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Commentary on: Kearns, RJ, Kyzayeva, A, Halliday, LO, et al. Epidural analgesia during labour and severe maternal morbidity: population based study. BMJ 2024;385.
Implications for practice and research Health research, policy and information should emphasise the advantages of intrapartum epidurals beyond pain relief, especially for women with pre-existing conditions and preterm labour. Health services must provide access to a 24-hour epidural service within their maternity care.
The use of intrapartum epidurals to manage pain during labour and birth has been globally accepted for decades.
Addressing physical inactivity is a promising dementia risk reduction strategy due to its direct benefits for brain health, and indirect benefits for other modifiable dementia risk factors. A potential limitation of previous interventions is that they often overlook how increasing physical activity affects other behaviours throughout the 24-hour day, such as sleep and sedentary behaviour, which are also important for brain health. Further, interventions are rarely tailored to the individual, considering their needs, preferences and constraints that may serve as barriers or facilitators to behaviour change. The current phase I randomised controlled trial, Small Steps, aims to investigate feasibility, acceptability and preliminary effectiveness of a personalised 24-hour time-use intervention to improve lifestyle and cognitive health in older adults.
Participants aged ≥65 years from Adelaide, South Australia will be recruited and randomised to either the Extended or Condensed programme. During the first 12 weeks, participants in the Extended programme will use a tailored website to set personalised weekly goals to move towards their ‘optimal’ 24-hour day for brain health, facilitated by weekly website ‘check-ins’ and weekly phone calls with a research staff member. Participants randomised to the Condensed programme will have access to the website educational resources only but will not undergo personalised goal setting or telephone calls. Following the introductory phase (first 12 weeks), phone calls will be gradually withdrawn for the Extended programme. Primary (feasibility and acceptability) and secondary outcomes (changes in time use, cognitive function and behaviour change metrics) will be assessed 12, 24 and 36 weeks after the beginning of the intervention.
Ethics approval has been obtained from the University of South Australia’s Human Research Ethics Committee (205989). Study findings will be disseminated through peer-reviewed journal articles, conference presentations, media releases and community engagement.
To highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic.
In acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses.
Discursive paper.
Nursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures.
COVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive.
Objective measures commonly fail to capture the complexity of the critical care nurses’ role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.
To investigate clinicians' perspectives on the transition from hospital to home and identify gaps in care for older adults living with frailty during the transfer of care.
Qualitative reflexive thematic analysis of focus groups
Focus groups were conducted with clinicians using purposive sampling. Participants were eligible if they had provided or overseen the clinical care of a patient transferring from hospital to home. Verbatim transcripts were analysed, and themes were identified using NVivo through the development of codes and exploration of core commonalities.
A total of 28 clinicians participated in five focus groups. Participants included nurses (n = 14), allied health (n = 8), medical officers (n = 2), managers and hospital executives (n = 4). Themes were categorised into four domains: (1) system fragmentation and finite resources challenge healthcare navigation for everyone; (2) the interplay of cultural and societal considerations in the context of ageing; (3) fragile cycle of care for older patients who frequent hospitalisation; and (4) effective communication and expertise being critical for quality care.
Despite decades of research, the transition from hospital to home for older adults living with frailty remains a persistent challenge. This study identified significant and continued unmet needs in navigating a complex health system, underscoring the evidence-practice gap in transitional care services. Results have informed the development and implementation of a feasibility study (TRANSFER-II), currently underway, that tests the feasibility of a nurse-coordinated model of transitional care support for older adults.
Transfers from hospital to home, frequent readmissions and transitions in care are common for older adults living with frailty. Understanding the enablers and barriers in transitional care for this vulnerable population can enhance the quality of care, improve communication and inform the development of more effective transitional care models. The findings underline the critical role nurses play in addressing systemic gaps and improving continuity of care for older adults across diverse health systems.
Transitional care is complex, and older populations are more at risk of returning to hospital. Findings highlight the significant unmet needs in navigating a complex health system and revealed the fragile cycle of care for older adults who frequent hospital. Reiterating the importance of effective communication and clinical expertise in delivering safe patient-centred nursing care.
This qualitative study was reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist.
Patients and carers contributed to the design of this qualitative study through consultation with a consumer advisory group, where potential transitional care interventions were discussed. These discussions highlighted a need to further explore transitional care unmet needs, informing the development of this focus group study.
Hearing loss is highly prevalent and impacts many aspects of a person’s life, including communication, social engagement, employment, general health and well-being. Yet, many people do not access hearing healthcare and are unaware of the range of hearing healthcare options available. Barriers to hearing healthcare include poor understanding of hearing loss and its impact; poor knowledge of help-seeking for hearing healthcare options; minimal support to help decide which option is best; and stigma related to hearing loss. These barriers lead to many people not receiving the hearing healthcare they need. Guided by theories of behaviour change and implementation science, HearChoice, an online tailored decision support intervention, has been co-developed to empower adults with hearing difficulties by offering them choice and control over their own hearing healthcare. HearChoice aims to facilitate informed decisions, accessibility and uptake of hearing healthcare, including a wide range of interventions, for adults with hearing difficulties. The objectives of the trial are to evaluate the effectiveness, health economics and feasibility of HearChoice.
