Publications by authors named "Ruth Endacott"

124 Publications

Human factors in escalating acute ward care: a qualitative evidence synthesis.

BMJ Open Qual 2021 Feb;10(1)

Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK.

Background: Identifying how human factors affect clinical staff recognition and managment of the deteriorating ward patient may inform process improvements. We systematically reviewed the literature to identify (1) how human factors affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies.

Methods: We undertook a Qualitative Evidence Synthesis of care escalation studies. We searched MEDLINE, EMBASE and CINHAL from inception to September 2019. We used the Critical Appraisal Skills Programme and the Grading of Recommendations Assessment-Development and Evaluation and Confidence in Evidence from Reviews of Qualitative Research tool to assess study quality.

Results: Our search identified 24 studies meeting the inclusion criteria. Confidence in findings was moderate (20 studies) to high (4 studies). In 16 studies, the ability to recognise changes in the patient's condition (soft signals), including skin colour/temperature, respiratory pattern, blood loss, personality change, patient complaint and fatigue, improved the ability to escalate patients. Soft signals were detected through patient assessment (looking/listening/feeling) and not Early Warning Scores (eight studies). In contrast, 13 studies found a high workload and low staffing levels reduced staff's ability to detect patient deterioration and escalate care. In eight studies quantifiable deterioration evidence (Early Warning Scores) facilitated escalation communication, particularly when referrer/referee were unfamiliar. Conversely, escalating concerning non-triggering patients was challenging but achieved by some clinical staff (three studies). Team decision making facilitated the clinical escalation (six studies).

Conclusions: Early Warning Scores have clinical benefits but can sometimes impede escalation in patients not meeting the threshold. Staff use other factors (soft signals) not captured in Early Warning Scores to escalate care. The literature supports strategies that improve the escalation process such as good patient assessment skills.

Prospero Registration Number: CRD42018104745.
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http://dx.doi.org/10.1136/bmjoq-2020-001145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919590PMC
February 2021

UK ambulance service resuscitation management of pulseless electrical activity: a systematic review protocol of text and opinion.

Br Paramed J 2020 Jun;5(1):20-25

The University of Plymouth.

Background: Out-of-hospital cardiac arrest patients with pulseless electrical activity are treated by paramedics using basic and advanced life support resuscitation. When resuscitation fails to achieve return of spontaneous circulation, there are limited evidence and national guidelines on when to continue or stop resuscitation. This has led to ambulance services in the United Kingdom developing local guidelines to support paramedics in the resuscitative management of pulseless electrical activity. The content of each guideline is unknown, as is any association between guideline implementation and patient survival. We aim to identify and synthesise local ambulance service guidelines to help improve the consistency of paramedic-led decision-making for the resuscitation of pulseless electrical activity in out-of-hospital cardiac arrest.

Methods: A systematic review of text and opinion will be conducted on ambulance service guidelines for resuscitating adult cardiac arrest patients with pulseless electrical activity. Data will be gathered direct from the ambulance service website. The review will be guided by the methods of the Joanna Briggs Institute (JBI). The search strategy will be conducted in three stages: 1) a website search of the 14 ambulance services; 2) a search of the evidence listed in support of the guideline; and 3) an examination of the reference list of documents found in the first and second stages and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Each document will be assessed against the inclusion criteria, and quality of evidence will be assessed using the JBI Critical Appraisal Checklist for Text and Opinion. Data will be extracted using the JBI methods of textual data extraction and a three-stage data synthesis process: 1) extraction of opinion statements; 2) categorisation of statements according to similarity of meaning; and 3) meta-synthesis of statements to create a new collection of findings. Confidence of findings will be assessed using the graded ConQual approach.
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http://dx.doi.org/10.29045/14784726.2020.06.5.1.20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783909PMC
June 2020

Ventilation bundle compliance in two Australian intensive care units: An observational study.

Aust Crit Care 2020 Oct 2. Epub 2020 Oct 2.

School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Monash Health, Dandenong Hospital, 135 David Street, Dandenong, Victoria, Australia.

Background: The ventilation bundle has been used in adult intensive care units to decrease harm and improve quality of care for mechanically ventilated patients. The ventilation bundle focuses on prevention of specific complications of mechanical ventilation; ventilator-associated pneumonia, sepsis, barotrauma, pulmonary oedema, pulmonary embolism, and acute respiratory distress syndrome. The Institute for Healthcare Improvement ventilation bundle consists of five structured evidence-based interventions: head of the bed elevation at 30-45°; daily sedation interruptions and assessment of readiness to extubate; peptic ulcer prophylaxis; deep vein thrombosis prophylaxis; and daily oral care with chlorhexidine.

Objectives: The objective of the study was to evaluate the use of the ventilation bundle in two intensive care units in Victoria, Australia.

Methods: This is a 3-month prospective observational study in two intensive care units. Patient medical records were reviewed on days 3, 4, and 5 of mechanical ventilation using a prevalidated ventilation bundle checklist.

Results: A total of 96 critically ill patients required mechanical ventilation for more than 2 d. Patients had a mean age of 64.50 y (standard deviation = 14.89), with an Acute Physiology, Age, Chronic Health Evaluation (APACHE) III mean score of 79.27 (standard deviation = 27.11). The mean ventilation bundle compliance rate was 88.3% on the three consecutive mechanical ventilation days (day 3 = 79.4%, day 4 = 91.1%, and day 5 = 96.7%). There was a statistically significant difference in the mean APACHE III score between patients who had head of bed elevation and those without head of bed elevation, on days 3 (p = <0.001) and 4 (p = 0.007).

