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Aim: To explore and validate an end of shift survey with a low response burden, practical application and generated evidence of related associations between workload, quality of work and patient care, missed care and job satisfaction., Design: A retrospective cross-sectional survey of the experiences of nursing staff., Methods: Data were collected from 265 nurses who responded to a questionnaire at the end of their shift in 2022. Exploratory factor analysis was undertaken using IBM SPSS v.27 and confirmatory factor analysis was undertaken using IBM AMOS v27. Hypotheses testing was undertaken using IBM SPSS v.27 using multiple regression analyses., Results: All of the hypotheses were supported. There was a negative association between workload and quality of work and job satisfaction. Quality of work was negatively associated with workload and missed care and positively associated with job satisfaction. The association between missed care and job satisfaction was negative., Conclusion: The EOSS is a valid and reliable tool with a low response burden. The tool supports previous research which demonstrated there is a negative relationship between level of workload and shift type with satisfaction, quality of work and potentially nurse retention., Implications for the Profession And/or Patient Care: In the context of a global nursing shortage nursing leaders must ensure that care we provide is of the highest quality. We must take every action to address high workload to reduce the risk that fundamental care is not sacrificed, job satisfaction is improved and nurses remain in the profession. The EOSS gives nurse leaders a reliable, practical, consistent, applied tool that will better enable associations to be observed between resource configuration, workload and critical impacts on nursing and patient care., Reporting Method: We have adhered to the relevant EQUATOR guidelines using the STROBE reporting method., Patient or Public Contribution: No Patient or Public Contribution., (© 2024 The Author(s). Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Aim: To identify strategies which support the implementation of interventions to promote compassionate nursing care with a focus on interventions designed to support improved patient outcomes and/or patient experience in acute hospitals., Methods: An integrative review using the PRISMA guidelines and a 5-stage framework consisting of problem identification, literature search, data evaluation, data analysis and presentation. CINAHL, Embase, Medline, PsychInfo and Web of Science were systematically searched using key search terms. Hand searches were conducted of the reference lists of eligible articles and searching key journals., Results: Six articles met the inclusion criteria with six different interventions described. A thematic analysis of the findings identified three key themes relating to the implementation of interventions which promote compassionate nursing care: (1) the importance of evidence; (2) support for nursing development; and (3) planning for and leading implementation., Conclusion: Compassionate care improves quality of life, the hospital experience and overall recovery. Strong nursing leadership and a supportive team environment are facilitators for delivery of compassionate care in acute settings. Excessive workload, overly rigid reporting and organisational indifference are barriers to delivery of compassionate care., Implications for Nursing Policy: Health policy is used to inform the systematic implementation and delivery of patient care informed by best evidence. Health setting, environment and culture are important facets of the implementation of a compassionate care framework. Furthermore, nurse engagement, teamwork and nurse leadership are key facilitators for delivery of compassionate care in acute hospital settings. These findings need to be taken into consideration by policy makers and nursing leaders when designing and implementing compassionate care interventions., Implications for Nursing Policy: Implementing interventions to improve compassionate nursing care can be challenging. This review identified the factors which should be considered by policy makers when implementing these interventions systematically throughout the healthcare system., (© 2023 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses.)

