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Autistic individuals undergoing magnetic resonance imaging (MRI) examinations may face significant challenges, mainly due to sensory overload and MRI environment-related limitations. This study aimed to explore radiographers' perspectives and experiences regarding MRI scanning of autistic individuals. Data collection was achieved using a specifically designed mixed methods questionnaire on Qualtrics. The snowball technique was used. This UK-wide survey was electronically distributed by three main recruitment agencies between December 2020 and February 2021. 130 valid responses were received. A lack of relevant training and knowledge related to autism was noted. Effective communication, optimisation and customisation of the MRI examination, and MRI environment adjustments facilitated the completion of a safe and effective MRI examination. Poor patient-radiographer communication, unavailability of Special Educational Needs (SEN) experts, lack of specialised radiographer training and lack of specific guidelines were identified as the main barriers to successful MRI examinations. Although routine MRI safety and patient care rules will apply, MRI scanning of autistic individuals requires customisation and reasonable adjustments in communication, environment, and training of clinical teams. In addition, guidelines should be established to be used as a reference point to improve clinical practice. The adjustments proposed by radiographers were all consistent with the interventions in the wider literature. MRI practice for personalised care of autistic individuals should be aligned with current evidence, to customise communication and offer workflow and environmental adjustments. Formal training related to autism, integrated within radiography academic curricula and better co-ordination and communication of interdisciplinary teams would provide the necessary skill mix to deliver safe, high quality MRI scans with optimal experience for autistic service users and their carer(s). [Abstract copyright: Copyright © 2021 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.]

Unnecessary telephone calls to reporting radiologists impede organizations’ workflow and may be associated with a higher chance of errors in reports. We conducted a prospective study in two cycles, which identified vetting plain CT heads as the most common reason for these calls and vetting CT urinary tracts (KUB) was also frequent. Clear vetting and protocolling guidelines exist for both of these scans, which do not routinely require discussion with a radiologist. Therefore, our approach was to create new flow diagrams to allow radiographers to directly accept routine requests for plain CT head and CT KUB scans in- and out-of-hours. After this intervention, incoming calls to radiology for vetting CT heads decreased by 30% and for vetting CT KUBs by 100%. The average wait time between CT head request and scan completion was reduced by 40%. The number of CT head and CT KUB scans performed remained stable. In future, maximizing the benefit of direct access in-patient imaging pathways will rely on effective and sustained communication of the protocols to the junior clinical staff rotating through the organization, as they were responsible for requesting the vast majority of tests.

Objectives The purpose of this study was to scope the literature that exists about factors influencing oral health workforce planning and management in developing countries (DCs). Methods The Arksey and O'Malley method for conducting a scoping review was used. A replicable search strategy was applied, using three databases. Factors influencing oral health workforce planning and management in DCs identified in the eligible articles were charted. Findings Four thousand citations were identified; 41 papers were included for review. Most included papers were situational analyses. Factors identified were as follows: lack of data, focus on the restorative rather than preventive care in practitioner education, recent increase in number of dental schools (mostly private) and dentistry students, privatization of dental care services which has little impact on care maldistribution, and debates about skill mix and scope of practice. Oral health workforce management in the eligible studies has a bias towards dentist‐led systems. Due to a lack of country‐specific oral health related data in developing or least developed countries (LDCs), oral health workforce planning often relies on data and modelling from other countries. Discussion and conclusion Approaches to oral health workforce management and planning in developing or LDCs are often characterized by approaches to increase numbers of dentists, thus not ameliorating maldistribution of service accessibility. Governments appear to be reducing support for public and preventative oral healthcare, favouring growth in privatized dental services. Changes to professional education are necessary to trigger a paradigm shift to the preventive approach and to improve relationships between different oral healthcare provider roles. This needs to be premised on greater appreciation of preventive care in health systems and funding models.

Aim This paper provides the main accomplishments of the Royal North Shore Hospital (RNSH) Pharmacy Department?s COVID-19 Pandemic Response Plan and key recommendations for other departments developing a remote model of care. Methods The overall objective was to preserve the active workforce by minimising staff-to-staff and staff-to-patient contact. The response plan involved splitting the department into teams, implementing a remote ward-based clinical pharmacy service, staff upskilling and optimising the physical environment. Results In April 2020, 1240 clinical tasks were completed remotely compared with 1254 tasks completed on site. In May 2020, 1700 tasks were completed offsite, compared with 1544 tasks onsite. The percentage of pharmacists rating themselves 5 out of 5 (very confident) in communicating over the phone increased from 34.8% prior to remote service delivery, to 60% after completion of the service. Counselling patients over the phone increased from 17.4% to 40% while providing remote clinical service increased from 26.1% to 80%. Discussion The paper provides key recommendations for other sites wanting to implement a remote model of care. There are details of recommendations for communication, adequate skill mix, upskilling, education, training, staff resilience, role expansion and administration. Conclusion The formation of a team hospital pharmacy department COVID-19 Pandemic Response Plan has provided assurance that a complete pharmacy service could continue in the event of reduced staffing. Intense, thoughtful, collaborative work was required in a short period of time to design an appropriate physical environment, create a remote working model of care, and to train and educate members of staff.

Background and PurposeOnly a limited number of items involved in missed nursing care inventories specifically focused on infection control practices. The study aimed to adapt and evaluate psychometric properties of the Czech and Slovak version of the Infection Control Missed Care survey; and to assess and compare the amount, type,and reasons for missed nursing care in infection prevention and control amongCzech and Slovak nurses.MethodsThe convenience sample of 1459 nurses from the Czechand Slovak republic was recruited. Analysis of the nurses’ responses to both subscales of the surveys and validation of their data was undertaken using the item response theory (Rasch scaling).ResultsThe now-modified Czech version consists only of 20 items measuring the type and frequency of missed care and 11 items focusing on the reasons for missed care. The now modified Slovak version consists of 34 items measuring the type and frequency of missed care and 17 items measuring the reasons for missed care. Reliability estimates with the removal of unreliable items showed acceptable reliability estimates for both sub-scales of the instrument.ConclusionsWith modification to the two subscales used in the survey (removal of poorly fitting items) it should be reliable, and the resulting data could be used for further investigation such as factor analysis or modelling. The modified Infection Control Missed Care survey could be useful in further research investigating a relationship between nurse staffing, skill mix, and infection control outcomes in acute care hospitals.

Patients who experience an in-hospital cardiopulmonary arrest event often have poor outcomes. Those outcomes are influenced by institutional factors, including the effectiveness of the responding team. Two main types of response teams may exist for in-hospital settings: basic life support trained staff providing initial interventions, and advanced cardiac life support teams. The interface between these two responses, and differences in discipline, experience, and skill mix, adds complexity to team dynamics. In-hospital cardiopulmonary arrest teams benefit from addressing these and other factors, which may lead to lack of clarity in role and responsibility identification and ultimately team performance.