Conclusion: The ventilation bundle elements were used in Australian intensive care units. The likelihood of having all ventilation bundle elements on day 3 was low if the patient's APACHE III score was high. However, the ventilation bundle compliance rate increased with mechanical ventilation days.
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http://dx.doi.org/10.1016/j.aucc.2020.09.002DOI Listing
October 2020

Identifying the health care-initiated and self-initiated interventions used by women for the management of rectal emptying difficulty secondary to obstructive defecation: a scoping review protocol.

JBI Evid Synth 2020 Oct 6;19(2):491-498. Epub 2020 Oct 6.

School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK.

Objective: This scoping review aims to identify interventions used by women for the management of rectal emptying difficulty secondary to obstructive defecation.

Introduction: Rectal emptying difficulty is typically a symptom of obstructive defecation syndrome. Even though a range of interventions are already available for this condition, this review is necessary to increase understanding of what interventions women find useful and are acceptable for them. This depth of understanding will facilitate the development of a specific care pathway to support women living with rectal emptying difficulty secondary to obstructive defecation syndrome.

Inclusion Criteria: This review will consider studies that include adult women (over 18 years of age) living in the community who have experienced difficulty with rectal emptying secondary to obstructive defecation and who have not had surgical intervention. Exclusion criteria include prolapse surgery and surgical techniques, oral laxatives, vaginal pessaries, cognitive impairment, pregnancy, and those residing in care homes.

Methods: The databases to be searched include MEDLINE, Embase, CINAHL, PsycINFO, Emcare, AMED, Web of Science, Scopus, PROSPERO, Open Grey, ClinicalTrials.gov, International Clinical Trials Registry Platform Search Portal, UK Clinical Trials Gateway, International Standard Randomised Controlled Trial Number Registry, JBI Evidence Synthesis, Epistemonikos, Cochrane Library, and gray literature. Studies conducted in English from any time period will be considered for inclusion. The titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review.
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http://dx.doi.org/10.11124/JBIES-20-00026DOI Listing
October 2020

The prevalence and management of deteriorating patients in an Australian emergency department.

Australas Emerg Care 2020 Sep 8. Epub 2020 Sep 8.

School of Nursing and Health Professions, Federation University, Gippsland Campus, Churchill, VIC 3842, Australia. Electronic address:

Background: Complex human and system factors impact the effectiveness of Rapid Response Systems (RRS). Emergency Department (ED) specific RRS are relatively new and the factors associated with their effectiveness are largely unknown. This study describes the period prevalence of deterioration and characteristics of care for deteriorating patients in an Australia ED and examine relationships between system factors and escalation of care.

Methods: A retrospective medical record audit of all patients presenting to an Australian ED in two weeks.

Results: Period prevalence of deterioration was 10.08% (n=269). Failure to escalate care occurred in nearly half (n=52, 47.3%) of the patients requiring a response (n=110). Appropriate escalation practices were associated with where the patient was being cared for (p=0.01), and the competence level of the person documenting deterioration (p=0.005). Intermediate competence level nurses were nine times more likely to escalate care than novices and experts (p=0.005). While there was variance in escalation practice related to system factors, these associations were not statistically significant.

Conclusion: The safety of deteriorating ED patients may be improved by informing care based on the escalation practices of staff with intermediate ED experience and competence levels.
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http://dx.doi.org/10.1016/j.auec.2020.07.008DOI Listing
September 2020

Trade agreements and the risks for the nursing workforce, nursing practice and public health: A scoping review.

Int J Nurs Stud 2020 Sep 7;109:103676. Epub 2020 Jun 7.

School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Road, Clayton, Victoria 3800, Australia; School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth PL48AA, United Kingdom.

Background: Trade agreements in the 21st century have evolved to include provisions that affect domestic public policy and public health in signatory countries. There are growing calls for health professionals and public health advocates to pursue an active advisory role in trade negotiations in order to anticipate and prevent negative outcomes for health services and public health.

Aim: This scoping review explored current literature to identify existing knowledge of the implications of trade agreements for the nursing workforce, nursing practice and public health using as an example the 2018 'Comprehensive and Progressive Agreement for Trans-Pacific Partnership'.

Design: Scoping review DATA SOURCES: Emerald Insight, Informit, Ovid MEDLINE, PubMed, ProQuest, Scopus, and a number of specialist Economics, International Trade and Business, and International Relations databases. Grey literature included national and international policy documents.

Review Method: Literature was selected according to extraction field criteria, supplemented by hand searching of relevant grey literature and snowballing references from the selected literature reference lists. Analysis was undertaken to identify key themes emerging from the literature.

Review Results: Six key themes relevant to nursing workforce, nursing practice or public health were 1. Lack of consultation with public health and health professionals in trade negotiations; 2. Implications of strengthened intellectual property provisions for equitable access to medicines (including biologics) and medical devices; 3. Threats to government capacity to regulate domestic policy for public health and health services through 'Investor State Dispute Settlement' provisions 4. Threats to government capacity to regulate domestic policy for public health and health services through 'Regulatory Coherence' 5. Potential limited benefits to communities and increased health inequities 6. Potential implications of increased temporary migration. Gaps were identified in the literature for implications for nursing practice and the nursing workforce from regulatory and labour provisions of trade agreements.