This online randomised controlled trial will recruit participants with hearing difficulties across Australia, with an anticipated sample size of 640. Participants will be randomised to either HearChoice (treatment) or an Australia-specific Hearing Option Grid (active control), both delivered online. Outcomes will be assessed at baseline when the interventions will be offered, at 7 days post-intervention (primary endpoint) and at 3 months post-intervention. An email reminder will be sent at 1-month post-intervention. The primary outcome is decisional conflict. Secondary outcomes include measures of readiness and self-efficacy to take action, hearing-related quality of life and empowerment, assessment of the value and impact of HearChoice, work performance and health, and feasibility measures. Primary analysis will compare outcomes between HearChoice and the active control at the primary endpoint.
The study was approved by the Curtin University Human Ethics Committee (HRE2023-0024). All participants will provide written informed consent prior to participation. A broad dissemination plan of the study findings includes peer-reviewed publications, scientific conference presentations, articles and presentations for the wider community and public written in lay and accessible language, and social media.
Australian New Zealand Clinical Trials Registry (ACTRN12624001139561).
by Patrick B. Wilson, Brian K. Ferguson, Ian P. Winter
Urine specific gravity (USG) is frequently utilized in sports practice and research to assess hydration status. Prior research suggests that individuals with large amounts of fat-free mass (FFM) and muscle have elevated USG, but little is known about whether the time of collection (first-morning vs. spot sampling) and various nutritional factors influence these relationships. This cross-sectional, observational study assessed fasted first-morning (n = 55) and non-fasted spot USG (n = 51) samples in adults and evaluated relationships of USG with body composition and nutrition intake. The InBody 770 was used to estimate FFM, skeletal muscle mass (SMM), and total body water (TBW). Protein, water, and sodium intakes from the 24-hour period before USG assessments were generated based on the Automated Self-Administered 24-hour Recall. Median USG was higher for fasted first-morning samples than non-fasted spot samples (1.018 vs. 1.011, Z = −5.2, pTo investigate discrepancies in perceptions regarding the accessibility and availability of rest and relaxation (R&R) spaces between hospital doctors in Scotland and NHS Scotland regional health boards (HBs), with the intention of informing best practices for organisational policy on the provision of R&R spaces both now and in the future.
A qualitative study, through an inhabited institutionalism (II) lens, of semi-structured interviews of hospital doctors across the career continuum in Scotland and all NHS regional HBs in Scotland providing written information relating to R&R space provision.
NHS Scotland during the COVID-19 pandemic and beyond.
Hospital doctors (n=30) who had participated in a larger qualitative study and provided specific insights on R&R spaces. All NHS Scotland regional HBs (n=14).
Although HBs reported the provision of R&R spaces, numerous doctors reported R&R spaces had been removed, relocated or were inaccessible. Furthermore, limited awareness of their availability attributed to inadequate communication, compounded the issue. This divergence between institutional reporting and front-line experience can be interpreted through the lens of II, which posits that institutional polices are often interpreted and implemented differently.
This study emphasises how crucial R&R spaces are to promoting doctors’ well-being especially during the time of high stress. HBs must not only guarantee the accessibility and physical availability of R&R spaces but also enhance their communication regarding the provision.
To explore the characteristics of oral healthcare education interventions for stroke clinicians and the effectiveness of these interventions in improving the oral health knowledge, attitudes, confidence, and practice among acute stroke clinicians.
Scoping review, guided by Arksey and O'Malley's (2005) framework.
Original full-text studies reporting educational oral healthcare interventions for stroke clinicians, including but not limited to nurses, were eligible for inclusion. Included studies were extracted and appraised using the Joanna Briggs Institute (JBI) Checklist aligned to the study methodology. Narrative synthesis was used to describe heterogeneous findings.
Key electronic bibliographic databases including CINAHL, Cochrane, MEDLINE (Ovid), ProQuest, Pubmed, and Scopus, in addition to grey literature, were searched for studies published between 1st January 2000 and 20th January 2024.
Five studies conducted in acute inpatient settings were included: two randomised controlled trials, two mixed-methods studies, and one quality improvement project. Most (n = 4) studies developed complex interventions that included education and other components (products, referral pathways, assessment tools), and were delivered either face-to-face or as an online program. Most studies reported positive changes in oral health knowledge, attitudes, and confidence. There was limited measurement of the acceptability and feasibility of the interventions, with only one study reporting positive feedback from clinicians. There was no evidence to support changes in clinical practice following any of the included interventions.
Existing evidence indicates interventions for stroke clinicians have some potential for building stroke clinicians' capacity to provide adequate oral healthcare. There is however no evidence linking these interventions to optimised patient outcomes. There is a need for research focused on the implementation and dissemination of tailored oral health educational interventions incorporating clinically meaningful outcomes.
