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The clinical practicum is a critical component of nursing education. In Spain, it is currently facing systemic challenges that compromise its quality and sustainability. A persistent nursing shortage, combined with increasing pressure on healthcare systems and a growing number of students intended to address this gap, is adding strain to clinical learning environments, which may compromise the capacity of nurses to provide adequate supervision and meaningful learning experiences for nursing students. This not only diminishes the quality of the training experiences, but also negatively affects the well-being of both students and nurses, further worsening the situation. This protocol outlines a study aimed at conducting an in-depth analysis of the current challenges affecting the clinical practicum and proposing a new model that effectively addresses them, with significant potential for adaptation and implementation across different health education fields and geographical locations.
The study will employ a sequential mixed-methods design comprising two integrated phases. In phase I, quantitative, qualitative and scoping review methodologies will be combined to identify current challenges and opportunities. Quantitative data will be obtained by administering questionnaires to nursing students and clinical mentors (CMs) tutoring them in Catalonia, examining potential barriers and facilitators to their mentoring role. Data will be analysed through descriptive and inferential statistics. Qualitative data will emerge from semistructured interviews with CMs and nurse coordinators, as well as from a visual elicitation technique, the ‘Emojional’ Calendar, conducted with students to understand their clinical practicum experiences. These will be analysed through an inductive thematic analysis approach. The scoping review, following the Arksey and O’Malley framework, will identify best practices in clinical practicums in nursing and other health studies globally. Phase II will involve a three-round qualitative Delphi study in which all preceding results will be presented to stakeholders and decision makers in order to redesign the clinical practicum model.
Ethical approval for this study was obtained from Hospital del Mar Clinical Research Ethics Committee (Ref #2023/11123). Results will be disseminated through peer-reviewed journals and conference presentations, as well as via strategic actions (forums and meetings with healthcare managers, deans and policymakers) and general outreach (talks, social media and websites) targeted at professionals, students and the public.
To examine the contexts and mechanisms that enable compassionate mentorship in healthcare, in order to generate evidence-informed insights for fostering healthier, more sustainable work environments.
A rapid realist review.
Systematic searches were conducted in Ovid MEDLINE (1946–December 2024), Embase (1974–December 2024) and CINAHL (1981–December 2024). Additional sources included Google Scholar searches, reference list scanning and grey literature (e.g., practice guidelines, policy briefs, professional reports). The review was conducted between August 2024 and July 2025.
Realist review methods were applied to answer the question: What works, for whom, under what circumstances and why? The review proceeded in four stages: defining scope and research questions with an expert panel; iterative searching and screening; data extraction and synthesis into context–mechanism–outcome configurations (CMOCs); and development of a programme theory.
Twenty-two documents were included, spanning nursing, medicine, allied health and interdisciplinary contexts. Six CMOCs were identified, encompassing the following themes: (1) relationship compatibility; (2) vulnerability and self-exploration; (3) growth through untapped strengths; (4) anti-oppression and equity; (5) mentors' pride and confidence; and (6) culture of mentorship. The resulting programme theory conceptualises compassionate mentorship as a dynamic, multi-level process with cumulative impacts on individual well-being, professional development and organisational culture.
Compassionate mentorship represents not only a relational practice but also a structural intervention for healthier workplaces. Programmes should prioritise compatibility, cultivate psychological safety, invest in mentee growth, embed equity, recognise mentor contributions and institutionalise mentorship culture.
These strategies offer actionable pathways to strengthen workforce resilience, retention and sustainability.
One co-author is a retired nurse, ethicist and person with lived experience in the healthcare system. This co-author was integral to this project, serving on the scientific steering committee from project conceptualisation and funding application through study conduct and publication.