Conclusions: The analysis of the literature reviewed is of international importance for the nursing workforce, nursing practice and public health. Policymakers must anticipate and respond to how the inclusion of labour or regulatory provisions in trade agreements will affect nursing practice and the nursing workforce, and how this may subsequently impact on the health of communities globally.
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http://dx.doi.org/10.1016/j.ijnurstu.2020.103676DOI Listing
September 2020

Admission Decision-Making in Hospital Emergency Departments: The Role of the Accompanying Person.

Glob Qual Nurs Res 2020 Jan-Dec;7:2333393620930024. Epub 2020 Jun 18.

University of Plymouth, Plymouth, United Kingdom.

In resource-stretched emergency departments, people accompanying patients play key roles in patients' care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used an ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 health care professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals' standardization of the patient-carer relationship contrasted with accompanying persons' varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients' care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relationship with the patients. Taking a relationship-centered approach could improve the attention to accompanying persons as co-producers of health care and participants in decision-making.
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http://dx.doi.org/10.1177/2333393620930024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7303774PMC
June 2020

Nurse Expertise: A Critical Resource in the COVID-19 Pandemic Response.

Ann Glob Health 2020 05 11;86(1):49. Epub 2020 May 11.

Nursing and Midwifery, Faculty Medicine, Nursing and Health Sciences, Monash University, AU.

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http://dx.doi.org/10.5334/aogh.2898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227394PMC
May 2020

Practice priorities for acute care nursing: A Delphi study.

J Clin Nurs 2020 Jul 23;29(13-14):2615-2625. Epub 2020 Apr 23.

Nursing and Midwifery, Monash University, Frankston, Vic., Australia.

Aims And Objectives: To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus.

Background: Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care.

Design: Delphi Method.

Method: A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist.

Results: High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care.

Conclusion: The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise.

Relevance To Clinical Practice: This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care.
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http://dx.doi.org/10.1111/jocn.15284DOI Listing
July 2020

Nurses' knowledge, experience and self-reported adherence to evidence-based guidelines for prevention of ventilator-associated events: A national online survey.

Intensive Crit Care Nurs 2020 Aug 6;59:102827. Epub 2020 Mar 6.

School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Monash Health, Dandenong Hospital, 135 David Street, Dandenong, Victoria, Australia.

Objective: To explore Australian intensive care nurses' knowledge of ventilator-associated pneumonia and self-reported adherence to evidence-based guidelines for the prevention of ventilator-associated events.

Design: A quantitative cross-sectional online survey was used.

Setting: The study was conducted in two Australia intensive care units, in large health services in Victoria and an Australia-wide nurses' professional association (Australian College of Critical Care Nurses).

Main Outcome Measures: Participants' knowledge and self-reported adherence to evidence-based guidelines.

Results: The median knowledge score was 6/10 (IQR: 5-7). There was a significant positive association between completion of post graduate qualification and their overall knowledge score p = 0.014). However, there was no association (p = 0.674) between participants' years of experience in intensive care nursing and their overall score. The median self-reported adherence was 8/10 (IQR: 6-8). The most adhered to procedures were performing oral care on mechanically ventilated patients (n = 259, 90.9%) and semi-fowlers positioning of the patient (n = 241, 84.6%). There was no relationship between participants' knowledge and adherence to evidence-based guidelines (p = 0.144).

Conclusion: Participants lack knowledge of evidence-based guidelines for the prevention of ventilator-associated pneumonia. Specific education on ventilator-associated events may improve awareness and guideline adherence.
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http://dx.doi.org/10.1016/j.iccn.2020.102827DOI Listing
August 2020

Patient diaries: Survey of paediatric intensive care units in the United Kingdom and Ireland.

Nurs Crit Care 2020 01 4;25(1):31-36. Epub 2019 Oct 4.

School of Nursing and Midwifery, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK.

Aim: The aim of the study was to explore the incidence, use, and scope of patient diaries in paediatric intensive care units (PICUs) in the United Kingdom and Ireland.

Design: This was an electronic survey sent to 30 PICUs in the United Kingdom and Ireland.

Results: All PICUs (n = 30) responded, and 43% (n = 13) offered diaries. For those units that did not supply diaries, the reasons given were concerns around the legal and professional implication of using diaries. Parental/carer consent to use a diary was obtained informally (79%, n = 11), and once there was agreement to provide a diary to parents, diaries were usually started immediately (72%, n = 12). Parents were the main contributors to the diaries (94%, n = 17), and the diaries were populated with photographs (94%, n = 15), drawings (100%, n = 16), and stickers (94%, n = 15). The reasons for offering diaries were to fill gaps in memories, to engage with families, and to explain what has happened in lay language. The owner of the diary was reported to be the family (82%, n = 14) and the child (12%, n = 2).

Conclusions: The use of patient diaries is an evolving intervention in paediatric intensive care settings in the United Kingdom and Ireland. This national survey has provided a clearer picture of how this intervention is used in the United Kingdom and Ireland. PICU patient diaries are used in a significant number of units, and how these are used is relatively standardized, although in some different ways from general ICUs.

Relevance To Clinical Practice: This survey provides a baseline for future exploration, understanding, and promotion of patient diaries, as a well evaluated tool for the critically ill child and his or her family.
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http://dx.doi.org/10.1111/nicc.12472DOI Listing
January 2020

What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study.

BMC Pregnancy Childbirth 2019 Sep 9;19(1):331. Epub 2019 Sep 9.

Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth, Devon, PL4 8AA, UK.

Background: In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres?

Methods: Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach.

Results: Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable.

Conclusions: Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.
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http://dx.doi.org/10.1186/s12884-019-2487-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734275PMC
September 2019

Community physiotherapy for people with dementia following hip fracture: Fact or fiction? A qualitative study.