Aim: To identify and synthesize empirical evidence on the role of healthcare leaders in the development of equitable clinical academic pathways for nurses., Design: Integrative literature review., Data Sources: Literature was searched using CINAHL, PubMed, ProQuest and Google Scholar databases., Review Methods: A total of 114 eligible articles published between 2010 and2022 were screened, 16 papers were selected., Results: Results highlighted the need for consistent national, regional, and organizational policy approaches to developing clinical academic careers for nurses. Government health departments and National Health boards must focus on increasing engagement in research and evidence-based nursing practice for high-quality patient care. Discriminatory practices and attitudes were identified as barriers. Discrimination due to gender was evident, while the impact of race, ethnicity, and other social categories of identity are under-researched. Educational leaders must unravel misconceptions about research, highlighting its relevance to patient care and bedside nurses' work. Academic leaders together with executive nurses, research funders and professional nursing bodies must create appropriately remunerated career structures. Transformative approaches are required to develop the clinical academic nurse role and understand its value in clinical practice., Conclusion: Multiple elements exist within complex systems that healthcare leaders can navigate collaboratively to develop and implement clinical nurse academic roles. This requires vision, acknowledgement of the value of nursing research and the importance of evidence-based research infrastructures., Impact: Findings highlight the collaborative role of healthcare leaders as critical to the success of critical academic careers for nurses. This review can inform those still to formalize this innovative role for nurses., Reporting Method: The review complies with the PRISMA guidelines for reporting systematic reviews. This paper contributes evidence about the healthcare leader's role in developing clinical academic pathways for nurses to the wider global clinical community., Patient or Public Contribution: No patient or public contribution was included in this review., (© 2024 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Objective: To identify and describe the attributes of relational care from an Indigenous Māori healthcare consumer perspective., Data Sources: CINAHL Plus, Ovid MEDLINE, ProQuest Nursing & Allied Health, Scopus, New Zealand Index, the Ministry of Health Library, New Zealand Research and Google Scholar were searched between 23 and 30 May 2022., Methods: This scoping review used the Joanna Briggs Institute methodology for scoping reviews, thematic analysis and the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework for the synthesis of the findings., Results: A total of 1449 records were identified, and 10 sources were selected for final review. We identified five relational attributes that were most important to Māori: (1) the expressive behaviours and characteristics of healthcare professionals (HCPs), (2) communication to facilitate the healthcare partnership, (3) appreciating differing worldviews, (4) the context in which healthcare is delivered and (5) whanaungatanga (meaningful relationships)., Conclusion: The relational attributes identified are inextricably linked. Connecting with HCPs and developing a therapeutic relationship is fundamental to improving consumer experience and engagement with mainstream healthcare services. Whanaungatanga is fundamental to meaningful engagements with HCPs. Future research should explore how relational care is practiced in acute care settings when clinician-consumer interactions are time-limited, examine how the health system influences the capacity for relational care and how Indigenous and Western paradigms can co-exist in healthcare., Implications: This scoping review can inform future projects addressing health equity for Indigenous communities by creating environments that prioritise culturally safe relational care and value Indigenous knowledge systems., Reporting Method: We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist., No Patient or Public Contribution: No patient or public contribution., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Background: In order to avoid perpetuating inequities faced by lesbian, gay, bisexual, transgender, queer, intersex, and other minority (LGBTQI+) communities, future nurses need to recognize and resist discriminatory, oppressive, heteronormative and cisnormative health and social systems., Objectives: To share the development, embedding, and formative evaluation of an interdisciplinary project to improve LGBTQI+ health content across an undergraduate nursing curriculum., Methods: This paper describes a collaborative interdisciplinary project to embed LGBTQI+ health content across a 3-year undergraduate nursing degree. An anonymous cross-sectional online survey was sent to 87 student nurses enrolled in the final semester of their undergraduate degree. The survey included six Likert scale-type questions and five open-ended questions. Qualitative data were analyzed by inductive, reflexive thematic analysis., Results: Most students rated the topic relevant 'extremely' relevant (77 %) to nursing. Students' self-reported comfort discussing LGBTQI+ health in class varied from 'extremely' (42 %) through to 'not at all' (6 %). Thematic analysis of student responses to open-ended questions identified five themes: (1) Becoming aware of LGBTQI+ diversity; (2) Personal values and beliefs; (3) Learning in order to improve clinical encounters; (4) Inconsistency and a lack of incorporation across the curriculum; and (5) (Dis)comfort in the learning environment., Conclusions: Opportunities to better embed LGBTQI+ competency included clear acknowledgement of wider systems of power and oppression, integration and consistent modeling by nursing faculty, and linkage of content to other equity issues to address the intersectional nature of inequities., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Aim and Objectives: This study aimed to explore inpatient healthcare delivery experiences of Māori (New Zealand's Indigenous people) patients and their whānau (extended family network) at a large tertiary hospital in New Zealand to (a) determine why Māori are less satisfied with the relational and psychosocial aspects of fundamental care delivery compared to other ethnic groups; (b) identify what aspects of care delivery are most important to them; and (c) contribute to the refinement of the Fundamentals of Care framework to have a deeper application of Indigenous concepts that support health and well-being., Background: Bi-annual Fundamentals of Care audits at the study site have shown that Māori are more dissatisfied with aspects of fundamental care delivery than other ethnic groups., Design: Retrospective analysis of narrative feedback from survey data using an exploratory descriptive qualitative approach., Methods: Three hundred and fifty-four questionnaires containing narrative patient experience feedback were collected from the study site's patient experience survey reporting system. Content analysis was used to analyse the data in relation to the Fundamentals of Care framework and Māori concepts of health and well-being. The research complies with the SRQR guidelines for reporting qualitative research., Results: Four themes were identified: being treated with kindness and respect; communication and partnership; family is the fundamental support structure; and inclusion of culture in the delivery of care., Conclusion: The current iteration of the Fundamentals of Care framework does not reflect in depth how indigenous groups view health and healthcare delivery. The inclusion of an Indigenous paradigm in the framework could improve healthcare delivery experiences of Indigenous peoples., Relevance to Clinical Practice: Research around the application and relevance of the Fundamentals of Care framework to Indigenous groups provides an opportunity to refine the framework to improve health equity, and healthcare delivery for Indigenous people., (© 2021 John Wiley & Sons Ltd.)

Background: There is a growing body of evidence addressing the patient experience of intensive care, including patient reports that the presence of an endotracheal tube is bothersome and distressing, and that endotracheal suction is moderately to extremely painful. Yet there remains little information about the patient experience of the endotracheal tube and suction in those patients receiving planned short-term mechanical ventilation., Aims and Objectives: This study aimed to describe the patient experience of the endotracheal tube and suction, following mechanical ventilation in post-operative cardiac surgical patients., Design: This qualitative study used inductive thematic analysis. Participants having planned cardiac surgery, anticipated to receive less than 12-hours mechanical ventilation, were approached pre-operatively and written consent provided., Methods: Ten participants were recruited using purposive sampling. Semi-structured interviews were conducted between days four and six post-operatively. One researcher interviewed all participants; two researchers independently read, coded, and agreed themes., Findings: None of the participants recalled endotracheal suction, while half had no recollection of the endotracheal tube. Three themes were identified; the experience of the endotracheal tube and extubation, the experience of emerging from sedation, and participants concerns about the future. The presence of the endotracheal tube was described as bothersome, whilst breathing through the tube and extubation were described as 'weird' and 'strange' but not painful., Conclusions: Knowledge of the patient experience can help inform nursing practice by improving pre and post-operative care planning., Relevance to Clinical Practice: This study adds to the body of knowledge about the patient experience of the endotracheal tube and extubation., Trial Registration: Prospective registration with the Australian New Zealand Clinical Trials Registry. www.anzctr.org.au (ACTRN12616001515482)., (© 2021 British Association of Critical Care Nurses.)