by Maria Grazia De Iorio, Michele Polli, Sara Ghilardi, Stefano Frattini, Mara Bagardi, Alessandra Paganelli, Maria Cristina Cozzi, Kenza Seghrouchni, Paola Giuseppina Brambilla, Giulietta Minozzi
Non-epidermolytic ichthyosis (NEI) is a hereditary skin disorder affecting several dog breeds, most notably the Golden Retriever. It is primarily caused by a loss-of-function variant in the PNPLA1 gene, while a second, less common form is associated with a deletion in the ABHD5 gene. This retrospective study aimed to assess the prevalence and temporal trends of both mutations in Golden Retrievers tested in Italy between 2017 and September 2025. A total of 508 genetic tests were analyzed, including 463 dogs tested for the PNPLA1 mutation, 42 for the ABHD5 deletion, and 3 for both variants. DNA was extracted from blood or buccal samples and analyzed by real-time PCR followed by confirmatory Sanger sequencing. Among the PNPLA1 tested dogs, 42% were clears (wt/wt), 37% carriers (wt/mut), and 21% affected (mut/mut), with calculated allele frequencies of 60% wild-type and 40% mutant. A significant temporal decline in mutant allele frequency was observed, accompanied by an increasing number of animals tested over time, suggesting growing interest in genetic screening and its impact on selective breeding. Conversely, all dogs tested for the ABHD5 deletion were wild-type, supporting its rarity in the breed. Overall, these findings confirm that PNPLA1-related ichthyosis remains one of the most prevalent hereditary disorders in Golden Retrievers, although its frequency is decreasing. The results emphasize the effectiveness of genetic testing in disease prevention and highlight the importance of continued monitoring to maintain genetic health within the breed.This study aimed to identify underserved regions and evaluate the population coverage based on travel time and distance to hospitals with gynaecologic oncologists in Indonesia.
The travel time and distance to hospitals with gynaecologic oncologists were evaluated using the Quantum Geographic Information System. Data from 139 gynaecologic oncologists and their affiliated hospitals were obtained from the Indonesian Society of Gynecologic Oncologists (November 2024) and cross-referenced with the Ministry of Health records. The female population density data were sourced from Facebook’s high-resolution settlement layer. Isochrones were generated to estimate travel times and distances using zonal statistics, which facilitated the calculation of population coverage.
A total of 139 gynaecologic oncologists were identified nationwide, practising in 243 hospitals (7.6% of the 3202 hospitals in Indonesia), with a concentration in Java (60.4%). 11 of the 38 provinces lack sub-specialists. Population coverage varies sharply: the travel time to a hospital with gynaecologic oncologists is ≤2 hours for 79.1% of women in Java, compared with 4.9% in Papua; overall, 34.4% reside more than 100 km away from hospitals with gynaecologic oncologists. Hospitals with gynaecologic oncologists are predominantly urban class B general hospitals, and 83.1% participate in the National Health Insurance Schemes. Exploratory district-level correlations showed positive associations between the number of such hospitals and total female population (r=0.44, p
Gynaecological oncology services in Indonesia remain heavily concentrated in Java, leaving nearly one-fifth of women residing more than 100 km away. The travel time is greater than 2 hours for many. Targeted expansion of the gynaecologic oncologists workforce, diagnostic and treatment infrastructure, and sustainable financing mechanisms are required to close these gaps.
Bipolar disorder affects around 2% of the population and is linked with reduced life expectancy and socioeconomic burden. Depressive episodes are difficult to treat and typically more prevalent, enduring and burdensome than manic episodes. The use of antidepressants alone has limited effect and is associated with significant clinical risk through polarity switch. Current National Institute for Health and Care Excellence guidelines recommend quetiapine, olanzapine (with or without fluoxetine) and lamotrigine; however, these medications have limited efficacy, tolerability and acceptability. The ASCEnD study aims to assess the clinical and cost-effectiveness of aripiprazole plus sertraline compared with quetiapine, offering potential improvements for outcomes in bipolar depression. The study is funded by the National Institute for Health and Care Research Health Technology Assessment programme (NIHR132773).
ASCEnD is a prospective, two-arm, superiority, individually 1:1 randomised, controlled, pragmatic, parallel group, type A open-label clinical trial of aripiprazole/sertraline medication combination compared with quetiapine for bipolar depression. The study is conducted in the UK National Health Service setting with the aim of recruiting and randomising 270 participants followed-up for 24 weeks. Adults with bipolar disorder self-refer or are recruited through primary and secondary care services. The primary outcome is change in depressive symptoms 12–16 weeks after randomisation. Secondary outcomes include measures of symptom change, treatment satisfaction, tolerability, medication adherence, concomitant medication use, psychosocial functioning, quality of life and cost-effectiveness and informal carer measures of quality of life and costs of caring. The exploratory outcome is change in participant reward and punishment responsiveness. Analysis will follow a prespecified statistical analysis plan. A nested qualitative study is included to examine feasibility and acceptability of the trial design.
A Clinical Trial Authorisation from Medicines and Healthcare products Regulatory Agency, and approval from the Health Research Authority (IRAS 1007468) and North East – Newcastle and North Tyneside 1 Research Ethics Committee (23/NE/0132) were obtained. Results will be disseminated through peer-reviewed publications, conference presentations and lay summaries for participants and patient and public groups.