Dementia (London) 2020 Nov 20;19(8):2750-2760. Epub 2019 Jun 20.

NIHR CLAHRC South West Peninsula, University of Exeter Medical School, Exeter, UK.

Background: Physiotherapy is a core component of rehabilitation following a hip fracture. Approximately 40% of people sustaining a hip fracture will have dementia, but there is little evidence to guide physiotherapy interventions in this population.

Objective: This study forms part of a process evaluation seeking to explore reasons why people with dementia were not referred for physiotherapy following a hip fracture and challenges that are faced treating these people in the community.

Methods: We undertook a series of structured focus groups and interviews with physiotherapists based in community-rehabilitation services in the South West of England. Qualitative data sought to explain reasons why people with dementia were not being referred for onward physiotherapy following discharge from the acute setting after hip fracture. Framework analysis was used to make sense of the data.

Results: Four focus groups and interviews were undertaken with physiotherapists and assistants working in community settings. Three main themes were determined - beliefs, the importance of pathways of care and the effect of resources on decision making.

Discussion: Out data suggest that people with dementia were often labelled as having 'no rehabilitation potential' in the acute setting and this excluded them from receiving ongoing therapy in the community setting. It was also suggested that physiotherapists were judging this potential using biomedical measures of outcome which fails to recognise the importance of person centred care for this population.

Conclusion: There was suggestion of therapeutic nihilism when considering rehabilitation for this population, whereby it is assumed that people with dementia cannot be rehabilitated, so they are not given the opportunity. It is unsurprising that outcomes for this population are poor considering the reluctance to provide physiotherapy to people with dementia following hip fracture.
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http://dx.doi.org/10.1177/1471301219857027DOI Listing
November 2020

Learning from aftercare to improve acute care.

Intensive Care Med 2019 07 13;45(7):1022-1024. Epub 2019 Jun 13.

Plymouth University Clinical School, Plymouth, UK.

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http://dx.doi.org/10.1007/s00134-019-05657-3DOI Listing
July 2019

'They do not care how much you know until they know how much you care': a qualitative meta-synthesis of patient experience in the emergency department.

Emerg Med J 2019 Jun 19;36(6):355-363. Epub 2019 Apr 19.

School of Nursing and Midwifery, Faculty of Health and Human Sciences, University of Plymouth Faculty of Health and Human Sciences, Plymouth, UK.

Background: Patient experience is positively associated with both clinical effectiveness and patient safety and should be a priority for emergency care providers. While both quantitative and qualitative approaches can be used to evaluate patient experience in the emergency department (ED), the latter is well aligned to develop a detailed understanding of features influencing the lived experience of ED patients. This study aimed to systematically review the literature of qualitative studies to identify determinants of adult patient experience in the ED.

Methods: A Preferred Reporting Items for Systematic review and Meta-Analysis compliant systematic review was conducted using PubMed, CINAHL, EMBASE, BNI and bibliography searches to identify qualitative studies exploring patient experiences in ED published in English between 1997 and 2018. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist. Descriptive text and quotations relating to patient experience were extracted from included studies and a meta-synthesis conducted using thematic analysis.

Results: A total of 625 records were screened from which 40 studies underwent full review and 22 were included. Results were coded by two researchers (BG and JML). Meta-synthesis identified 198 discrete units of analysis which were clustered around five analytical themes. These were based on the perceived 'needs' of patients visiting the ED and were defined as communication, emotional, competent care, physical/environmental and waiting needs. Findings were translated into a conceptual model for optimising patient experience in the ED.

Conclusion: This meta-synthesis provides a framework for understanding the determinants of patient experience in the ED. The resulting conceptual model and recommendations may have the potential to directly inform practice and improve the patient experience.
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http://dx.doi.org/10.1136/emermed-2018-208156DOI Listing
June 2019

Public involvement in designing a study on patient-witnessed cardiopulmonary resuscitation in hospital.

Nurs Crit Care 2020 09 17;25(5):313-320. Epub 2019 Apr 17.

School of Nursing and Midwifery, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK.

The aim of this paper is to report the findings of the consultation rounds with former patients and health care professionals to inform the design of a qualitative study. We aimed to understand stakeholders' views regarding the relevance of a proposed study looking at the impact of patients witnessing cardiopulmonary resuscitation on other patients in hospital, the appropriateness of the proposed methodology and ethical aspects. We conducted an online survey (n = 22) and telephone interviews (n = 4) with former patients linked to the British Heart Foundation charity and a focus group (n = 15) with hospital health care professionals involved in cardiopulmonary resuscitation activities. Data were analysed using thematic analysis. The consultation rounds provided valuable advice on three major themes: conceptual aspects, methodological aspects and practical suggestions. The conceptual aspects were related to the relevance of the proposed study, the emotional impact for participating patients and how the social interaction among patients could influence the witnessing experience. Methodological advice included recruitment strategies and data collection methods such as the use of individual and focus group interviews, the timeframe of interviews with patients and the topics of the interview guides. In the third theme, practical suggestions were provided, such as strategies to advertise the study, improving the public's and participants' engagement throughout the study process and disseminating the findings. Overall, the study proposed in this consultation was considered relevant and worthy by patients and health care professionals to raise awareness and generate new evidence on an unconsidered aspect of cardiopulmonary resuscitation and of patients' hospital experience. These stakeholders' consultation rounds constituted a valuable exercise to design high-quality research based on a shared vision among researchers, service users and clinicians. They also provided pragmatic advice to inform critical care practice to support patients witnessing cardiopulmonary resuscitation in hospital.
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http://dx.doi.org/10.1111/nicc.12429DOI Listing
September 2020

'I cried too' - Allowing ICU nurses to grieve when patients die.