Objective: The patient experience of a gout flare is multidimensional. To establish the most appropriate methods of flare measurement, there is a need to understand the complete experience of a flare. This qualitative study aimed to examine what factors contribute to the severity of a flare from the patient perspective., Methods: Face-to-face interviews were conducted with patients with gout. Participants were asked to share their experience with their worst gout flare and contrast it to their experience of a less severe or mild flare. Interviews were audio recorded and transcribed verbatim. Data were analyzed using a reflexive thematic approach., Results: In total, 22 participants with gout (17 male participants, mean age 66.5 years) were interviewed at an academic center in Auckland, New Zealand. Four key themes were identified as contributing to the severity of a flare: 1) flare characteristics (pain intensity, joint swelling, redness and warmth, duration, and location); 2) impact on function (including walking, activities of daily living, wearing footwear, and sleep); 3) impact on family and social life (dependency on others, social connection, and work); and 4) psychological impact (depression, anxiety, irritability, and sense of control)., Conclusion: A wide range of interconnecting factors contribute to the severity of a gout flare from the patient perspective. Capturing these domains in long-term gout studies would provide a more meaningful and accurate representation of cumulative flare burden., (© 2020, American College of Rheumatology.)

Aims and Objectives: Identify the key concepts, principles and values embedded within Indigenous Māori models of health and wellbeing; and determine how these could inform the development of a Māori-centred relational model of care., Background: Improving health equity for Māori, similar to other colonised Indigenous peoples globally, requires urgent attention. Improving the quality of health practitioners' engagement with Indigenous Māori accessing health services is one area that could support improving Māori health equity. While the Fundamentals of Care framework offers a promising relational approach, it lacks consideration of culture, whānau or family, and spirituality, important for Indigenous health and wellbeing., Design and Methods: A qualitative literature review on Māori models of health and wellbeing yielded nine models to inform a Māori-centred relational model of care. We followed the PRISMA guidelines for reporting literature reviews., Results: Four overarching themes were identified that included dimensions of health and wellbeing; whanaungatanga (connectedness); whakawhanaungatanga (building relationships); and socio-political health context (colonisation, urbanisation, racism, and marginalisation). Health and wellbeing for Māori is a holistic and relational concept. Building relationships that include whānau (extended family) is a cultural imperative., Conclusions: This study highlights the importance and relevance of relational approaches to engaging Māori and their whānau accessing health services. It signals the necessary foundations for health practitioners to build trust-based relationships with Māori. Key elements for a Māori-centred model of relational care include whakawhanaungatanga (the process of building relationships) using tikanga (cultural protocols and processes) informed by cultural values of aroha (compassion and empathy), manaakitanga (kindness and hospitality), mauri (binding energy), wairua (importance of spiritual wellbeing)., Relevance to Clinical Practice: Culturally-based models of health and wellbeing provide indicators of important cultural values, concepts and practices and processes. These can then inform the development of a Māori-centred relational model of care to address inequity., (© The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Objective: The patient experience of gout flares is multidimensional, with several contributing factors including pain intensity, duration, and frequency. There is currently no consistent method for reporting gout flare burden in long-term studies. This study aimed to determine which factors contribute to patient perceptions of treatment efficacy in long-term studies of gout flare prevention., Methods: This study involved face-to-face interviews with people with gout using visual representations of gout flare patterns. Participants were shown different flare scenarios over a hypothetical 6-month treatment period that portrayed varying flare frequency, pain intensity, and flare duration. The participants were asked to indicate and discuss which scenario they believed was most indicative of successful treatment over time. Quantitative data relating to the proportion of participants selecting each scenario were reported using descriptive statistics. A qualitative descriptive approach was used to code and categorize the data from the interview transcripts., Results: Twenty-two people with gout participated in the semistructured interviews. All 3 factors of pain intensity, flare duration, and flare frequency influenced participants' perception of treatment efficacy. However, a shorter flare duration was the most common indicator of successful treatment, with half of participants (n = 11, 50%) selecting the scenario with a shorter flare duration over those with less painful flares., Conclusion: Flare duration, flare frequency, and pain severity are all taken into account by patients with gout when considering treatment efficacy over time. Long-term studies of gout should ideally capture all these factors to better represent patients' experience of treatment success., (Copyright © 2021 by the Journal of Rheumatology.)

Objective: This paper presents the first Naturalistic Decision Making model of prehospital resuscitation decision-making, which has clear implications for education, practice and support., Methods: A mixed-methods exploratory sequential research design consisting of interviews with ambulance personnel (study 1), focus groups with ambulance educators, managers and peer supporters (study 2), and an online survey of graduating paramedic students (study 3). This paper reports the model developed from integrated findings, across all three studies. All research was undertaken in New Zealand and underpinned by a critical realist worldview., Results: The Prehospital Resuscitation Decision Making model identifies key processes, challenges and facilitators before, during and after ambulance personnel attend a cardiac arrest event. It is the only descriptive model of resuscitation decision making which acknowledges the decision-maker, non-prognostic factors and the importance of adequate preparation and support., Conclusions: This research project is the first to comprehensively explore and model ambulance personnel perspectives on decisions to start, continue or stop resuscitation. The decision-making process is complex and difficult to simply formularise. Education and supports must assist ambulance personnel in navigating this complexity. Where resuscitation is withheld or terminated, ambulance personnel need to feel confident that they can effectively provide after-death care., (© 2021 Australasian College for Emergency Medicine.)