Staff in skilled nursing facilities (SNFs) are essential health care workers, yet they can also be a source of COVID-19 transmission. We used detailed staffing data to examine the relationship between a novel measure of staff size (that is, the number of unique employees working daily), conventional measures of staffing quality, and COVID-19 outcomes among SNFs in the United States without confirmed COVID-19 cases by June 2020. By the end of September 2020, sample SNFs in the lowest quartile of staff size had 6.2 resident cases and 0.9 deaths per 100 beds, compared with 11.9 resident cases and 2.1 deaths per 100 beds among facilities in the highest quartile. Staff size, including staff members not involved in resident care, was strongly associated with SNFs' COVID-19 outcomes, even after facility size was accounted for. Conventional staffing quality measures, including direct care staff-to-resident ratios and skill mix, were not significant predictors of COVID-19 cases or deaths. Reducing the number of unique staff members without decreasing direct care hours, such as by relying on full-time rather than part-time staff, could help prevent outbreaks.

Background With China’s population ageing rapidly, stroke is becoming one of the major public health problems. Nurses are indispensable for caring for older patients with acute and convalescent stroke, and their working experiences are directly linked to the quality of care provided. The study aims to investigate registered nurses’ experiences of caring for older stroke patients. Methods A qualitative descriptive design was adopted. Data were collected via semi-structured interviews with 26 registered nurses about their lived experiences of caring for older stroke patients. Thematic analysis was used to analyze the data. Results Two main themes were identified. First, the nurses identified an obvious gap between their ideal role in elderly care and their actual practice. The unsatisfactory reality was linked to the practical difficulties they encountered in their working environment. Second, the nurses expressed conflicting feelings about caring for older stroke patients, displaying a sense of accomplishment, indifference, annoyance, and sympathy. Caring for older stroke patients also affects nurses psychologically and physically. The nurses were clear about their own roles and tried their best to meet the elderly people’s needs, yet they lack time and knowledge about caring for older stroke patients. The factors influencing their working experiences extend beyond the personal domain and are linked to the wider working environment. Conclusions Sustaining the nursing workforce and improving their working experiences are essential to meet the care needs of older people. Understanding nurses’ lived working experiences is the first step. At the individual level, nurse mangers should promote empathy, relieve anxiety about aging, and improve the job satisfaction and morale of nurses. At the institutional level, policymakers should make efforts to improve the nursing clinical practice environment, increase the geriatric nursing education and training, achieve a proper skill mix of the health workforce, and overall attract, prepare and sustain nurses regarding caring for older people in a rapidly aging society.

INTRODUCTION: The Covid-19 pandemic has required countries to prepare their health workforce for a rapid increase of patients. This research aims to analyse the planning and health workforce policies in Germany, a country with a largely decentralised workforce governance mechanism. METHODS: Systematic search between 18 and 31 May 2020 at federal and 16 states on health workforce action and planning (websites of ministries of health, public health authorities), including pandemic preparedness plans and policies. The search followed World Health Organisation (WHO) Europe's health workforce guidance on Covid-19. Content analysis was performed, informed by the themes of WHO. RESULTS: The pandemic preparedness plans consisted of no or limited information on how to expand and prepare the health workforce during pandemics. The 16 states varied considerably regarding implementing strategies to expand health workforce capacities. Only one state adopted a policy on task-shifting despite a federal law on task-shifting during pandemics. CONCLUSIONS: Planning on the health workforce, its capacity and skill-mix during pandemics was limited in the pandemic response plans. Actions during the peak of the pandemic varied considerably across states, were implemented ad hoc and with limited planning. Future action should focus on integrated planning and evaluation of workforce policies.

We describe an innovative research protocol to: (a) examine patient-level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing.A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015-December 2019.Patients in the cohort will be followed from admission until 30-day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time-varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high-impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure-to-rescue; (b) in-hospital falls; (c) hospital-acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non-linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020.To our knowledge, this study is the first multisite patient-level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.目的: 我们描述了一份创新的研究方案: (a) 检查急诊护理医院护士配置方法与不良事件风险之间的患者水平纵向关联; (b) 确定安全护士配置的可能阈值。 设计: 2015年1月至2019年12月期间, 魁北克省 (加拿大) 16家医院收治的成人医疗、外科和重症监护病房患者动态队列研究。 方法: 将从入院到出院后30天里, 对队列研究中的患者进行随访, 以评估与随后发生的不良事件相关的选定护士工作实践的暴露情况。将使用电子工资单数据, 测量住院期间各轮班的五种人员配置方法, 并采用以下时变指标: (a) 各患者的护理工作时间; (b) 技能混合; (c) 加班使用; (d) 教育混合和; 以及 (e) 经验。将从参与站点检索的电子健康记录数据中测量四个可能与护士配置方法相关的高影响不良事件: (a) 抢救失败; (b) 住院量下降; (c) 院内获得性肺炎和; 以及 (d)静脉血栓栓塞。为检测所选护士人员配置暴露与各种不良事件风险之间的关系, 将拟合单独的多变量Cox比例风险脆弱性回归模型, 同时调整患者、护理单位和医院特征, 并进行聚类分析。为评估可能的人员配置阈值, 将拟合灵活的非线性样条函数。我们于2019年10月, 获得该项研究的资助,于2020年2月获得研究伦理/机构的批准。 讨论: 据我们所知, 此项研究是第一次多地点患者水平的纵向调查, 其针对普通护士配置方法与不良事件风险之间的关联。希望我们的研究结果能帮助医院管理者最有效地利用稀缺的护理资源, 并找出减少不良事件发生的人员配置方法。.

OBJECTIVES Coronavirus disease 2019 is a new contagious disease that has spread rapidly across the world. It is associated with high mortality in those who develop respiratory complications and require admission to intensive care. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy option for selected severely ill patients who deteriorate despite the best supportive care. During the coronavirus disease 2019 pandemic, extra demand led to staff reorganization; hence, cardiac surgery consultants joined the ECMO retrieval team. This article describes how we increased service provisions to adapt to the changes in activity and staffing. METHODS The data were collected from 16 March 2020 to 8 May 2020. The patients were referred through a dedicated Web-based referral portal to cope with increasing demand. The retrieval team attended the referring hospital, reviewed the patients and made the final decision to proceed with ECMO. RESULTS We reported 41 ECMO retrieval runs during this study period. Apart from staffing changes, other retrieval protocols were maintained. The preferred cannulation method for veno-venous ECMO was drainage via the femoral vein and return to the right internal jugular vein. There were no complications reported during cannulation or transport. CONCLUSIONS Staff reorganization in a crisis is of paramount importance. For those with precise transferrable skills, experience can be gained quickly with appropriate supervision. Therefore, the team members were selected based on skill mix rather than on roles that are more traditional. We have demonstrated that an ECMO retrieval service can be reorganized swiftly and successfully to cope with the sudden increase in demand by spending cardiac surgeons services to supplement the anaesthetic-intensivist roles.