Authors:
Ruth Endacott

Intensive Crit Care Nurs 2019 06 26;52:1-2. Epub 2019 Feb 26.

School of Nursing and Midwifery, Plymouth University, Plymouth UK; School of Nursing & Midwifery, Monash University, Frankston, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.iccn.2019.02.002DOI Listing
June 2019

Implementation of paediatric pain care-bundle across South-West England clinical network of Emergency Departments and Minor Injury Units: A before and after study.

Int Emerg Nurs 2019 Mar 29;43:56-60. Epub 2018 Oct 29.

Plymouth University/Royal Devon and Exeter Hospital Clinical School, Faculty of Health and Human Sciences, Plymouth University, Plymouth PL4 8AA, UK; School of Nursing and Midwifery, Monash University, Melbourne, VIC 3199, Australia. Electronic address:

Introduction: Pain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs).

Methods: A total of 29 centres - 5 EDs and 24 MIUs - participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records).

Results: The likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72-8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51-2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86-3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01).

Conclusions: Rates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle.
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http://dx.doi.org/10.1016/j.ienj.2018.10.001DOI Listing
March 2019

Exploring patients' and healthcare professionals' experiences of patient-witnessed resuscitation: A qualitative study protocol.

J Adv Nurs 2019 Jan 17;75(1):205-214. Epub 2018 Sep 17.

School of Nursing and Midwifery, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK.

Aim: The aim of this study was to explore the experiences of patients and healthcare professionals regarding patients witnessing resuscitation on another patient in hospital clinical wards.

Design: Phenomenological qualitative study.

Methods: Participants will be recruited from nine wards in a university hospital in England. Data collection will include two in-depth interviews with patients who witnessed resuscitation: the first interview one week after witnessing resuscitation and the second interview after one month. Individual and focus group interviews with healthcare professionals will be also conducted. Data will be transcribed, managed in NVivo 11 and analysed using phenomenological analysis. The National Health Service, Health Research Authority and University Ethics Committee approved the study (May 2018). The study is funded by Resuscitation Council UK (December 2017) and will be conducted between May 2018-March 2019.

Conclusion: While witnessed resuscitation is a major topic of interest in nursing, specific research on the impact of patients who witness resuscitation on fellow patients is limited. This study will use qualitative methodology to inform the evidence base of a clinical problem with limited understanding. The findings of this study will contribute to the framework of witnessed resuscitation and to identifying the barriers and enablers towards a greater support of patients who witness resuscitation in hospital. This new acquired knowledge will be beneficial to the improvement of future nursing care.

Impact: The evidence gained from this study can support the development and implementation of guidelines and inform hospital policies to support patients witnessing resuscitation to optimize the quality of nursing care provided.
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http://dx.doi.org/10.1111/jan.13824DOI Listing
January 2019

Women's experiences of managing digitation: do we ask enough in primary care?

JRSM Open 2018 Aug 6;9(8):2054270418783616. Epub 2018 Aug 6.

School of Nursing and Midwifery, Faculty of Health and Human Sciences, Plymouth University, Devon, UK.

The aim of this paper was to consider the available evidence for the current management of pelvic organ prolapse, which is a common presentation in primary care. However, not all women will present, only presenting when symptoms become bothersome. Particular attention was paid to understanding the problem of rectocele and its influence on obstructive defaecation symptoms. The burden of rectocele and its consequences are not truly known. Furthermore, healthcare professionals may not always enquire about bowel symptoms and patients may not disclose them. Complex emotions around coping and managing stress add to the challenges with seeking healthcare. Therefore, the impact on the lived experience of women who have difficulty with rectal emptying can be significant. The review identified a dearth of knowledge about women living with the problem of obstructive defaecation resulting in the use of digitation. Improving the management of digitation, an under-reported problem, is necessary to improve the quality of life for women. Primary care needs to increase access to conservative measures for women struggling with bothersome symptoms, such as constipation, the need to digitate or anxiety.
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http://dx.doi.org/10.1177/2054270418783616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080083PMC
August 2018

Top ten concerns burdening people with cancer: Perceptions of patients with cancer and the nurses caring for them.

Eur J Oncol Nurs 2018 Apr 5;33:102-106. Epub 2018 Mar 5.

Plymouth University/Royal Devon and Exeter Hospital Clinical School, University of Plymouth, Faculty of Health and Human Sciences, Plymouth, PL4 8AA, United Kingdom. Electronic address:

Purpose: We examined the concerns that nurses perceive patients to have, whether these are congruent with patients' concerns and whether they vary according to cancer site. We also examined Distress Thermometer scores according to cancer site.

Method: A cross-sectional survey design: (i) secondary analysis of an existing Holistic Needs Assessment (HNA) and Distress Thermometer (DT) dataset was used, (ii) a survey of specialist nurse teams to identify their perceptions of patient concerns. Data collected between January 2015 and June 2016 from the HNA database from one NHS Trust in England (n = 1233 patients). Specialist nurse teams for breast, colorectal, gynaecology, skin and urology cancers identified the concerns that they perceived their patients would report.

Results: The HNA showed high internal consistency (Cronbach's alpha 0.86). Across the five cancer sites, nurses identified between 3 and 6 of the top ten concerns (TTC) expressed by patients, with wide variation across cancer sites. Nine of the TTC were significantly associated (p < 0.05) with a specific cancer site. The breast and gynaecological cancer groups both recorded significantly higher median Distress Thermometer scores than the urology, skin and colorectal cancer groups (Kruskall-Wallis χ (4, n = 1228) 186.695, p=<.01).