With the global lymphatic filariasis (LF) elimination goal set to 2030, it is necessary to address challenges hindering the last-mile efforts. Never treated individuals are those who self-report that they have never taken the drugs for LF during any mass drug administration (MDA) rounds. Hence, it is necessary to identify these individuals and assess if they can be potential reservoirs of infection and understand the reasons for non-compliance.
This mixed method study, proposed for a period of 2 years, will assess the filarial infection status of never treated individuals from four LF-endemic districts in India. A multi-stage cluster sampling design will be followed to select the health subcentres from one highly endemic block in each of the selected districts. A random sample of 2535 never treated individuals from each block will be assessed for filarial infection by a cross-sectional blood survey. Qualitative surveys, including in-depth interviews and focus group discussions, will be conducted to elicit the reasons for their non-compliance. The prevalence of filarial infection will be summarised as frequencies and percentages. Univariate and multivariate logistic regression analysis will be performed to find the factors associated with filarial infection. Exploring the various reasons, such as sociocultural, behavioural and programmatic drivers of non-participation, will enable the programme to design tailored communication and community engagement strategies to bring them under the umbrella of MDA and thereby support the ongoing LF elimination efforts.
This study has been approved by the institutional ethics committee (IHEC 07-0824/N/F, dated 25 September 2024). After completion of the study, a workshop will be held with all stakeholders to disseminate the study findings.
To adapt the SOCAV programme—originally developed for residential dementia care—for home care use, and to evaluate its feasibility and potential to foster behavioural change in nurses and informal caregivers supporting self-direction in people with dementia.
Development and feasibility study guided by the Medical Research Council framework for complex interventions. Feasibility was evaluated using Bowen’s framework (demand, acceptability, practicality, implementation, limited efficacy). Data collection involved semistructured interviews, focus groups and reflective coaching diaries, as well as validated outcome measures (self-direction, quality of life and depressive symptoms) assessed at multiple time points. Qualitative data were analysed using qualitative content analysis (Bowen’s feasibility framework) and constant comparative analysis; quantitative data were analysed descriptively.
Two home care teams in different Dutch municipalities.
Development phase: 16 participants (4 people with dementia, 6 informal caregivers, 6 nurses). Feasibility phase: 59 participants (12 people with dementia, 14 informal caregivers, 33 nurses).
SOCAV-Home Care integrates person-centred communication training with reflective coaching for nurses and joint meetings involving people with dementia and informal caregivers. It aims to embed self-direction into daily care routines.
The programme was feasible and well-received, though demanding. Nurses reported increased reflection, more person-centred communication and greater professional confidence. Informal caregivers showed attitudinal shifts from control to autonomy-supportive care. Programme complexity, scheduling difficulties and emotional burden contributed to dropout. Quantitative trends showed reduced behavioural symptoms in people with dementia, though no statistical analysis was performed due to sample size.
SOCAV-Home Care shows potential to foster behavioural change in nurses and informal caregivers, promoting self-direction and relational care in dementia home care. Findings, grounded in rich reflective data, offer a valuable foundation for further evaluation. Simplifying delivery and enhancing flexibility are key to broader implementation. Future research should evaluate the sustainability strategies proposed and examine long-term outcomes in diverse home care contexts.
NCT07347639; Post-results.
To identify implementation strategies that effectively facilitate the adoption of social needs care coordination activities using enabling technologies among care management teams serving patients in community-based health centres.
Modified Delphi process.
Discrete, feasible implementation strategies were identified through literature review and semi-structured interviews with care management staff and subject matter experts in clinical informatics, workflow redesign, and product engineering. A modified Delphi was conducted with eight subject matter experts and nine health centre care management staff. Iterative rounds of online surveys were used to achieve consensus on the most relevant implementation strategies and their delivery methods.
The modified Delphi process achieved consensus on nine discrete implementation strategies needed to advance care management teams' ability to screen, refer and track social needs. Prioritised strategies included developing champions, enhancing quality improvement capacity, training staff on using enabling technologies and providing tailored technical assistance for workflow refinement. Consensus was also reached on a monthly cadence for most of the implementation strategies.
Consensus was reached on strategies to enhance care management teams' implementation of social needs screening, referrals and tracking using enabling technologies. These strategies will comprise an intervention to be pilot tested, refined and assessed in a cluster randomised clinical trial.