OBJECTIVES The objective of this study is to determine orthopaedic consultants' perceptions of an advanced practice physiotherapy (APP) service in paediatrics. DESIGN This is a qualitative study that use semi-structured interviews to explore consultant doctors' experiences of an APP paediatric orthopaedic service and its development. Data were transcribed verbatim and subsequently underwent thematic analysis. PARTICIPANTS Five orthopaedic consultants in two hospital settings participated, and all of whom had experience of working with paediatric orthopaedic APPs. RESULTS Seven themes were derived from the analysis, with all participants in the study identifying factors affecting the development of the service and demonstrating broad support for the APP role, with benefits noted as including improved efficiency of service, expansion of skill mix within the team, positive impressions of the standard of care and improved education and liaison with the families and community practitioners at large. CONCLUSIONS This paper highlights many of the factors that should be considered when introducing an APP service in an outpatient setting. This study demonstrates consistent cross-site positive regard in the skill and competency of the APP in paediatric orthopaedics, to enhance orthopaedic services for children.

Supplemental Digital Content is available in the text., Background: Cross-sectional studies of hospital-level administrative data have suggested that 4 nurse staffing practices—using adequate staffing levels, higher proportions of registered nurses (RNs) (skill mix), and more educated and experienced RNs—are each associated with reduced hospital mortality. To increase the validity of this evidence, patient-level longitudinal studies assessing the simultaneous associations of these staffing practices with mortality are required. Methods: A dynamic cohort of 146,349 adult medical, surgical, and intensive care patients admitted to a Canadian University Health Center was followed for 7 years (2010–2017). We used a multivariable Cox proportional hazards model to estimate the associations between patients’ time-varying cumulative exposure to measures of RN understaffing, skill mix, education, and experience, each relative to nursing unit and shift means, and the hazard of in-hospital mortality, while adjusting for patient and nursing unit characteristics, and modeling the current nursing unit of hospitalization as a random effect. Results: Overall, 4854 in-hospital deaths occurred during 3,478,603 patient-shifts of follow-up (13.95 deaths/10,000 patient-shifts). In multivariable analyses, every 5% increase in the cumulative proportion of understaffed shifts was associated with a 1.0% increase in mortality (hazard ratio: 1.010; 95% confidence interval: 1.002–1.017; P=0.009). Moreover, every 5% increase in the cumulative proportion of worked hours by baccalaureate-prepared RNs was associated with a 2.0% reduction of mortality (hazard ratio: 0.980; 95% confidence interval: 0.965–0.995, P=0.008). RN experience and skill mix were not significantly associated with mortality. Conclusion: Reducing the frequency of understaffed shifts and increasing the proportion of baccalaureate-prepared RNs are associated with reduced hospital mortality.

Background Hospices provide end-of-life care to patients who have complex health care needs and whose symptoms are difficult to control. Understanding why some hospices offer inpatient hospice care to patients could bring more evidence for policy makers and researchers to focus on the role of inpatient care in hospice. Purpose The purpose of this study was to examine market and organizational factors that are associated with the provision of hospice inpatient care. Methodology This study used a retrospective, longitudinal design (2009-2013). The study sample was drawn from three data resources: the Area Health Resources Files, the Provider of Services files, and Hospice Cost Reports from Centers for Medicare & Medicaid Services. The sample size was 2,391 hospices or 10,999 hospice observations over 5 years. A generalized linear mixed-effects model was used to examine the association between market and organizational factors and hospice inpatient services offering. Results On average, 94.59% of hospices offer inpatient services to patients. Proportion of adults who were over 65 years old (OR = 1.12) and Medicare-managed care penetration (OR = 1.02) were positively associated with the provision of hospice inpatient services. The number of hospitals with hospice program was negatively related to hospice inpatient services offering (OR = .95). Other factors such as nursing skill mix, volunteer dependence, and census region were also associated with inpatient services offering. Practice implications The age demand of hospice care and Medicare-managed care penetration are related to hospice inpatient services offering. Hospices located in the market with more competition from hospitals that offer hospice program are less likely to offer inpatient care.

BackgroundWhen healthcare professionals’ workloads are greater than available resources, care activities can be missed, omitted or delayed, potentially leading to adverse patient outcomes. Prioritisation, a precursor to missed care, involves decision-making about the order of care task completion based on perceived importance or urgency. Research on prioritisation and missed care has predominantly focused on acute care settings, which differ from residential aged care facilities in terms of funding, structure, staffing levels, skill mix, and approaches to care. The objective of this study was to investigate how care staff prioritise the care provided to residents living in residential aged care.MethodsThirty-one staff members from five Australian residential aged care facilities engaged in a Q sorting activity by ranking 34 cards representing different care activities on a pre-defined grid from ‘Least important’ (− 4) to ‘Most important’ (+ 4). Concurrently, they participated in a think-aloud task, verbalising their decision-making processes. Following sorting, participants completed post-sorting interviews, a demographics questionnaire and semi-structured interviews. Q sort data were analysed using centroid factor analysis and varimax rotation in PQMethod. Factor arrays and data from the think-aloud task, field notes and interviews facilitated interpretation of the resulting factors.ResultsA four-factor solution, representing 22 participants and 62% of study variance, satisfied the selection criteria. The four distinct viewpoints represented by the solution were: 1. Prioritisation of clinical care, 2. Prioritisation of activities of daily living, 3. Humanistic approach to the prioritisation of care, and 4. Holistic approach to the prioritisation of care. Participants’ prioritisation decisions were largely influenced by their occupations and perceived role responsibilities. Across the four viewpoints, residents having choices about their care ranked as a lower priority.ConclusionsThis study has implications for missed care, as it demonstrates how care tasks deemed outside the scope of staff members’ defined roles are often considered a lower priority. Our research also shows that, despite policy regulations mandating person-centred care and the respect of residents’ preferences, staff members in residential aged care facilities tend to prioritise more task-oriented aspects of care over person-centredness.