Conclusions: One of the aims of the eHNA is to enable service delivery appropriate to patient needs. Our findings suggest that this will only be achieved if eHNA is examined, and services developed, by individual cancer site. The misconception of patient needs by specialist nurses underscores the importance of review of information provided by patients during consultations.
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http://dx.doi.org/10.1016/j.ejon.2018.02.004DOI Listing
April 2018

Are physiotherapists employing person-centred care for people with dementia? An exploratory qualitative study examining the experiences of people with dementia and their carers.

BMC Geriatr 2018 03 2;18(1):63. Epub 2018 Mar 2.

NIHR CLAHRC South West Peninsula, University of Exeter Medical School, Exeter, UK.

Background: People with dementia may receive physiotherapy for a variety of reasons. This may be for musculoskeletal conditions or as a result of falls, fractures or mobility difficulties. While previous studies have sought to determine the effectiveness of physiotherapy interventions for people with dementia, little research has focused on the experiences of people receiving such treatment. The aim of this study was to gain an in-depth understanding of people's experiences of receiving physiotherapy and to explore these experiences in the context of principles of person-centred care.

Methods: Semi-structured interviews were undertaken with people with dementia or their carers between September 2016 and January 2017. A purposive sampling strategy recruited participants with dementia from the South West of England who had recently received physiotherapy. We also recruited carers to explore their involvement in the intervention. Thematic analysis was used to analyse the data.

Results: A total of eleven participants were recruited to the study. Six people with dementia were interviewed and five interviews undertaken separately with carers of people with dementia. Three themes were identified. The first explores the factors that enable exercises to be undertaken successfully, the second deals with perceived resource pressures, and the final theme "the physiotherapy just vanished" explores the feeling of abandonment felt when goals and expectations of physiotherapy were not discussed. When mapped against the principles of person-centred care, our participants did not describe physiotherapy adopting such an approach.

Conclusion: Lack of a person-centred care approach was evident by ineffective communication, thus failing to develop a shared understanding of the role and aims of physiotherapy. The incorporation of person-centred care may help reduce the frustration and feelings of dissatisfaction that some of our participants reported.
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http://dx.doi.org/10.1186/s12877-018-0756-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834867PMC
March 2018

Perceived language proficiency and pain assessment by registered and student nurses in native English-speaking and EAL children aged 4-7 years.

J Clin Nurs 2018 Mar 10;27(5-6):1081-1093. Epub 2018 Jan 10.

School of Nursing and Midwifery, Plymouth University, Plymouth, UK.

Aims And Objectives: To identify the factors that influence decisions made by health professionals when assessing the pain of native English speaking and children whose English is an additional language.

Background: Pain assessment in children is often poorly executed following acute injury. Whilst a range of pain assessment tools have been developed, little guidance is provided for assessing pain in children with English as an additional language.

Design: Factorial survey design.

Methods: Twenty minor injuries unit nurses and 20 children's nursing students participated in an electronic survey to make judgements on 12 scenarios describing a child attending a minor injuries unit following an incident, accompanied by a parent. Respondents had to decide the most important form of pain assessment, and whether they would ask a parent or an interpreter to assess the pain of the child. An open-ended question asked about the difficulties found in making a judgement.

Results: Observation of the child's behaviour was the most common pain assessment reported. The visual analogue scale was significantly associated with children with proficient English. Respondents were significantly more likely to involve parents in the assessment if they could speak English well compared to parents with poor English skills. Moreover, nursing students were significantly more likely than registered nurses to call for support from an interpreter. Thematic analysis identified three themes related to difficulties with pain assessment: contrasting approaches, differing perceptions of pain and overcoming challenges.

Conclusions: The reduced ability to communicate between child, parent and healthcare professional highlights the need to identify forms of assessment based on individual cases.

Relevance To Clinical Practice: The number of children with English as an additional language has seen a marked rise over the last decade. In situations where communication ability is reduced, assessment of pain should be tailored to meet the needs of the child. This may require timely access to interpreter services.
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http://dx.doi.org/10.1111/jocn.14134DOI Listing
March 2018

Health professional perspectives of patient safety issues in intensive care units in Saudi Arabia.

J Nurs Manag 2018 Mar 27;26(2):209-218. Epub 2017 Sep 27.

Monash University, Nursing and Midwifery, Frankston, Vic, Australia.

Aim: To examine attitudes to patient safety in two intensive care units from the perspective of health care professionals in Saudi Arabia.

Background: Despite adverse errors leading to poor patient outcomes, there is a paucity of literature, including staff perceptions, on adverse errors in Saudi Arabian intensive care units.

Methods: A descriptive cross-sectional design was used. Health professionals (n = 144) completed the safety attitude questionnaire-intensive care unit.

Results: The scores from the six safety domains of the safety attitude questionnaire-intensive care unit showed all respondents had a negative attitude towards patient safety, with participants in one intensive care unit scoring lower in all domains. The mean scores across all domains ranged from 47.1 to 70.3 on a 100-point scale, with the lowest score reported in the "perceptions of management" domain. Respiratory therapists reported a significantly higher job satisfaction score than nurses, and physicians rated communication amongst themselves and nurses as high.

Conclusion: There are significant challenges for safety culture in this study, with negative attitudes across all domains.