Background: It is well-documented that women tend to be worse off post-stroke. They are often frailer, have less independence, lower functionality, increased rates of depression, and overall a lower quality of life. People who have had strokes benefit from rehabilitative support to increase their independence and reduce the risk of stroke reoccurrence. Despite the gender differences in the effects of stroke, interventions explicitly aimed at helping women have not been identified., Purpose: This systematic review aimed to summarize the effectiveness of the health promoting behavioural interventions for reducing risk factors and improved self-management in women post-stroke, compared to usual care., Method: Seven databases, Medline (Ovid), CINAHL, PsychInfo, Embase, PubMed, Scopus, and Google Scholar, were reviewed for randomized controlled trials covering post-stroke interventions. The following keywords were used: health promotion, secondary prevention, woman, women, female, sex difference, gender difference, after stroke, and post-stroke., Results: Ten randomised controlled trials were found. These demonstrated common successful approaches for rehabilitation, but none specifically described health promotion strategies for women. Core components of successful programs appeared to be a structured approach, tailored to clientele and formalised support systems through their carer, family networks, or community engagement. Comprehensive reminder systems were successful for stroke risk reduction., Conclusion: Women are disproportionately affected by stroke and are often in the frail category. Tailored structured health promotion programs with family and caregiver support combined with a comprehensive reminder system would appear to enable women post-stroke., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Objectives: To synthesise existing evidence that identifies characteristics, behaviours or predictors of the struggling nursing student early on in their studies and the risk that this poses to vocational dissonance., Design: An integrative literature review., Data Sources: A search of the online databases CINAHL Plus, Medline and PsychINFO was conducted., Methods: Using predetermined inclusion and exclusion criteria, a systematic search across online databases was conducted for papers published between the years 2000 and 2018. Data were extracted using a standard proforma and evaluated for quality. Data were then categorised and compared until themes emerged that reflected the aim of this review., Results: From a total of 3024 studies, 14 papers were included in the review. Overall, this review indicates that it is challenging to identify the struggling nursing student early on in their education. Thematic analysis of the included studies identified three key themes: 1) defining the undefinable, 2) red flag characteristics of the struggling student; and 3) the power imbalance of student and educator., Conclusions: There is limited evidence to define and describe the characteristics of the struggling nursing student. Future research should focus on describing and defining characteristics that are early markers of struggle and vocational dissonance., Competing Interests: Declaration of competing interest No conflict of interest has been declared by the authors., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Aims: Gout flares are an important concern for people with gout and an understanding of patients' experiences with gout flares is central in developing meaningful outcome measures for clinical trials. This study aimed to systematically review and thematically synthesize the qualitative literature reporting the patient experience of gout flares, to inform the development of flare-specific outcome measures., Methods: MEDLINE, EMBASE, CINAHL Plus and PsycINFO electronic databases were searched in October 2019 to identify original qualitative research articles reporting on the patient experience of gout flares. Methodological quality of all included papers was assessed using the Critical Appraisal Skills Program (CASP) tool. Following data extraction, coding and synthesis was undertaken using reflexive thematic analysis., Results: Sixteen papers reporting the patient experience of gout flares were included. The majority of CASP criteria were met by most studies, indicating good methodological quality. Four predominant and overlapping themes were identified from the thematic analysis: gout flare characteristics (pain, swelling, location, duration and frequency); impact on function and activities of daily living (walking, housework and yard work, self-care, exercise and sports, driving, sleep); effects on social and family life (social participation, inability to plan, employment, dependency, relationships, intimacy); and psychological impact (boredom, irritability, fear, shame and embarrassment, isolation, financial worry, depression and anxiety)., Conclusions: Gout flares impact many aspects of patients' lives, including physical and psychological and social and family life. The patient experience of gout flares goes beyond what is routinely measured in research settings. Measurement and reporting methods that capture these aspects of patients' experiences with gout flares would provide more meaningful outcome measures in clinical trials of flare prevention., Competing Interests: Declarations of Competing Interest ND has received consulting fees, speaker fees or grants from AstraZeneca, Horizon, Amgen, Kowa, Takeda, Abbvie, Pfizer, and Janssen, outside the submitted work. Angelo Gaffo has received research support from Amgen, outside of the submitted work. The other authors declare no competing interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aim and Objective: This paper reports on the proceedings of the second Australasian International Learning Collaborative conference and summit., Background: In December 2019, over a hundred people attended the second Australasian International Learning Collaborative Conference and Summit. This was the first to be held in Aotearoa New Zealand, the land where cultural safety was developed, its origins being in nursing education. Perhaps not surprisingly, culture, cultural safety and the context of care featured highly in the presentations and workshops., Design and Methods: Discussion paper., Results: A key outcome of the conference proceedings and workshops was the call for nurses and the International Learning Collaborative to work in partnership with indigenous groups to iterate the importance of the Fundamentals of Care framework and evaluate the impact of that on health equity. Other essential messages were to value establishing relationships, to continue to talk about the fundamentals of care, to research and to own them. Nurses were reminded to use their humanity to create a climate and culture in which patients and staff feel valued, safe and trusted., Conclusions: Future iterations of the Fundamentals of Care framework must incorporate indigenous worldviews, which emphasise the importance of relationships, family and spirituality on wellbeing. Such additions will provide an opportunity for the International Learning Collaborative to optimally respond and direct nursing practice., Relevance to Clinical Practice: International Learning Collaborative members and conference attendees learned, listened and worked on meeting the challenges of consistently implementing and applying the fundamentals of care in practice and its importance to education, research and policy. The takeaway message is, when this does not happen, nurses must speak up., (© 2020 John Wiley & Sons Ltd.)