Background: There is a high bureaucratic and administrative burden associated with health care tasks (test requesting, visits scheduling, supporting documents provision) that has historically largely fallen on health care professionals, which is one among the factors contributing to low job satisfaction and lower productivity. Incorporating new professional roles that help to better respond to the needs of both patients and professionals can increase the quality and efficiency of service provision. Objective: To evaluate the impact of the clinical assistant’s introduction in the Sant Joan de Déu Barcelona Children’s Hospital’s pediatric oncology department, in terms of displacement of activity loads carried out by this new professional role and the consequent time freed up for physicians. Methodology: Observational and retrospective study using administrative data based on the analysis of the type of activity performed by clinical assistants and the measurement of the time freed up in favor of the physicians, based on in situ timekeeping, to approximate the potential skill mix productivity increase. Results: Since its implementation in the pediatric oncology department, clinical assistants have performed 13,553 requests (69.93% of the total), representing a total saving of 266.83 hours or 6.67 workweeks of 40 hours. They performed 74.25% of outpatient surgical requests in the oncology department, 87.5% of day hospital requests and 54.13% of total requests in the outpatient consultations area. Conclusion: The introduction of clinical assistants in the oncology department could be efficient to the extent that it displaces a good part of the bureaucratic and administrative tasks previously performed by health care professionals. This delegation allows them to work more closely to the maximum of their competences and the physicians to have more time for higher added value clinical tasks. In terms of efficiency, this role change enables to optimize the clinical process, reducing the cost by 56% compared to the conventional model.

Background Whilst our established support for people living with breathlessness was long-standing, it was not multidisciplinary or fully evidence-based. We wanted to address this for the benefit of patients and the wider health system. The Cambridge Breathlessness Intervention Service (CBIS) model is an evidence-based approach to support people living with advanced lung conditions to manage their breathlessness (Higginson, Bausewein, Reilly, et al., 2014). Consultation with service users suggested that patients wanted support to: manage breathlessness, improve mental wellbeing, mobility and symptom management as well as help with planning ahead and reducing isolation. Aims To implement and evaluate a breathlessness intervention using a multidisciplinary skill mix and trained community volunteers. Methods Using the CBIS model as a framework, we reshaped, redeployed and trained our team to deliver this intervention at home. We supplemented this with a layer of social support provided by experienced compassionate neighbour volunteers. We evaluated the impact of the intervention through: before and after breathlessness self-rating scales, interviews with patients and case studies documenting the use of different parts of the service (e.g. physiotherapist, nurse, occupational therapist, rehabilitation assistant, complementary therapy). Results This project has been delivered during the COVID-19 pandemic, so there were practical issues around seeing patients face-to-face, and we were unable to support as many as expected. To date, 28 patients have been referred to the service. Of these, 18 received input. We will report on changes in self-rating scores and feedback from interviews with patients and families. To date, only a few participants opted to have a compassionate neighbour. Conclusions Initial findings suggest that although delivery of this project was hampered by the pandemic, patients valued the service and benefitted from practical input from the MDT. Limitations on being able to provide face-to-face support may have influenced uptake of compassionate neighbours and reduced the number of patients seen.

ObjectivePharmacists are increasingly contributing to the skill mix of general practice surgeries to help alleviate pressures faced by UK doctors working in primary care. However, they need support in overcoming barriers to their integration. The purpose of this work was to evaluate a programme designed to support pharmacists’ transition to working in general practice settings. We explored the learning needs of pharmacists’, the barriers and enablers to their integration and provide recommendations based on our results.InterventionA qualitative evaluation of a 1-year transition programme in Wales starting in September 2018 to support pharmacists’ transition to working in general practice settings.Design and settingWe employed an interpretative phenomenological approach involving 10 pharmacists across Wales enrolled on the transition to general practice training programme, and their tutors. Data were collected across two sequential phases: in phase 1 telephone interviews were held with pharmacists midway through their training; in phase 2, focus groups were conducted with both pharmacists and tutors towards the end of the programme.ResultsPharmacists enter general practice settings with a variety of prior experience. The programme provided a framework that pharmacists found helpful to map their experience to but the programme needed to be flexible to individual learning needs. The tutor role was typically regarded as the most valuable component, but interaction with the wider general practice team was critical to ease the transition. Pharmacists encountered a lack of clarity about their role which impeded their integration into the workplace team.ConclusionsA formal programme with a designated tutor can support pharmacists’ transition into general practice settings. The programme’s competency framework facilitated reciprocal understanding of the pharmacist’s role in the team, helped to manage expectations and enhanced collaborative practice. Recommendations to facilitate pharmacist integration into general practice settings are provided.

Background Growing demands on healthcare globally, combined with workforce shortages, have led to greater skill mix in healthcare settings. Pharmacists are increasingly moving into complex areas of practice, a move supported by policy and education/training changes. Aim To understand the nature of extended roles for pharmacists practising at an advanced level in primary care and community pharmacy settings, to explore how clinical and physical examination was incorporated into practice and to understand the impact of providing such examination on practice and on patient relationships. Method Telephone interviews (N = 15) were conducted with a purposive sample of pharmacists using clinical and physical examination in their practice in Great Britain. The sample included primary care pharmacists (N = 5), community pharmacists (N = 4), pharmacists working across settings (N = 5) and one working in another primary care setting. Participants were recruited through professional networks, social media and snowballing. Results Primary care pharmacists and community pharmacists were utilising clinical and physical examination skills in their practice. Some community pharmacists were operating locally-commissioned services for low acuity conditions. Incorporating such examinations into practice enabled pharmacists to look at the patient holistically and enhanced pharmacist/patient relationships. Barriers to practise included lack of timely sharing of patient data and perceived reluctance on the part of some pharmacists for advanced practice. Conclusion With growing opportunities to provide patient-focussed care, it remains to be seen whether pharmacists, both in Great Britain and elsewhere, are able to overcome some of the organisational, structural and cultural barriers to advanced practice that currently exist in community pharmacy.

Objectives The aim of this study was to examine the strength of improvement recommendations proposed after investigation of fall incidents in health care facilities that result in major injuries. Methods This study was conducted using a retrospective multi-incident analysis design. The study setting was 4 tertiary teaching hospitals, 1 subacute rehabilitation facility, and a residential aged care facility in a metropolitan health district in New South Wales, Australia. Ninety-eight injurious fall incidents during a 2-year period (2015-2016) were investigated. Recommendations were grouped into 3 categories: strong (including environmental modifications, equipment, workflow or process redesign), medium (including changes in communication or documentation processes, staffing numbers and/or skill mix, education to address identified knowledge deficits), and weak (including alerts/warning/labels or expected practice without any associated policy or procedure). Results The majority of the incidents (34.7%; n = 34) occurred between 1300 and 1859 hours, 65.3% (n = 64) occurred in the patient's room, and 79.4% (n = 81) of the injuries were fractures. There were 224 recommendations made for 79 incidents, and 19 incidents did not have any recommendations. The average number of improvement recommendations proposed per incident investigation was 2.3 (SD, 2.1; range, 0-9). Nineteen (8.5%), 80 (35.7%), and 125 (55.8%) recommendations were classified as strong, medium, and weak, respectively. Half of the investigative teams included representatives from more than one professional group. There were a significantly greater number of medium recommendations made by multi-disciplinary teams compared with single-disciplinary teams (odds ratio, 1.83; 95% confidence interval, 1.05-3.21). There was no significant difference in the number of strong and weak recommendations made between the 2 teams. Conclusions This study found that only 8.5% of recommendations were classified as strong. This suggests that a major challenge lies in formulating robust recommendations; hence, efforts should focus on enhancing the strength of improvement recommendations.