Findings from this study will inform the development of strategies to further the adoption of enabling technologies to support social needs care coordination.
This work is key to the design of a type 2 hybrid implementation-effectiveness trial that will assess whether user-informed, evidence-based implementation strategies can improve care management teams' adoption of enabling technologies to facilitate social needs care coordination for patients.
The research team includes a patient advisor with community-based nursing expertise and a nurse practitioner-clinical informaticist leader who was involved in data collection and interpretation of findings.
Trial registration: Clinicaltrials.gov registration # NCT06489002. Registered July 5, 2024, https://clinicaltrials.gov/study/NCT06489002?term=NCT06489002&rank=1.
To explore nursing professionals' perceptions of the intersectional positioning of their profession within healthcare and society, examining how axes of oppression shape healthcare responses and resource management.
A qualitative study framed in critical theory paradigm employing constructivist grounded theory, as outlined by Charmaz.
The study was conducted in Catalonia, Spain, between 2022 and 2023. A total of 26 nursing professionals participated, representing a range of professional roles and settings. Theoretical sampling guided participant recruitment and was saturated after 17 in-depth interviews and 2 thematic focus groups. Interviews and focus groups were transcribed verbatim. Thematic analysis, informed by Charmaz's approach, was applied to identify key dimensions and themes. Intersectionality theory was used as a critical analysis framework.
A predominant theme emerged from data identified as ‘intersectional disempowerment of nursing profession’. Four categories shape this positioning: (1) symbolic and historical undervaluation of care, rooted in nursing's feminization and patriarchal norms; (2) patriarchal influence on professional leadership, manifested by men disproportionately occupy leadership roles, reinforcing vertical segregation; (3) intra-professional hierarchies and technocratic influence, forcing prestige disparities within nursing and promoting horizontal segregation; and (4) internalised barriers among nurses regarding professional prestige, authority and recognition which combined undermine nursing's visibility, legitimacy and influence within healthcare.
Nursing cannot be understood as a neutral profession. Its societal positioning is deeply shaped by structural inequities, gendered assumptions and entrenched hierarchies, which collectively undermine its potential for autonomy and recognition.
This study highlights the need to challenge intersectional hierarchies in nursing, promoting equitable recognition, policy reforms and leadership opportunities to enhance nurses' authority, visibility and professional empowerment within healthcare systems. Addressing these challenges requires systemic policy reforms and a critical re-evaluation of societal perceptions. What problem did the study address? Nursing's social image is strongly shaped by biomedical, technocratic and social views. The gap between nursing's public image and identity limits professional growth and recognition. Analysing how power relations intersect in nursing's social position is essential. What were the main findings? Nursing's role is shaped by the intersection of gender, prestige, socioeconomic status and social recognition. Nurses' empowerment must be tied to transforming unjust institutions and systemic structures. Where and on whom will the research have an impact? This study provides a critical analysis of the intersectional positioning of the nursing profession. The findings have implications at multiple levels: micro, by offering nurses a critical perspective on their professional positionality; meso, by providing healthcare managers with insights into the underlying factors contributing to nursing's undervaluation; and macro, by fostering reflection within the broader healthcare community on the power dynamics shaping interprofessional relationships.
This study did not include patient or public involvement in its design, conduct, or reporting.
The manuscript is based on the Consolidated Criteria for Reporting Qualitative Research (COREQ).
To explore how nursing teams (co)organise their work environment by going beyond caregiving.
A descriptive qualitative study with a phenomenological approach.
Semi-structured group interviews were conducted in 2022 with nurses and managers from 18 nursing teams in a general hospital located in the Netherlands. In each group interview, 2–3 participants per team took part. The interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis.
The analysis identified four main themes contributing to a more supportive work environment: (1) embracing diversity, (2) stretching nursing roles, (3) raising voices, and (4) aligning nurses and managers. These themes show how nursing teams go beyond caregiving and actively shape and co–organise their work environment.
Teams that extend their roles create more supportive work environments, enhancing patient care and professional development. These findings contribute to the understanding of organising professionalism in nursing and provide insights for nursing teams striving to improve their work environments.
Nursing teams can use the four themes—as team features—to reflect upon their organising roles and engagement with their work environment. Our findings offer practical insights for nurses with responsibilities in areas such as team development and leadership. They can focus on team diversity, voicing, stretching roles, and organisational alignment, and facilitate their teams to become more assertive.
The Consolidated criteria for Reporting Qualitative research guideline was followed.
No patient or public involvement.
