Victoria, Australia, during 2011–12, was examined for frequency of documented evidence of assessments, interventions or new problems related to eight factors contributing to common preventable harms during hospitalisation. Results: Assessments of skin integrity (94%–97%), mobility (95%–98%) and pain (93%–97%) were most often documented. Gaps in assessment of continence (4%–31%), nutrition (9%–49%), cognition (delirium, depression and dementia) (10%–24%) were most common. No patient record had evidence of all eight factors being assessed. Almost 80% of records had interventions documented for one or more factors that contribute to preventable harms. In almost 20% of patient records, a new preventable harm was documented during hospitalisation. Conclusions: The mnemonic Have you SCAND MMe Please? brings together eight factors known to contribute to preventable harms common in older hospitalised patients. This framework was useful to identify gaps in assessment and interventions for factors that contribute to preventable harms during acute hospital care. Future research should test if the mnemonic can assist nurses with comprehensive harm prevention during acute hospitalisation. Relevance to clinical practice: The mnemonic Have you SCAND MMe Please? represents eight factors that contribute to preventable harms common in older hospitalised patients. This framework provides a model for harm prevention to assist nurses to implement comprehensive harm prevention to improve quality of care and safety for older hospitalised patients. [ABSTRACT FROM AUTHOR]

Aims and objectives: To understand the beliefs, attitudes and perceptions of nurses regarding family participation and collaboration in the care of their hospitalized adult relative. Background: Family participation in care is known to enhance the quality of patient care. Nurses are uniquely placed to support such participation, including the delivery of fundamental care. However, nurses' attitudes and beliefs may help or hinder participation. Design: A mixed methods approach with an exploratory sequential design was used. Setting: A regional referral hospital in Australia. Participants: Nurses were eligible to participate in the study if they were permanent staff of the hospital, and who in their day‐to‐day work had direct contact with adult patients and their families on acute care wards. Methods: Observer‐as‐participant observation data and semi‐structured interviews were undertaken. 30 hr of observational data were gathered, and 14 nurses were interviewed. Data collection occurred between September and December 2016. Following separate analysis, data were triangulated. Results: Analysis uncovered two contrasting categories: (i) enacting family participation (four themes); and (ii) hindering family participation (five themes). Conclusion: The findings of our study demonstrated that the practices of nurses do not always align with healthcare policies, and strategies to support nurses to enact patient‐ and family‐centred practices are needed. Relevance to clinical practice: Nurses can use these findings to make informed evidence‐based changes to the way they practice and communicate with families to ensure fundamental care is delivered. [ABSTRACT FROM AUTHOR]

Objective. The aim of the present study was to explore the potential of coronial inquest data to inform patient safety improvement in hospitals at a system level. Methods. A retrospective analysis of 20 years of South Australian (SA) coronial inquest findings was performed using both qualitative content analysis methods and statistical descriptive analyses. Results. In all, 113 cases were analysed. More than one-third of deaths (39%) were associated with emergency care. Analysis revealed 11 recurrent themes and two notable contributing factors that highlighted specific areas of concern for SA hospitals over that time period. The most common action recommended by coroners (49.6%; n = 56 cases) was the review or development of policy, protocol, procedure or guidelines designed to improve patient care. In almost one-quarter (24%) of deaths reviewed, coroners alerted health authorities to poor standards of care and/or instructed individual clinicians to review the standard of their clinical practice. Conclusions. The analysis provided a retrospective review of coronial inquest data associated with hospital care over a 20-year period. The findings highlight specific areas of concern for patient safety over that time. More broadly, this analysis contributes to an emerging body of evidence in the Australian academic literature that demonstrates the value of systematic analysis of coronial data at a system level to inform patient safety improvement in Australian healthcare. [ABSTRACT FROM AUTHOR]

This article outlines the development of the Australian Gold Coast Integrated Care Model based on the elements identified in contemporary research literature as essential for successful integration of care between primary care, and acute hospital services. The objectives of the model are to proactively manage high risk patients with complex and chronic conditions in collaboration with General Practitioners to ultimately reduce presentations to the health service emergency department, improve the capacity of specialist outpatients, and decrease planned and unplanned admission rates. Central to the model is a shared care record which is maintained and accessed by staff in the Coordination Centre. We provide a process map outlining the care protocols from initial assessment to care of the patient presenting for emergency care. The model is being evaluated over a pilot three year proof of concept phase to determine economic and process perspectives. If found to be cost-effective, acceptable to patients and professionals and as good as or better than usual care in terms of outcomes, the strategic intent is to scale the programme beyond the local health service. [ABSTRACT FROM AUTHOR]

The purpose of this cross-sectional study was to identify the prevalence of incontinence and incontinence-associated dermatitis (IAD) in Australian acute care patients and to describe the products worn to manage incontinence, and those provided at the bedside for perineal skin care. Data on 376 inpatients were collected over 2 days at a major Australian teaching hospital. The mean age of the sample group was 62 years and 52% of the patients were male. The prevalence rate of incontinence was 24% (91/376). Urinary incontinence was significantly more prevalent in females (10%) than males (6%) ( χ2 = 4·458, df = 1, P = 0·035). IAD occurred in 10% (38/376) of the sample group, with 42% (38/91) of incontinent patients having IAD. Semi-formed and liquid stool were associated with IAD ( χ2 = 5·520, df = 1, P = 0·027). Clinical indication of fungal infection was present in 32% (12/38) of patients with IAD. Absorbent disposable briefs were the most common incontinence aids used (80%, 70/91), with soap/water and disposable washcloths being the clean-up products most commonly available (60%, 55/91) at the bedside. Further data are needed to validate this high prevalence. Studies that address prevention of IAD and the effectiveness of management strategies are also needed. [ABSTRACT FROM AUTHOR]

To develop a process for improving the integration of care across the rural acute and primary care settings using asthma as a case study.Development of the process on the analysis of case note audit, survey, interviews and a workshop.A rural region of South Australia.A work plan for improving general practitioner (GP)–hospital integration was developed that resulted from analysis of the defined problem, GPs and stakeholder involvement, communication between all stakeholders, provision of an incentive to bring all the stakeholders together, and identification of evidence-based solutions.Managing chronic disease in a community requires the integration of care across the primary and acute care setting. To be successful, GP–hospital integration initiatives require stakeholder involvement, locally developed solutions, engagement of GPs, communication and a well-developed plan. This project provides a process for achieving this.The present study outlines a process to improve the management of asthma for a specific community group in a rural region. It also provides a process to improve GP–hospital integration, which can be applied to a range of settings and health conditions to improve patient care. [ABSTRACT FROM AUTHOR]