The contribution of registered nurses towards safe patient care has been demonstrated in many studies. However, most of the evidence linking staffing levels to outcomes is cross-sectional with intrinsic limitations including an inability to establish that presumed cause (staffing) precedes the effect. No reviews have summarised longitudinal studies considering nurse staffing and patient outcomes.To identify and assess the evidence for an association between nurse staffing levels, including the composition of the nursing team, and patient outcomes in acute care settings from longitudinal studies.We undertook a systematic review of studies where the association between nurse staffing with patient outcomes was assessed in a longitudinal design. Studies with repeated cross-sectional analyses were excluded unless a difference-in-difference design was used. We searched Medline, CINAHL, Embase and the Cochrane Library up to February 2022. We used the ROBINS-I tool to assess risk of bias. We synthesised results in a tabular form and a narrative grouped by outcome.27 papers were included. Studies were conducted in a variety of settings and populations, including adult general medical/surgical wards and adult and neonatal intensive care units. Staffing measures were operationalised in a variety of different ways, making direct comparisons between studies difficult and pooled estimates impossible. Most studies were either at serious (n = 12) or critical (n = 5) risk of bias, with only 3 studies at low risk of bias. Studies with the most risk of bias were judged as likely to underestimate the effect of higher registered nurse staffing. Findings are consistent with an overall picture of a beneficial effect from higher registered nurse staffing on preventing patient death. The evidence is less clear for other patient outcomes with a higher risk of bias, but in general the proposition that higher registered nurse staffing is likely to lead to better patient outcomes is supported. Evidence about the contribution of other nursing staff groups is unclear.The causal relationship between low registered nurse staffing and mortality is plausible and these estimates of relationships from longitudinal studies provide further support. To address residual uncertainties, future studies should be conducted in more than one hospital and using standardised measures when reporting staffing levels.Having more registered nurses on hospital wards is causally linked to reduced mortality - new review shows there is little room for doubt @ora_dall @workforcesoton @turnel.

Aim The aim of this study is to describe ratio and skill mix for nursing staff in Swedish emergency departments over a specific 24-h period. Background The link between number of patients per nursing staff and missed nursing care is well described within the in-hospital setting, showing association with negative outcomes such as increased mortality. Potential association within the emergency department setting is still unexplored. Method This is a national descriptive cross-sectional benchmark study. Results The majority (n = 54; 89%) of Swedish emergency departments participated. The patients-per-registered nurse ratio varied between the shifts, from 0.3 patients to 8.8 patients (mean 3.2). The variation of patients per licenced practical nurse varied, from 1.5 to 23.5 patients (mean 5.0). The average skill mix was constant at around 60% registered nurses and 40% licenced practical nurses. Conclusion The varying ratios for patient per registered nurse and licenced practical nurse in Swedish emergency departments are noteworthy. Furthermore, the patient flow and nursing staff numbers did not match one another, resulting in higher nursing staff ratios during the evening shift. Implications for nursing management Findings can be used to improve rosters in relation to crowding, to manage the challenging recruitment and retention situation for nursing staff and to improve patient safety.

AimsTo highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic.BackgroundIn acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses.DesignDiscursive paper.FindingsNursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures.ConclusionCOVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive.Relevance to clinical practiceObjective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.

How to maximise the expertise of dental professionals and utilise multidisciplinary teams to improve patient care.

Introduction Radiographer role development has touched boundaries across the multidisciplinary team and more recently branched into the field of gynaecology. Radiographers are now able to perform tasks that were traditionally performed by radiologists and gynaecologists to implement a radiographer-led Hysterosalpingogram (HSG) service. The aims of the study were to (i) implement a radiographer-led HSG service with a view to decreasing waiting times. (ii) To determine ladies perceptions and satisfaction levels. Method Local clinical guidelines were developed with the radiologist/gynaecologist and trainee HSG radiographers. A robust system of work was initiated which required maintaining comprehensive log books to record examinations performed and reports written. These were audited and compared with those of the radiologist. Audit cycles were monitored through Q Pulse to ensure good practise was maintained. Patient satisfaction surveys were developed and distributed to 100 consecutive ladies attending for HSG over a 6 month period from January–July 2017. Results The radiographer-led service has increased the number of appointment slots offered for HSG's throughout the year as the service now runs every week. HSG's were performed by 5 staff members but now only require 3 staff. A 75% response rate was achieved from the questionnaire survey and shows high patient satisfaction levels. Ladies reported being better informed about their examination resulting in decreased anxiety, concerns and discomfort. Conclusion The implementation of this service has successfully reduced waiting lists for HSG examinations from 14 to 0 weeks. The Trust has saved £15,000 on staff salaries per annum since the service started.

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.A quantitative systematic review included studies published in English between January 2000 - September 2018.Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.目的: 在于探讨护士技巧组合(注册护士提供的总时数比例)与急性护理医院患者结果之间的联系。 设计: 一项定量系统综述包括2000年1月至2018年9月期间以英语发表的各项研究。 资料来源: 搜索了Cochrane Library、CINAHL Plus with Full Text、MEDLINE、Scopus、Web of Science和Joanna Briggs Institute。纳入了观察性和实验性研究设计。如果定量成分符合标准,则纳入混合方法设计。 综述方法: 使用了Joanna Briggs Institute的系统综述指南及其关键评估工具。当75%或者更多具备显著结果的研究发现这种联系时,就确定了反向关联。 结果: 共纳入了63篇文章。12名患者的结果与护理技巧组合呈负相关(即,较高的护理技能组合与患者结果的改善显著相关)。这些是住院天数;溃疡、胃炎和上消化道出血;急性心肌梗死;约束使用;救援失败;肺炎;败血症;尿路感染;死亡率/30天死亡率;压力性损伤;感染和休克/心脏骤停/心力衰竭。 结论: 护理技巧组合影响了12例患者的结果。然而,需要使用实验性或纵向研究设计来进一步调查,从而建立因果关系。需要就技巧组合的定义达成共识,以便能够更有力地评估技巧组合变化对患者结果的影响。 影响: 在降低死亡率和救援失败等不良患者结果方面,技巧组合可能比护士人数更为重要,尽管最佳的人员配置在人力资源规划中仍然让人难懂。.