Background: An urgent need to improve palliative care in hospital has been identified. Moreover, service users consistently report care delivered by nurses in hospital as lacking compassion. Compassion is a fundamental component of nursing care, and promoting compassionate care has been identified as a policy priority in many countries. To help address this within the hospital context, we recently completed research exploring bereaved family experiences of good end of life care in hospital. We found that family accounts of good care aligned with Nolan and Dewar's compassionate care framework and subsequently extended the framework to the bi-cultural context of Aotearoa, New Zealand., Aims and Objectives: In this discussion paper, we explore synergies between our newly developed Kapakapa Manawa Framework: a bi-cultural approach to providing compassionate care at the end of life and the Fundamentals of Care. We argue that our framework can be used to support the implementation of the relational component of the Fundamentals of Care and the delivery of compassionate nursing practice in hospitals in Aotearoa, New Zealand., Design: Discussion paper., Methods: Review of relevant literature and construction of two vignettes describing good end of life care from the perspectives of bereaved family-one Māori and one non-Māori. The vignettes provide practical examples of how the values of the Kapakapa Manawa Framework can be enacted by nurses to provide compassionate care in alignment with the relationship component of the Fundamentals of Care., Conclusions: Whilst the Kapakapa Manawa bi-cultural compassionate care framework has grown out of research conducted with people nearing the end of their lives, it has the potential to improve nursing care for all hospital inpatients., Relevance to Clinical Practice: Addressing the wider policy and health system factors detailed in the Fundamentals of Care will support its implementation in the clinical setting., (© 2019 John Wiley & Sons Ltd.)

Background: Many ambulance personnel can withhold or terminate resuscitation on-scene, but these decisions are emotionally, ethically and cognitively challenging. Although there is a wealth of research examining training and performance of life-saving resuscitation efforts, there is little published research examining how ambulance personnel are prepared and supported for situations where resuscitation is unsuccessful, unwanted or unwarranted., Aim: To identify and describe existing preparation and support mechanisms for ambulance personnel enacting decisions to terminate resuscitation and manage patient death in the field., Method: Focus groups were held with senior ambulance personnel working in clinical education and peer support roles., Results: Participants believed professional and personal exposure to death and dying and positive social modelling by mentors were essential preparation for ambulance personnel terminating resuscitation and managing patient death. Ambulance personnel responded to patient death idiosyncratically. Key supports included on-scene or phone back-up during the event and informal peer and managerial support after the event., Conclusion: Clinical and life experience is highly-valued by ambulance personnel who provide training and support. However, novice ambulance personnel may benefit from greater awareness and rehearsal of skills associated with terminating resuscitation and managing the scene of a patient death. Organisations need to acknowledge idiosyncratic staff needs and offer a variety of support mechanisms both during and after the event., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

An understanding of students' career interests at entry and exit from undergraduate nursing programmes could inform decisions regarding curricula and clinical placements. Since 2006, the University of Auckland has surveyed healthcare students at entry to and exit from their respective programmes, collecting information on a range of demographic, and career-related factors. This article describes career interests of over 500 undergraduate nursing students in New Zealand over a ten-year period. All Bachelor of Nursing cohorts commencing between 2006 and 2016 were invited to complete a questionnaire which included questions about their career interests. In total 1875 questionnaires were completed (89% response rate). Among the overall cohort at entry, there was strongest interest for emergency care and child health, and least interest in older person's health. At exit, child health and surgery (general) were of strongest interest to the cohort, while older person's health remained of least interest. The analysis of the paired data (n = 564) identified decreases in interest for mental health and child health over the course of the programme, while there was an increased interest in primary health care. Changes in career interests indicate that education and clinical exposure to specialty areas during the programme may influence career interests., Competing Interests: Declaration of competing interest The authors have no conflicts of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Around the world, many paramedics are authorised to withhold or terminate resuscitation. Research indicates this can be a challenging part of their role. Little is known about graduating paramedic student confidence, concerns and learning in this area., Methods: An online cross-sectional survey of students nearing completion of a paramedic degree in New Zealand, including piloting of a newly-developed confidence scale., Results: Seventy-two participants reported varying exposure to termination of resuscitation and patient death. Participants felt most confident providing technical procedurally-based care and least confident with non-technical skills. Participants' greatest concerns included making 'the right call', supporting grieving family, controlling emotions and encountering conflict. Clinical exposure with supportive mentoring, clinical simulation, peer reflection and resolved personal experience with death, were considered most useful for professional development., Conclusions: Exposure to termination of resuscitation and management of the scene of a patient death is variable amongst graduating paramedics. Novice paramedics may benefit from opportunities to observe and rehearse non-technical skills including delivering death notification and communicating with bystanders and bereaved family. The Confidence with Resuscitation Decision-Making and Patient Death Scale has favourable psychometric properties and utility as an outcome measure for future research in this area., (Copyright © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Background: There is a paucity of data relating to the association of gout with the occurrence of hypertension and diabetes mellitus in patients with stroke. This study aimed to determine the association of gout with the risk of hypertension and diabetes mellitus in a cohort of stroke patients from Auckland, Aotearoa New Zealand., Methods: A cross-sectional study was conducted among stroke survivors in South and East Auckland, New Zealand from the years 2010 to 2014. Electronic health record data were collected and analysed using Statistical Package for Social Science version 23. Multivariate logistic regression modelling adjusted for age, gender, and ethnicity was conducted to determine the association of gout with the risk of hypertension and diabetes mellitus in patients discharged with a diagnosis of stroke., Results: The age-, gender-, and ethnicity-adjusted odds ratio for having hypertension and diabetes mellitus among stroke survivors with gout history were 3.25 (95% confidence interval 1.32-8.03) and 1.94 (95% confidence interval 1.12-3.36), respectively. Māori stroke survivors with gout history had the highest risk of having diabetes mellitus with age- and gender-adjusted odds ratio of 5.10 (95% confidence interval 1.90-18.93)., Conclusion: The findings from this study suggest gout may be independently associated with an increased risk of hypertension and diabetes mellitus in patients with stroke. Māori who are the indigenous population of New Zealand show a greater risk of diabetes mellitus associated with a gout diagnosis compared to other populations. This finding highlights the importance of the need for further research with Māori stroke survivors and other indigenous populations.