To clarify the concept of disempowerment in adults with chronic illness.
The Walker and Avant approach to concept analysis was used.
A systematic literature search was performed on 14 February 2024, using the following databases: CINHAL, PubMed, PsycINFO, Sociological Abstracts and ProQuest Dissertations & Theses Global A&I: The Humanities and Social Sciences Collection. Studies examining adults' experience of individual disempowerment stemming from chronic illness were included. Definitions and descriptions of the concept in the included studies were extracted and synthesised into defining attributes, antecedents, and consequences.
Forty-five articles were included. Two defining attributes were identified: (1) diminishing opportunities to take control and (2) clients' dissatisfaction with diminishing control. Antecedents were changes in health status related to chronic illness and expectation mismatch within the client, or between clients and their care partners. The consequence of disempowerment was disengagement in the context of disempowerment.
Disempowerment was found as the state of dissatisfaction with diminishing opportunities to control personal lives, which stems from changes in health status and expectation mismatch and leads to disengagement in the context of disempowerment. Contrary to prior studies, where disempowerment was often considered an outcome of an imbalanced relationship between clients and care partners, the present findings showcased disempowerment as a holistic illness experience, involving changes in health status. The understanding of disempowerment as the dissatisfaction with the situation of diminishing opportunities to take control differentiates this concept from the opposite of empowerment, which is conceptualised as clients' ability to make decisions or manage diseases. Findings further highlight the importance of understanding clients' illness experience comprehensively and providing care in a manner that is matched with clients' abilities, expectations and needs. It is suggested that operationalising the concept based on this understanding is necessary in order to understand correlations between disempowerment, its causes and consequences.
Disempowerment has been applied to describe interruptions in their states of being, perceived role performances, and independence in adults with chronic illness from diverse perspectives in the extant literature, such as the opposite of empowerment, action to take away control over personal lives and a state of diminishing ability to tackle problems. Through clarifying the concept, this article will guide the communication, measurement tool development and response in clinical practice.
No patient or public contribution.
To explore how older women experiencing poverty in a high-income country perceive their family caregiver role from a gender perspective.
Descriptive qualitative study.
A convenience sample of seventeen older female caregivers experiencing poverty was interviewed in-depth between October 2023 and March 2024. Reflexive thematic analysis was conducted following the phases described by Braun & Clarke. ATLAS.ti software was used for data analysis.
Three main themes were developed from the data analysis: (1) The duality of family caregiving: between informal female support and structural neglect, (2) family care in later life as a continuation of a life devoted to others, (3) older female family caregiving as a gender issue.
Older female caregivers experiencing poverty have limited formal support and unequal access to resources. Older women experiencing poverty experience both gratitude and despair in their caregiving role, which inevitably deteriorates their health.
Nursing interventions for older female caregivers experiencing poverty should include an assessment of social determinants of health, focusing on gender and socio-economic barriers. Implementing system navigation interventions, such as community-based case management, resource referral programmes, and personalised care coordination, could connect older female family caregivers to essential resources and support networks, thus addressing their mental health needs and promoting equity, which would enhance their overall well-being and dignity.
Experiencing poverty increases the vulnerability of older female caregivers, exacerbating gender inequality. These women often face mental health issues as they face the pressure of meeting their own needs and those of their care recipients with a lack of formal support. This neglect can lead to serious health problems, which emphasises the need for equitable nursing interventions.
The study is reported following the COREQ guidelines.
No patients or public were involved in the study development and implementation.
To explore the lived experiences of Chinese older adult cancer patients in Hong Kong navigating the challenges of long COVID.
A descriptive phenomenological study.
Semi-structured interviews were conducted with 27 purposively sampled older Chinese cancer survivors in Hong Kong between January 2023 and January 2024. Data were analysed using Colaizzi's thematic analysis method.
Four key themes emerged: (1) the invisible scars of COVID-19: unrecognised and diverse symptoms; (2) the double-edged sword of protection: shielding from COVID-19 while battling cancer and long COVID; (3) forging strength in the crucible: adapting and thriving with cancer and long COVID and (4) nurturing resilience: the integral role of nursing in supporting cancer patients with long COVID during a pandemic.
Older Chinese cancer patients with long COVID experience a dual burden of unrecognised physical symptoms and profound psychological distress from isolation. Despite this, they demonstrate remarkable resilience, a process that can be actively supported through specialised nursing care.