Aims To identify nurse staffing groups in acute care facilities. Design This retrospective descriptive study used a configurational approach. Methods Data from a two‐month target period from January–March 2016 were collected for 40 facilities in four different hospitals in one of the largest regions of Quebec. Multiple factorial analysis and hierarchical ascendant classification were used to generate a limited number of nurse staffing groups. Results/Findings Four distinct nurse staffing groups emerged from this study. The least resourced model relied mainly on less qualified personnel and agency staff. The moderately resourced basic model was assessed as average across all staffing dimensions, but employed less overtime, relying mostly on auxiliary nurses. The moderately resourced professional group, also moderate in most variables, involved more overtime and fewer less qualified personnel. The most resourced group maximized highly qualified personnel and minimized instability in the nursing team. Conclusion This study covered multiple staffing groups with widely varying characteristics. Most groups entailed risks for quality of care at one or more levels. Few care units approached the theoretical staffing ideal.

Background In 2014, the number of HPV vaccine doses given to adolescent girls as part of the English school-based immunization programme was reduced from three to two. This was based on evidence that a two-dose schedule provides long-lasting protection against HPV infection. In 2015/16 a small decline in HPV vaccination coverage in adolescent girls was noted; from 86.7% for the three-dose schedule in 2013/14 to 85.1% for the two-dose schedule. This evaluation examined whether service-related factors contributed to this decline. Methods In May–August 2017, we conducted semi-structured qualitative interviews with 39 participants responsible for commissioning or delivering immunization programmes in six local authorities in the South West, North Central Midlands and South Central Midlands, England. Results Effective planning and data management were key for successful service provision of HPV vaccination, as well as close collaboration between commissioners, service providers and data system managers, a team skill mix with experienced staff, pro-active engagement with schools and service providers equipped to respond to parental concerns. Conclusions To maintain and improve the high HPV adolescent girls’ vaccine coverage rates achieved in England, in the context of an expanding school-based immunization programme, it is essential to strengthen the organizational capacity of the delivery system.

IntroductionOccupational therapists have a key role in supporting people experiencing cancer and its consequences. A complex skill mix is required to fulfil this role, creating a training need for ...

Clinical decision-making is an important element in midwifery practice. Midwives are required to have a sound knowledge to manage complications during childbirth. Any misjudgement by a midwife may lead to adverse birth outcomes. The aim of this paper is to review factors that contribute to clinical decision-making of midwives. This was achieved by reviewing published research articles. Studies have shown that shortage of human and material resources, poor skill mix, absence of mentors and lack of autonomy are some of the contributing factors that may affect midwives’ decision-making.

The UK has an ageing population more and more elderly people are living with diabetes. Jill Hill explores the condition as well as other healthcare challenges that comes with caring for this particular patient group With the increasingly ageing population worldwide, more older people are living with diabetes. The conditions that often accompany older age, such as dementia, renal impairment, visual impairment and manual dexterity difficulties, can make diabetes management complex and self-care challenging. However, the status of older people varies considerably, and so choice of glucose-lowering agents and clinical targets should be individualised to maximise safety and ensure that the risks of treatments do not outweigh the benefits. For many patients, there will be an increasing dependence on others to manage their diabetes care, therefore an appropriate skill mix among health professionals and carers, adequate training and regular competency assessment are crucial to support patients to remain safe and symptom free from diabetes.

ObjectiveTo compare outcome of clinical advice given by emergency physicians (EPs) versus non-physician clinical advisors (NPCAs) on a UK National Health Service 111 centre.MethodThis was a prospective study conducted between July 2016 and February 2017. We targeted calls in which call handlers using standard NHS 111 clinical decision support software would have advised the caller to attend a hospital ED. These calls were passed to a clinical assessment service (CAS) and reviewed by either an EP (July to November 2016) or an NPCA (December 2016 to February 2017).ResultsDuring the preintervention year, 80.2% of callers were advised to attend the ED within 1 or 4 hours, 1.2% were referred to out of hours (OOH) primary care and 0.3% to self-care. During the study, call handlers designated 2606 calls as needing to attend the ED in 1 or 4 hours and passed these on to the clinical advisors. There was a reduction of 75%–81% in cases advised to attend the ED in both intervention groups; EPs advised 396 of 1558 callers (25.4%) to attend ED; NPCAs advised 194 of 1048 callers (18.5%) to attend ED. For calls not requiring the ED, EPs recommended self/home care management in 38.1% of these calls, NPCAs recommended self-care for 15.7% (difference=22.4%; 95% CI 19.0% to 25.7%). EPs recommended 4.5% to attend OOH primary care, while NPCAs recommended OOH primary care for 42.1% (difference=37.6%, 95% CI 34.3% to 40.8%).ConclusionsA CAS within NHS 111 using clinicians decreases referrals to the ED. EPs use fewer services and resources. Further work needs to be undertaken to determine the workforce skill mix for an NHS 111 CAS.

ObjectiveTo explore the factors contributing to prescribing error in paediatric intensive care units (PICUs) using a human factors approach based on Reason’s theory of error causation to support planning of interventions to mitigate slips and lapses, rules-based mistakes and knowledge-based mistakes.MethodsA hierarchical task analysis (HTA) of prescribing was conducted using documentary analysis. Eleven semistructured interviews with prescribers were conducted using vignettes and were analysed using template analysis. Contributory factors were identified through the interviews and were related to tasks in the HTA by an expert panel involving a PICU clinician, nurse and pharmacist.ResultsPrescribing in PICU is composed of 30 subtasks. Our findings indicate that cognitive burden was the main contributory factor of prescribing error. This manifested in two ways: physical, associated with fatigue, distraction and interruption, and poor information transfer; and psychological, related to inexperience, changing workload and insufficient decision support information. Physical burden was associated with errors of omission or selection; psychological burden was linked to errors related to a lack of knowledge and/or awareness. Social control through nursing staff was the only identified control step. This control was dysfunctional at times as nurses were part of an informal mechanism to support decision making, was ineffective.ConclusionsCognitive burden on prescribers is the principal latent factor contributing to prescribing error. This research suggests that interventions relating to skill mix, and communication and presentation of information may be effective at mitigating rule and knowledge-based mistakes. Mitigating fatigue and standardising procedures may minimise slips and lapses.

The burden of physical impairments and disabilities is growing across high-, middle-, and low-income countries, but populations across the globe continue to lack access to basic physical rehabilitation. Global shortages, uneven distributions, and insufficient skill mix of human resources for health and rehabilitation (HRH&R) contribute to such inequitable access. However, there are no international standards to classify HRH&R and to promote their global monitoring and development. In this article, we conceptually develop an international classification of HRH&R based on the concept of monitoring HRH&R through their stock of practices and competencies, and not simply counting rehabilitation professionals such as physical or occupational therapists. This concept accounts for the varying HRH&R configurations as well as the different training, competencies, or practice regulations across locations, even within the same profession. Our perspective specifically develops the concept of a proposed classification, its structure, and possible applications. Among the benefits, stakeholders using the classification would be able to: (1) collect locally valid and internationally comparable data on HRH&R; (2) account for the rehabilitation practices and competencies among nonspecialized rehabilitation workers (eg, in less resourced/specialized contexts); (3) track competency upgrades or practice extensions over time; (4) implement competency-based human resources management practices, such as linking remuneration to competency levels rather than to professional categories; and (5) inform the development of (inter-)professional education, practice regulation, or even task-shifting processes for the whole of HRH&R. The proposed classification standard, still in a concept-development stage, could help drive policies to achieve the “right” stock of HRH&R, in terms of practices and competencies.