Background: Migrant nurses have reported difficulties adapting to their new culture and providing culturally sensitive care for people with dementia. However, to date no studies have explored the impact of student nurse's cultural heritage on their beliefs and understanding of dementia., Objectives: To explore the cultural beliefs of dementia of student nurses studying in England, Slovenia, Philippines and New Zealand., Design: An explorative hermeneutic phenomenology design., Settings: Higher Education Institutes delivering undergraduate nursing education in England (University of Greenwich and University of Essex), Slovenia (Angela Boškin Faculty of Health Care), New Zealand (University of Auckland), and the Philippines (University of Silliman)., Participants: Student nurses studying nursing in England (n = 81), Slovenia (n = 41), Philippines (n = 53) and New Zealand (n = 6). Participants from England and New Zealand were from diverse cultural backgrounds. Student nurses at the beginning of their studies (n = 100) and towards the end of their studies (n = 81) participated., Methods: Completion of focus groups (n = 23), in England (n = 10), Slovenia (n = 6), Philippines (n = 6), and New Zealand (n = 1). All focus groups were audio recorded and transcribed verbatim. Data was analysed by applying an inductive theoretical approach of the Framework Method, which supports the generation of themes through open unhindered coding, pinpointing, examining, and recording patterns within the data., Results: Two major themes were identified in the data: familial piety and dementia discourse. Familial piety emerged from the importance of family and caring for family members with dementia, subthemes included: 'my granddad': familial experience, and 'better to be with her': familial home. Dementia discourse emerged from the terminology student nurses applied, such as: 'preconceptions and misconceptions' of aggression, and 'considered crazy' stigma of dementia due to a lack of awareness., Conclusions: The cultural heritage of student nurses impacted on their beliefs of dementia; however their understanding of the needs, care and support of a person with dementia changed and developed through clinical experience and education., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Little is known about the quality of end of life care in long-term care (LTC) for residents with different diagnostic trajectories. The aim of this study was to compare symptoms before death in LTC for those with cancer, dementia or chronic illness., Methods: After-death prospective staff survey of resident deaths with random cluster sampling in 61 representative LTC facilities across New Zealand (3709 beds). Deaths (n = 286) were studied over 3 months in each facility. Standardised questionnaires - Symptom Management (SM-EOLD) and Comfort Assessment in End of life with Dementia (CAD-EOLD) - were administered to staff after the resident's death., Results: Primary diagnoses at the time of death were dementia (49%), chronic illness (30%), cancer (17%), and dementia and cancer (4%). Residents with cancer had more community hospice involvement (30%) than those with chronic illness (12%) or dementia (5%). There was no difference in mean SM-EOLD in the last month of life by diagnosis (cancer 26.9 (8.6), dementia 26.5(8.2), chronic illness 26.9(8.6). Planned contrast analyses of individual items found people with dementia had more pain and those with cancer had less anxiety. There was no difference in mean CAD-EOLD scores in the week before death by diagnosis (total sample 33.7(SD 5.2), dementia 34.4(SD 5.2), chronic illness 33.0(SD 5.1), cancer 33.3(5.1)). Planned contrast analyses showed significantly more physical symptoms for those with dementia and chronic illness in the last month of life than those with cancer., Conclusions: Overall, symptoms in the last week and month of life did not vary by diagnosis. However, sub-group planned contrast analyses found those with dementia and chronic illness experienced more physical distress during the last weeks and months of life than those with cancer. These results highlight the complex nature of LTC end of life care that requires an integrated gerontology/palliative care approach.

Background: Clinical decision making is a complex, but important, research area. Decision-making theories have evolved to recognise that, although heuristics and biases can lead to error, expert clinician decision makers can also use intuition to good effect. More research is needed to understand how nurses and other clinicians make sense of complexity and uncertainty., Aim: This paper discusses the utility of interpretative phenomenological analysis to elucidate clinical decision making, expertise and intuition., Methods: A narrative review of published interpretative phenomenological analysis studies exploring clinical decision-making, and discussion of an exemplar study., Results: A limited number of interpretative phenomenological analysis studies have been published in this area. By seeking out descriptions of real-world decision making, interpretative phenomenological analysis research provides ecologically valid insights into what it is like to make time-critical, high-stakes decisions with limited information., Conclusion: Contributing to the study of complex clinical decision making in combination with other research approaches, interpretative phenomenological analysis research has significant unrealised potential to inform education, assessment and support interventions and the development of clinical guidelines. Future applications could enhance understanding of multi-disciplinary decision-making and the development of expertise and intuition, over time., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Importance: Exercise is recommended as an adjuvant treatment for venous leg ulceration (VLU) to improve calf muscle pump function. However, the association of exercise with VLU healing has not been properly aggregated, and the effectiveness of different exercise interventions has not been characterized., Objective: To summarize the association of different exercise interventions with VLU healing when used as an adjuvant to any form of compression., Data Sources: The Cochrane Controlled Trials Register, MEDLINE, Embase, CINAHL, PsycInfo, and SCOPUS databases were searched through October 9, 2017., Study Selection: Randomized clinical trials (RCTs) of any exercise compared with no exercise in participants with VLU were included, where compression was used as standard therapy and a healing outcome was reported. Independent title screening and full text review by 2 authors (A.J., J.S.) with appeal to a third author (J.P.) if disagreement was unresolved. Of the 519 articles screened, a total of 6 (1.2%) studies met the inclusion criteria for systematic review, including 5 for meta-analysis., Data Extraction and Synthesis: Independent quality assessment for Cochrane risk of bias and data extraction by 2 authors with appeal to third author if disagreement unresolved (PRISMA). Data pooled using fixed effects model., Main Outcomes and Measures: The a priori primary outcome was any healing outcome (proportion healed, time to healing, or change in ulcer area). Secondary outcomes (adverse events, costs, and health-related quality of life) were only collected if a primary outcome was reported., Results: Six RCTs were identified and 5 (190 participants) met inclusion criteria for meta-analysis. The exercise interventions were progressive resistance exercise alone (2 RCTs, 53 participants) or combined with prescribed physical activity (2 RCTs, 102 participants), walking only (1 RCT, 35 participants), or ankle exercises (1 RCT, 40 participants). Overall, exercise was associated with increased VLU healing at 12 weeks although the effect was imprecise (additional 14 cases healed per 100 patients; 95% CI, 1-27 cases per 100; P = .04). The combination of progressive resistance exercise plus prescribed physical activity appeared to be most effective, again with imprecision (additional 27 cases healed per 100 patients; 95% CI, 9-45 cases per 100; P = .004)., Conclusions and Relevance: The evidence base may now be sufficiently suggestive for clinicians to consider recommending simple progressive resistance and aerobic activity to suitable patients with VLU while further research is produced.