Existing oral healthcare educational interventions appear to have a positive effect on stroke clinicians' oral health knowledge, confidence, and attitudes. Educational interventions in oral healthcare are perceived to be acceptable and feasible; however, further research is needed to design and test the effect of new interventions.
Integrated oral healthcare is particularly important for stroke survivors who are at greater risk of preventable aspiration pneumonia. This scoping review highlights the characteristics of existing educational programs for stroke clinicians, their effectiveness, and gaps in existing evidence. Review findings substantiate the need for future research to enhance existing oral healthcare interventions, to translate knowledge acquired from training into clinical practice, and to capture appropriate measures of effect.
The PRISMA-ScR Checklist.
This review was registered with the Open Science Framework registry (https://doi.org/10.17605/OSF.IO/4BWVF).
To determine the effects of nurse-coordinated interventions in improving readmissions, cumulative hospital stay, mortality, functional ability and quality of life for frail older adults discharged from hospital.
Systematic review with meta-analysis.
A systematic search using key search terms of ‘frailty’, ‘geriatric’, ‘hospital’ and ‘nurse’. Covidence was used to screen individual studies. Studies were included that addressed frail older adults, incorporated a significant nursing role in the intervention and were implemented during hospital admission with a focus on transition from hospital to home.
This review searched MEDLINE (Ovid), CINAHL (EBSCO), PubMed (EBSCO), Scopus, Embase (Ovid) and Cochrane library for studies published between 2000 and September 2023.
Of 7945 abstracts screened, a total 16 randomised controlled trials were identified. The 16 randomised controlled trials had a total of 8795 participants, included in analysis. Due to the heterogeneity of the outcome measures used meta-analysis could only be completed on readmission (n = 13) and mortality (n = 9). All other remaining outcome measures were reported through narrative synthesis. A total of 59 different outcome measure assessments and tools were used between studies. Meta-analysis found statistically significant intervention effect at 1-month readmission only. No other statistically significant effects were found on any other time point or outcome.
Nurse-coordinated interventions have a significant effect on 1-month readmissions for frail older adults discharged from hospital. The positive effect of interventions on other health outcomes within studies were mixed and indistinct, this is attributed to the large heterogeneity between studies and outcome measures.
This review should inform policy around transitional care recommendations at local, national and international levels. Nurses, who constitute half of the global health workforce, are ideally situated to provide transitional care interventions. Nurse-coordinated models of care, which identify patient needs and facilitate the continuation of care into the community improve patient outcomes.
Review findings will be useful for key stakeholders, clinicians and researchers to learn more about the essential elements of nurse-coordinated transitional care interventions that are best targeted to meet the needs of frail older adults.
When frail older adults experience transitions in care, for example discharging from hospital to home, there is an increased risk of adverse events, such as institutionalisation, hospitalisation, disability and death. Nurse-coordinated transitional care models have shown to be a potential solution to support adults with specific chronic diseases, but there is more to be known about the effectiveness of interventions in frail older adults. This review demonstrated the positive impact of nurse-coordinated interventions in improving readmissions for up to 1 month post-discharge, helping to inform future transitional care interventions to better support the needs of frail older adults.
This systematic review was reported in accordance with the Referred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
No Patient or Public Contribution.
To evaluate the effect of a novel, co-designed, digital AF educational program, ‘INFORM-AF’, to reduce re-hospitalisation of people with AF.
The secondary aims are to examine the effect of the intervention on: (a) reducing cardiovascular-related hospitalisation, (b) increasing medication adherence, AF-related knowledge, and Atrial fibrillation (AF)-related quality of life and (c) determining the cost-effectiveness of the intervention.
AF is an increasingly prevalent cardiac arrythmia that involves complex clinical management. Comprehensive education is essential for successful self-management of AF and is associated with positive health-related outcomes. There has been an increase in technology-based education for AF. However, its effects on hospitalisation, medication adherence and patient-reported outcomes are unclear.
A prospective, randomised (1:1), open-label, blinded-endpoint, multicentre clinical trial.
Eligible participants are aged 18 years or above, diagnosed with AF, and own a smartphone. The study will be conducted at two metropolitan hospitals. In the intervention group, participants will receive the AF educational program delivered via Qstream®. In the control group, participants will receive the Stroke Foundation ‘Living with AF’ booklet. The primary outcome is re-hospitalisation within 12 months from an indexed presentation or hospital admission.
This clinical trial is part of a developing program of work that will examine mHealth educational-behavioural interventions on cardiovascular outcomes. Findings from this pilot study will inform the development of a digital educational framework for patients living with AF.
There remain many gaps in providing high-quality patient education for patients with AF. This trial will test a new theory-driven, smartphone-based education program on important clinical outcomes, including rehospitalisation.
This study evaluates a novel, co-designed, digital AF educational program, ‘INFORM-AF’, to reduce the re-hospitalisation of people with AF. Study results are expected to be reported in 2025. Findings are expected to inform practice recommendations for AF patient education that may be included in future clinical practice guideline recommendations.
SPIRIT Checklist.
JL is a consumer co-researcher on the project and provided critical input into intervention design, and feedback and input across the study duration.
FreshRSS 