Objective The objective of this review was to determine the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings within low- and middle-income countries. Introduction Health care systems in low- and middle-income countries experience a high proportion of the global burden of disease, which is aggravated by several health care constraints. The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging in low- and middle-income countries. Health care systems in low- and middle-income countries, however, are still expected to address universal health care access and provide high-quality health care. Systematic reviews examining nurse staffing and its effect on patient and nurse workforce outcomes are largely from the perspective of high-income countries. There is a need to understand the evidence on nurse staffing and its impact in the context of low- and middle-income countries. Inclusion criteria Empirical studies that addressed acute care nurse staffing levels, such as nurse-to-patient ratio or nurses' qualifications, experience, and skill mix, and their influence on patient and nurse workforce outcomes were included in the review. Studies conducted in a low- or middle-income country were included. Outcomes must have been measured objectively using validated tools. Methods Studies published until July 2019 were identified from CINAHL, PubMed, Scopus, Embase, PsycINFO, Cochrane Library, Web of Science, and ProQuest Dissertations and Theses. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. Narrative synthesis was conducted due to high heterogeneity of included studies. The level of evidence was determined using GRADEpro. Results Twenty-seven studies were included in this review and the level of evidence was low, mainly due to the design of included studies. Low nurse-to-patient ratio or high nurse workload was associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls, and abandonment of treatment. Findings on the effect of nurse staffing on length of hospital stay and incidence of pressure ulcers were inconsistent. Extended work hours, less experience, and working night or weekend shifts all significantly increased medication errors. Higher nurse workload was linked to higher levels of nurses' burnout, needlestick and sharps injuries, intent to leave, and absenteeism. Conclusions Lower nurse-to-patient ratios and higher nurse workload are linked to in-hospital mortality, hospital-acquired infections, and medication errors among patients, and high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave their job among nurses in low- and middle-income countries. The results of this review show similarities with the evidence from high-income countries regarding poor outcomes for patients and nurses. These findings should be considered in light of the lower nurse-to-patient ratios in most low- and middle-income countries. Systematic review registration number PROSPERO CRD42018119428.

Aim To evaluate frequencies, types of and reasons for missed nursing care during the COVID-19 pandemic at inpatient wards in a highly specialized university hospital. Background Registered nurse/patient ratio and nursing competence are known to affect patient outcomes. The first wave of the COVID-19 pandemic entailed novel ways for staffing to meet the expected increased acute care demand, which potentially could impact on quality of care. Methods A comparative cross-sectional study was conducted, using the MISSCARE Survey. A sample of nursing staff during the first wave of the COVID-19 pandemic (n = 130) was compared with a reference sample (n = 157). Results Few differences between samples concerning elements of missed care and no significant differences concerning reasons for missed care were found. Most participants perceived the quality of care and the patient safety to be good. Conclusion The results may be explained by three factors: maintained registered nurse/patient ratio, patients' dependency levels and that nursing managers could maintain the staffing needs with a sufficient skill mix. Implications for nursing management Nursing managers impact on the occurrence of MNC; to provide a sufficient registered nurse/patient ratio and skill mix when staffing. They play an important role in anticipatory planning and during infectious disease outbreaks.

The growing prevalence of venous leg ulcers in an ageing population presents challenges for wound care and management. The Lindsay Leg Club model is an alternative approach to the management of leg health that can improve patient outcomes. This article reports on an audit of a relational database located within the Leg Club Network, containing records of more than 17 000 patients (known as members) who attended a Leg Club in a 5‐year period (2014‐2019). Overall, over 266 000 member leg assessments and treatments were entered into the database. The average nurse‐member attendance time was 28 min, with a skill mix of 23% senior nurses, 70% qualified and associate nurses, and 7% nurses in supervisory roles. Healing rates averaged 62% after 12 weeks. Recurrence rates were 20% after 12 weeks. Annual clinical and volunteer hours averaged 821 and 800 h, respectively. Staffing costs were £28 per wound treatment or leg assessment with a typical duration of 27 min; 71% of members were aged 70 to 94 years old, which indicates the need for a service that caters to the specific requirements of this age group. However, no data on psychosocial and well‐being outcomes were recorded. Their inclusion in further developments of this database is recommended.

Background Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry. Objectives The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis. Design A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study. Setting The setting was NHS dental practices in North West England. Participants A total of 217 low-risk patients in eight high-street dental practices participated. Interventions The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm). Main outcome measure The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists. Results No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined. Limitations The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate. Conclusions Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value. Future work Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation. Trial registration Current Controlled Trials ISRCTN70032696. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Aims To examine the association between type of nursing staff and nursing-sensitive outcomes in long-term institutional care. Design This systematic review included studies published in English, German, and Dutch between January 1997 and January 2020. Data sources The databases Medline (PubMed), CINAHL, PsycINFO, Embase, and the Cochrane Library were searched. Original quantitative studies were included. Review methods The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were followed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to critically appraise the reporting of the studies. Results Fifteen articles were included. Of 33 quality of care outcomes, 21 were identified as nursing-sensitive outcomes of which 13 showed a significant association with nursing staff, specifically: Activities of daily living, aggressive behavior, bladder/bowel incontinence, contractures, expressive language skills, falls, infection (including vaccination), range of motion, pain, pressure ulcers, and weight loss. However, studies reported inconsistent results regarding the association among RNs, LPNs, CNAs, and HCAs and these nursing-sensitive outcomes, evidence shows that more RNs have a positive impact on nursing-sensitive outcomes. As to the evidence regarding the other type of nursing staff, especially HCA, findings regularly showed a negative association. Conclusion Future research should be expanded with structure and process variables of which the mediating and moderating effect on nursing-sensitive outcomes is known. These may explain variances in quality of care and guide quality improvement initiatives. Researchers should consider fully applying Donabedian's structure-process-outcomes framework as it is a coherent entirety for quality assessment. Impact This review provides an overview of quality of care outcomes that are responsive to nursing interventions in long-term institutional care. As the effects can be monitored and documented, quality assessment should focus on these nursing-sensitive outcomes. The inconclusive results make it difficult to provide recommendations on who should best perform which care.