Introduction: When faced with a patient in cardiac arrest, ambulance personnel must rapidly make complex decisions with limited information. Much of the research examining decisions to commence, continue, withhold or terminate resuscitation has used retrospective audits of registry data and clinical documentation. This study offers a provider-perspective which characterises uncertainty and highlights clinical, cognitive, emotional and physical demands associated with decision-making in the cardiac arrest context., Method: Semi-structured interviews with a purposive sample of sixteen demographically diverse ambulance personnel, currently employed in a variety of emergency ambulance response roles across New Zealand., Results: All participants readily identified clinical, cognitive, emotional and ethical challenges associated with resuscitation decision-making. Four main themes were identified: grey areas; exceptional cases; scene challenges; and personal responses. A lack of information or a mix of favourable and unfavourable prognostic factors created decision-making uncertainty or "grey areas". Exceptional cases such as first-encounters also increased uncertainty and presented emotional, ethical and clinical challenges. Cardiac arrest scenes were often challenging, and participants described managing bystander expectations and responses and logistical limitations including adverse environmental conditions, fatigue and task-overload, and crew resource management., Conclusion: This unique research presents a provider-perspective on the challenges faced by ambulance personnel deciding to commence, continue, withhold or terminate resuscitation efforts. Knowledge of personal values and strategies for managing personal responses appear to be central to certainty and coping. Simulated training should move beyond resuscitation task performance, to incorporate challenging elements and encourage ambulance personnel to explore their personal values, stressors and coping strategies., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: The purpose of this study was to explore ambulance personnel's decisions to commence, continue, withhold or terminate resuscitation efforts for patients with out-of-hospital cardiac arrest., Method: Semistructured interviews with a purposive sample of 16 demographically diverse ambulance personnel, currently employed in a variety of emergency ambulance response roles, around New Zealand., Results: Participants sought and integrated numerous factors, beyond established prognostic indicators, when making resuscitation decisions. Factors appeared to be integrated in four distinct phases, described under four main identified themes: prearrival impressions, immediate on-scene impressions, piecing together the big picture and transition to termination of resuscitation. Commencing or continuing resuscitation was sometimes a default action, particularly where ambulance personnel felt the context was uncertain, unfamiliar or overwhelming. Managing the impact of termination of resuscitation and resulting scene of a death required significant confidence, psychosocial skills and experience., Conclusion: This unique, exploratory study provides new insights into ambulance personnel's experiences of prehospital resuscitation decision-making. Prognostication in out-of-hospital cardiac arrest is known to be challenging, but results from this study suggest that confidence in a poor prognosis for the cardiac arrested patient is only part of the resuscitation decision-making picture. Results suggest ambulance personnel may benefit from greater educational preparation and mentoring in managing the scene of a death to avoid inappropriate or prolonged resuscitation efforts., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

INTRODUCTION In New Zealand (NZ), there are shortages of health professionals in rural areas and in primary care. AIM This study aims to examine the association of student debt levels of medical, nursing, pharmacy and optometry students with: (1) preferred geographical location of practice, specifically preference to work in urban vs. rural areas; and (2) preferred career specialties, specifically interest in primary health care. METHODS Medical, nursing, pharmacy and optometry students completed a questionnaire at graduation that included questions about levels of New Zealand Government Student Loan debt and preferences regarding location of practice and career specialty. In an additional survey, medical students were asked to self-rate the effect of financial factors on their career choices. RESULTS Debt patterns varied across programmes. Medical and pharmacy students with high debt were significantly more likely than students with low debt to prefer rural over urban practice (P = 0.003). There was no difference in level of interest in a primary care specialty by debt level for any programme. Medical students reported little influence of debt on career choice, although students with high debt levels were less concerned over career financial prospects than students with lower levels of debt. DISCUSSION Current levels of student debt do not deter students from planning a career in rural or primary care settings. Somewhat surprisingly, higher levels of debt are associated with greater rural practice intentions for medical and pharmacy students, although the underlying reasons are uncertain.

Purpose: We investigated stroke rehabilitation clinician's perceptions of the patient as an active partner in setting goals within stroke rehabilitation and factors that influence patient engagement., Methods: Semi-structured interviews, subject to general inductive analysis with 20 Clinicians' working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams)., Results: There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke's impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians')., Conclusions: Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians' identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation. Implications for rehabilitation Goal setting is often promoted as a relatively simple, straightforward way to structure interactions with patients Patient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitation Clinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics.