Implication For Nursing Management: Managers may need to review and consider policies relating to safety culture including workforce planning, leadership and patient centred care. Further research into this global health priority is required to contribute to improving patient safety in intensive care units.
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http://dx.doi.org/10.1111/jonm.12536DOI Listing
March 2018

Development of a balance, safe mobility and falls management programme for people with multiple sclerosis.

Disabil Rehabil 2018 12 7;40(24):2857-2866. Epub 2017 Aug 7.

a School of Health Professions , Plymouth University , Plymouth , UK.

Purpose: To utilise stakeholder input to inform the structure, format and approach of a multiple sclerosis (MS) balance, safe mobility and falls management programme.

Materials And Methods: Using a three-round nominal group technique, participants individually rated their agreement with 20 trigger statements, followed by a facilitated group discussion and re-rating. Three mixed groups included service users (n = 15) and providers (n = 19). Quantitative analysis determined agreement, whilst qualitative responses were analysed thematically.

Results: Median scores for each of the 20 trigger statements did not change significantly over sequential rounds, however, deviations around the medians indicated more agreement amongst participants over time. Key recommendations were: Aims and approach: The programme should be tailored to the needs of people with MS. Falls and participation-based outcomes are equally important. Structure and format: The programme should balance expected burden and anticipated benefit, moving away from models requiring weekly attendance and promoting and supporting self-efficacy. Optimising engagement: Support to maintain engagement and intensity of practice over the long term is essential. Sustainability: Adequate funding is necessary. Staff should have MS specific knowledge and experience.

Conclusions: Participants collaboratively identified critical components of a MS balance, safe mobility and falls management programme. They also highlighted the importance of a collaborative, user-centred, MS-specific approach. Implications for Rehabilitation People with multiple sclerosis need condition-specific interventions focussed on maximising balance and safe mobility and reducing falls. Programme design should support self-efficacy and flexible engagement. Adequate support and funding are seen as essential by both service users and providers.
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http://dx.doi.org/10.1080/09638288.2017.1362041DOI Listing
December 2018

Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses.

J Clin Nurs 2018 Mar;27(5-6):e913-e920

School of Nursing and Midwifery, Monash University, Clayton, Vic., Australia.

Aims And Objectives: To determine, from the perspectives of enrolled nurses and registered nurses, the current scope of enrolled nurse practice and to identify the activities that most enrolled nurses frequently performed in their workplace.

Background: Enrolled nurse scope of practice in Australia has evolved and expanded over the past decade. However, the unclear role, function and competency differentiation between enrolled nurse and registered nurse leads to role confusion and ongoing professional debate.

Design: Exploratory Descriptive Study.

Methods: A cross-sectional online survey of enrolled nurses and registered nurses across Australia was conducted examining their levels of agreement on statements related to the scope of practice and the clinical and nonclinical activities that enrolled nurses were required to perform in their workplace.

Results: Valid responses were received from 892 enrolled nurses and 1,198 registered nurses. Enrolled nurses mostly agreed that they understood their scope of practice; did not undertake roles for which they were unprepared; sometimes undertook activities other than direct patient care; and believed that they operated equally to many registered nurses. The majority of enrolled nurses reported that they performed tasks mostly related to basic patient care in their workplace. There were a number of significant differences between perspectives of registered nurses and enrolled nurses.

Conclusions: Clarifying the roles and scope of practice between the registered nurse and the enrolled nurse is important, and explicit differences in responsibility and accountability between their roles must be clearly articulated to harmonise perceptions about role and capability. Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned.

Relevance To Clinical Practice: Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned.
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http://dx.doi.org/10.1111/jocn.13987DOI Listing
March 2018

The Experiences of Specialist Nurses Working Within the Uro-oncology Multidisciplinary Team in the United Kingdom.

Clin Nurse Spec 2017 Jul/Aug;31(4):210-218

Author Affiliations: Visiting Fellow (Mr Punshon), School of Health and Social Care, London South Bank University; Professor in Clinical Nursing (Critical Care) (Prof Endacott), Plymouth University/Royal Devon and Exeter Hospital Clinical School; Senior Urology Nurse Specialist and BAUN President (Ms Aslett), Basingstoke and North Hampshire Foundation Trust, Hampshire; Urology & Continence Nurse Specialist (Ms Brocksom), St James's University Hospital, Leeds; Lead urology clinical nurse specialist/prostate cancer advanced nurse practitioner (Ms Fleure), Guy's and St Thomas' NHS Foundation Trust; Workforce Analyst (Ms Howdle), Mouchel Management Consulting Limited and Centre for Workforce Intelligence; Head of Outreach (Ms Masterton), Prostate Cancer UK; Research Assistant (Ms O'Connor), Centre for Health and Social Care Innovation, Plymouth University; Consultant (Mr Swift), Mouchel Management Consulting Limited and Centre for Workforce Intelligence; Lead, Cardiovascular, End of Life Care (Mr Trevatt), London Region, NHS England; and Chair of Healthcare & Workforce Modelling (Prof Leary), School of Health and Social Care, London South Bank University, London, UK.

Purpose: United Kingdom prostate cancer nursing care is provided by a variety of urology and uro-oncology nurses. The experience of working in multidisciplinary teams (MDT) was investigated in a national study.

Design: The study consisted of a national survey with descriptive statistics and thematic analysis.

Methods: A secondary analysis of a data subset from a UK whole population survey was undertaken (n = 285) of the specialist nursing workforce and the services they provide. Data were collected on the experience of working in the MDT.