Aims and objectives This study aimed to identify and compare missed nursing care types and reasons between South Korea and the United States of America. Background Patient safety has become a significant task of the healthcare delivery systems worldwide. The omission of nursing care constitutes a growing concern because it threatens both patient safety and nursing care quality. Design This study used a cross-sectional, descriptive and comparative design. Methods Data were collected from registered nurses working in two university-affiliated tertiary hospitals and a general hospital in Korea and a Midwest United States tertiary hospital. In addition, the STROBE checklist was used in this study. Results While substantial, the level of missed nursing care reported by Korean nurses was lower than that of United States nurses. Only three nursing care activities, setting up meals, patient assessment and skin/wound care, did not significantly differed between two countries. More basic nursing care types such as ambulation, feeding and mouth care were missed more than others in both countries. The reasons for missed care differed between two countries. However, both Korean and US nurses reported labour resource problems as reasons for missed care. Conclusions Although the types of missed nursing care differed significantly between countries, both Korean and US nurses reported labour resource problems for the top reasons for missed care. Thus, comparing missed nursing care could assist nursing administrators in developing strategies to improve care quality and patient safety. Relevance to clinical practice The level and reasons for missed nursing care are very influential factors for patient outcomes and patient safety. Appropriate skill mix and staffing are needed to decrease extent of missed care, so that enhancing patient safety and quality of nursing care.

Background Despite its association with patient safety, few studies on missed nursing care have been conducted in nursing homes. We aimed to describe individual and environmental factors in a sample of registered nurses (RNs) reporting missed nursing care in nursing homes, and to explore the association between these factors and missed nursing care. Methods In the present, multicentre cross-sectional study, 217 RNs from 43 nursing homes in Northern Italy reported all episodes of missed nursing care (ie, any aspect of required care that was omitted or delayed) that occurred in the 20 most dependent residents (according to RNs’ judgement; 860 residents in total) over 3 consecutive days. Multilevel multivariable logistic regression models were used to test possible explanatory factors of missed nursing care (individual, work-related, organisational, and work environment factors), which were entered in a step-wise manner. Results Younger RNs (P = .026), freelance RNs (P = .046), RNs with a permanent contract (P = .035), and those working in publicly-owned nursing homes reported more episodes of missed nursing care (P < .012). Public ownership (odds ratio [OR] = 9.88; 95% CI 2.22–44.03; P = .003), a higher proportion of residents with severe clinical conditions (OR = 2.45; 95% CI 1.12–5.37; P = .025), a lower proportion of RNs (OR = 2.24; 95% CI 1.10–4.54; P = .026), and perceived lack of time to care for residents (OR = 2.33; 95% CI 1.04–5.26; P = .041) were statistically significantly associated with missed nursing care. Conclusion Factors associated with missed nursing care are similar in hospitals and nursing homes, and include heavy workload and perceived lack of time for care. Because missed nursing care in nursing homes represents tasks performed specifically by RNs, missed nursing care in this setting should be measured in terms of these tasks. An optimal skill mix is crucial to guarantee not only comfort and basic care for nursing home residents, but also good outcomes for residents with severe clinical conditions.

Background Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice. Methods A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis. Results Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity. Conclusions Conducting small-change experiments, anchored by action and appraisal rather than by design, clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Introduction: Community hospitals (CHs) could address the emerging complex care needs of patients. We investigated which characteristics of patients’ and CHs affect patient outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver this care. Methods: We analysed all elderly patients discharged from the CHs of Emilia-Romagna, Italy. CH skill mix and care processes were collected with an ad hoc survey. The primary outcome was improvement in the Barthel index (BI) on discharge. Hierarchical regression analysis was performed to test the associations under study. Results: 53% of the patients had a BI improvement ≥10. After adjusting for the diverse case mix of the patients, no significant association was found between CH characteristics and BI improvement. Patient characteristics explained only a portion of the variability in CH performance. Discussion: Heterogeneity in case mix reflects the nature of CHs, which play context-specific roles as integrators between primary care services and hospitals. Residual variability in BI improvement rates across CHs might be attributed to aspects of care not detected in our survey. Conclusions: More research is needed to study the impact of CH skill mix and care processes on patient outcomes.

Question(s)What is the impact of including an allied health assistant (AHA) role on physiotherapy service delivery in terms of service provision, scope of practice and skill mix changes in an acute respiratory service?DesignA pragmatic pre-post design study examined physiotherapy services across two three-month periods: current service delivery [P1] and current service delivery plus AHA [P2].Outcome measuresClinical and non-clinical activity contributing to physiotherapy services delivery quantified as number, type and duration (per day) of all staff activity, and categorised for skill level (AHA, junior, senior).ResultsOverall physiotherapy service delivery increased in P2 compared to P1 (n=4730 vs n=3048). Physiotherapists undertook fewer respiratory (p < 0.001) and exercise treatments (p < 0.001) but increased patient reviews for inpatients (p < 0.001) and at multidisciplinary clinics in P2 (56% vs 76%, p < 0.01). The AHA accounted for 20% of all service provision. AHA activity comprised mainly non-direct clinical care including oversight of respiratory equipment use (e.g. supply, set-up, cleaning, loan audits) and other patient related administrative tasks associated with delegation handovers, supervision and clinical documentation (72%) and delegated supervision of established respiratory (5%) and exercise treatments (10%) and delegated exercise tests (3%). The AHA completed most of the exercise tests (n = 25). AHA non-direct clinical tasks included departmental management activities such as statistics and ongoing training (11%). No adverse events were reported.ConclusionInclusion of an AHA in an acute respiratory care service changed physiotherapy service provision. The AHA completed delegated routine clinical and non-clinical tasks. Physiotherapists increased clinic activity and annual reviews. Including an AHA role offers safe and sustainable options for enhancing physiotherapy service provision in acute respiratory care services.

ObjectivesEmergency departments (EDs) are complex adaptive systems and improving patient flow requires understanding how ED processes work. This study aimed to explore the patient flow process in an ED in Trinidad and Tobago, identifying organisational factors influencing patient flow.MethodsMultiple qualitative methods, including non-participant observations, observational process mapping and informal conversational interviews were used to explore patient flow. The process maps were generated from the observational process mapping. Thematic analysis was used to analyse the data.SettingThe study was conducted at a major tertiary level ED in Trinidad and Tobago.ParticipantsPatient and staff journeys in the ED were directly observed.ResultsSix broad categories were identified: (1) ED organisational work processes, (2) ED design and layout, (3) material resources, (4) nursing staff levels, roles, skill mix and use, (5) non-clinical ED staff and (6) external clinical and non-clinical departments. Within each category there were individual factors that appeared to either facilitate or hinder patient flow. Organisational processes such as streaming, front loading of investigations and the transfer process were pre-existing strategies in the ED while staff actions to compensate for limitations with flow were more intuitive. A conceptual framework of factors influencing ED patient flow is also presented.ConclusionThe knowledge gained may be used to strengthen the emergency care system in the local context. However, the study findings should be validated in other settings.