When faced with an out-of-hospital cardiac arrest patient, prehospital and emergency resuscitation providers have to decide when to commence, continue, withhold or terminate resuscitation efforts. Such decisions may be made difficult by incomplete information, clinical, resourcing or scene challenges and ethical dilemmas. This systematic integrative review identifies all research papers examining resuscitation providers' perspectives on resuscitation decision-making for out-of-hospital cardiac arrest patients. A total of 14 studies fulfilled the inclusion criteria: nine quantitative, four qualitative and one mixed-methods design. Five themes were identified, describing factors informing resuscitation provider decision-making: the arrest event; patient characteristics; the resuscitation scene; resuscitation provider perspectives; and medicolegal concerns. Established prognostic factors are generally considered important, but there is a lack of resuscitation provider consensus on other factors, indicating that decision-making is influenced by the perspective of resuscitation providers themselves. Resuscitation decision-making research typically draws conclusions from evaluation of cardiac arrest registry data or clinical notes, but these may not capture all salient factors. Future research should explore resuscitation provider perspectives to better understand these important decisions and the clinical, ethical, emotional and cognitive demands placed on resuscitation providers.

Purpose: The burden of stroke is immense, with approximately 30 million stroke survivors globally. Approximately one-quarter of residents in long-term care (LTC) facilities are stroke survivors. This review aims to integrate the existing knowledge from the literature and elucidate themes around the care of stroke survivors in LTC facilities., Method: A systematic search was performed in PubMed, Ovid MEDLINE, the Cochrane Library and CINAHL. Articles that met the eligibility criteria were selected. Synthesis of results according to similar themes was performed., Results: A total of 1920 articles were screened for eligibility, of which 22 met the eligibility criteria. Of the 22 articles selected, five and 17 articles comprised interventional and observational studies, respectively. Three themes were identified: rehabilitation, stroke specific care and secondary stroke drug prevention. These were found to be lacking within LTC facilities. There is also a dearth of interventional studies in stroke survivors from LTC facilities., Conclusions: The care of stroke survivors in LTC facilities is lacking in rehabilitation, stroke specific care and secondary stroke prevention. This needs to be addressed through conducting further research to build a strong body of evidence to influence change in the care of this vulnerable group of patients. Implications for Rehabilitation Care of stroke survivors in long-term care facilities Stroke survivors make up almost a quarter of residents in long-term care facilities. They suffer from functional impairments and many other disabilities as a result of more severe stroke, precluding them from living in their own homes. Rehabilitation, stroke-specific care and secondary stroke prevention for stroke survivors are lacking in long-term care facilities despite strong evidence showing benefits for these interventions in stroke survivors living in the community. Interventions to address the unmet need in stroke survivors living in long-term care facilities are vital for optimal care of this vulnerable group of patients.

Objective: Following an acute stroke, there is a high risk of recurrence. However, the leading cause of mortality following a stroke is due to coronary artery disease (CAD) and myocardial infarction (MI) but that risk has not been robustly quantified. We sought to reliably quantify the risk of ischaemic heart disease (IHD) in patients presenting with acute ischaemic stroke (AIS) in the absence of a known cardiac history., Setting: A meta-analysis study. PubMed, MEDLINE, EMBASE and Google Scholar were searched for potential studies up to October 2015. Included studies reported an acute cerebral ischaemic event and followed for CAD or MI within 1 year in patients without known IHD. Using arcsine transformed proportions for meta-analysis, studies were combined using a generic inverse variance random-effects model to calculate the pooled standardised mean difference and 95% CIs. These were interpreted as the percentage prevalence of CAD or incidence of MI following AIS., Results: 17 studies with 4869 patients with AIS demonstrated a mean average of asymptomatic CAD in 52%. Anatomical methods of CAD detection revealed a prevalence of asymptomatic ≥ 50% coronary stenosis in 32% (95% CI 19% to 47%; p<0.00001). 8 studies with 47229 patients with ischaemic stroke revealed an overall risk of MI in the year following stroke of 3% (95% CI 1% to 5%; p<0.00001) despite the absence of any cardiac history., Conclusions: One-third of patients with ischaemic stroke with no cardiac history have more than 50% coronary stenosis and 3% are at risk of developing MI within a year. Our findings provide a reliable quantitative measure of the risk of IHD following AIS in patients with no cardiac history., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: Nurses' contribution during inpatient rehabilitation is well documented. However, despite being the largest professional group in this setting, the specialty of rehabilitation nursing is poorly recognised. This article reports on the first of a four-phase study that aimed to clarify and develop the nursing contribution to inpatient rehabilitation for older persons. The aim of this study was to identify activity patterns and time use during daytime and evenings of older adult patients undergoing inpatient rehabilitation., Methods: Direct observation using behavioural modelling was undertaken of a convenience sample of 37 older people undergoing inpatient rehabilitation in a specialist unit of a large tertiary hospital in New Zealand. The primary outcome was the observation of meaningful activity. Binomial logistic regression was used to study the association between relevant variables., Findings: Meaningful activity was most likely to involve walking without assistance and to occur 08:00 to 14:00 h and 16:00 to 21:00 h during weekdays. Patients were more likely to receive treatment during the weekend. Irrespective of time, registered nurses were the health professionals most often present with patients., Conclusions: There is likely to be unrealised opportunities for registered nurses to support improved rehabilitation outcomes. Registered nurses' involvement in rehabilitation needs to be actively optimised., Implications for Rehabilitation: Nurses' engagement with older adults in rehabilitation settings is likely to be substantial, placing them as key members of the rehabilitation team. Nurses make a pivotal contribution to inpatient rehabilitation based on specialised knowledge and skills but this contribution is not well understood. Opportunities are likely, at times when allied health professionals are less often present, e.g. evenings and weekends, for registered nurses to more intentionally overlap rehabilitation activities with other care requirements.