Results: Forty-five percent of the respondents felt that they worked in a functional MDT, 12% felt that they worked in a dysfunctional MDT, and 3.5% found the MDT meeting intimidating. Furthermore, 34% of the nurses felt that they could constructively challenge all members of the MDT in meetings. Themes emerging from open-ended questions were lack of interest in nonmedical concerns by other team members, ability to constructively challenge decisions or views within the meeting, and little opportunity for patients' wishes to be expressed.

Conclusions: Despite expertise and experience, nurses had a variable, often negative, experience of the MDT. It is necessary to ensure that all participants can contribute and are heard and valued. More emphasis should be given to patients' nonmedical needs.
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http://dx.doi.org/10.1097/NUR.0000000000000308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5469566PMC
September 2017

The impact of sharps injuries on student nurses: a systematic review.

Br J Nurs 2016 Oct;25(19):1064-1071

Professor in Clinical Nursing (Critical Care), Plymouth University.

Aims And Objectives: The purpose of this review was to discover the impact of sharps injuries in the student nurse population.

Background: Much is known and reported about sharps injuries in registered nurses, but there has been a lack of published evidence regarding sharps injuries within the student nurse population.

Method: A systematic review of nursing, health and psychology databases was conducted. The limits set were publications between 1980 and 2014 in the English language. Studies were identified then, following a rigorous critical and quality appraisal with validated tools, were selected for the systematic review.

Results: A total of 40 articles met the inclusion criteria, reporting studies conducted in 18 countries. Psychological and physical impacts of sharps injuries in student nurses were reported, such as fear, anxiety and depression, although these impacts were not quantified using a validated instrument.

Conclusion: The impact of sharps injuries can be severe, both psychological and physical. This systematic review shows that further research is needed into this, especially in under-researched areas such as the UK, to establish the impact of sharps injuries within this population. Further research would also aid the education and prevention of this harmful problem. The review also emphasises the psychological issues relating to sharps injuries, the impact these can have on individuals and the support and counselling that student nurses require after injury.

Relevance To Practice: These findings highlight the potential psychological issues that can result from sharps injuries in this population.
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http://dx.doi.org/10.12968/bjon.2016.25.19.1064DOI Listing
October 2016

Navigating communication with families during withdrawal of life-sustaining treatment in intensive care: a qualitative descriptive study in Australia and New Zealand.

J Clin Nurs 2017 Mar 28;26(5-6):690-697. Epub 2016 Nov 28.

Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand.

Aims And Objectives: To explore how nurses navigate communication with families during withdrawal of life-sustaining treatment in intensive care.

Background: Death in the intensive care unit is seldom unexpected and often happens following the withdrawal of life-sustaining treatment. A family-centred approach to care relies on the development of a therapeutic relationship and understanding of what is happening to the patient. Whilst previous research has focused on the transition from cure to palliation and the nurse's role in supporting families, less is known about how nurses navigate communication with families during treatment withdrawal.

Design: A qualitative descriptive approach was used. Semi-structured focus groups were conducted with adult critical care nurses from four intensive care units, two in Australia and two in New Zealand.

Results: Twenty-one nurses participated in the study. Inductive content analysis revealed five key themes relating to how nurses navigate family communication: (1) establishing the WHO; (2) working out HOW; (3) judging WHEN; (4) assessing the WHAT; and (5) WHERE these skills were learnt.

Conclusions: Navigating an approach to family communication during treatment withdrawal is a complex and multifaceted nursing activity that is known to contribute to family satisfaction with care. There is need for support and ongoing education opportunities that develop the art of communication in this frequently encountered aspect of end-of-life care.

Relevance To Clinical Practice: How nurses navigate communication with families during treatment withdrawal is just as important as what is communicated. Nurses need access to supports and education opportunities in order to be able to perform this vital role.
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http://dx.doi.org/10.1111/jocn.13585DOI Listing
March 2017

Family centred care before and during life-sustaining treatment withdrawal in intensive care: A survey of information provided to families by Australasian critical care nurses.

Aust Crit Care 2016 Nov 9;29(4):210-216. Epub 2016 Sep 9.

School of Nursing & Midwifery, Monash University, Peninsula Campus, PO Box 527, Frankston, VIC 3199, Australia; School of Nursing & Midwifery, Plymouth University, Drake Circus, Plymouth PL4 8AA, UK.

Background: A core component of family-centred nursing care during the provision of end-of-life care in intensive care settings is information sharing with families. Yet little is known about information provided in these circumstances.

Objective: To identify information most frequently given by critical care nurses to families in preparation for and during withdrawal of life-sustaining treatment.

Design: An online cross-sectional survey.

Methods: During May 2015, critical care nurses in Australia and New Zealand were invited to complete the Preparing Families for Treatment Withdrawal questionnaire. Data analysis included descriptive statistics to identify areas of information most and least frequently shared with families. Cross tabulations with demographic data were used to explore any associations in the data.

Results: From the responses of 159 critical care nurses, information related to the emotional care and support of the family was most frequently provided to families in preparation for and during withdrawal of life-sustaining treatment. Variation was noted in the frequency of provision of information across body systems and their associated physical changes during the dying process. Significant associations (p<0.05) were identified between the variables gender, nursing experience and critical care experiences and some of the information items most and least frequently provided.

Conclusions: The provision of information during end-of-life care reflects a family-centred care approach by critical care nurses with information pertaining to emotional care and support of the family paramount. The findings of this study provide a useful framework for the development of interventions to improve practice and support nurses in communicating with families at this time.
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http://dx.doi.org/10.1016/j.aucc.2016.08.006DOI Listing
November 2016