This study offers original contributions to the limited literature on the intersection of cancer, long COVID, and ageing. It provides in-depth insights into the lived experiences of this vulnerable population, highlighting the diversity of long COVID symptoms, the psychological impact of pandemic-related precautions, and the crucial role of nursing in fostering resilience.
This study highlights the urgent need for nurses to recognise the unique challenges of this population. It provides a foundation for developing nurse-led, resilience-focused interventions that integrate tailored education, emotional support, and resource navigation into oncology care. These findings can inform practice and policy to better support the well-being of a vulnerable and growing patient demographic.
The study adhered to the consolidated criteria for reporting qualitative research (COREQ) checklist.
No patient or public contribution.
To determine the application rate of the preventive measures, alternate air anti-decubitus mattress and postural changes in patients who develop hospital-acquired pressure injury (HAPI) on the basis of their preventive or reactive temporality.
This is an ambispective observational study that included adult patients without pressure injuries admitted to Mancha Centro Hospital (Spain) who developed at least one HAPI during hospitalisation (August 2022 to March 2023).
The main variables were the implementation of preventive measures and the time of their application. Other variables were comorbidities, sociodemographic and clinical variables, Braden and Barthel scale, variables related to the application of preventive measures and information to characterise HAPI.
180 patients who developed 276 HAPI during their admission were included; 73.9% of the patients received a risk assessment upon admission, and 53.9% were re-evaluated. At some point during admission, an anti-decubitus mattress was placed in 73.3% of the patients, and 76.1% received postural changes.
Among the patients at risk at the time of HAPI onset, 49.4% had received anti-decubitus mattress preventively, 23.9% had received it reactively, and 26.7% did not receive it. Among the patients without contraindication for postural changes, 51.4% received them before the lesions appeared, 33.6% received them after the lesions appeared, and 13.6% did not receive them.
We detected a significant association between the preventive application of anti-decubitus mattress and postural changes with the Braden reassessment; admission to the intensive care unit; mechanical ventilation, vasopressors, nasogastric tube; mental state confused; hospital isolation; low Barthel and Braden scores; impaired mobility; inability to perform postural changes; diaper; urinary/faecal incontinence; and sedatives.
Only approximately half of the patients received preventive measures. Although patients with a more unfavourable clinical profile were more likely to receive these measures, increased awareness and training among healthcare professionals are necessary to ensure broader and more consistent implementation of preventive strategies.
This study explores the real-world use of preventive measures in hospitalized patients who develop HAPI. In half of the patients, these measures were applied reactively, highlighting the need to introduce strategies that facilitate the implementation of evidence-based practices.
This study was reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies.
In the present study, data from patients have been obtained, but the patients or caregivers have not contributed to the development of the manuscript.
The ‘Wound Hygiene Italia’ project was designed to provide expert-driven recommendations for the assessment, management and monitoring of venous leg ulcers, tailored to diverse settings of care (hospital, ambulatory and home care). The recommendations, developed by a multidisciplinary panel, emphasise the implementation of the Wound Hygiene strategy, a systematic approach targeting biofilm as a primary barrier to wound healing. Wound management is structured around four steps: cleansing, debridement, edge refashioning and dressing selection adapted to the wound bed characteristics, care setting and clinical capabilities, embedded in a holistic approach through comprehensive patient assessment and monitoring of overall well-being. The findings highlight the necessity of interdisciplinary collaboration, standardised tools and continuous patient monitoring, as assessed by objective metrics, such as wound size measurements and photographic documentation. Effective communication with patients and caregivers is also essential to ensure treatment adherence and foster trust in the care process. This framework integrates evidence-based practices to optimise outcomes and patient quality of life. By addressing both clinical and psychosocial factors, the recommendations promote a holistic, patient-centred approach that underscores the importance of education, structured follow-ups and tailored interventions.
To describe prescription patterns, dosing and persistence of guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction in Singapore, and to identify factors associated with the use of quadruple therapy (ACE inhibitor (ACEi)/angiotensin II receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), β-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter-2 (SGLT2) inhibitor).
Retrospective, observational cohort study.
Secondary and tertiary care settings across seven public hospitals in Singapore.
3999 adults hospitalised from 2020 to 2022 with a first heart failure-related admission and left ventricular ejection fraction ≤40%. Patients with absolute contraindications to specific GDMT classes were excluded from eligibility calculations.
Primary outcomes were the proportions of eligible patients prescribed each GDMT class and quadruple therapy at discharge. Secondary outcomes were 6-month prescription patterns, dose attainment and predictors of quadruple therapy use.
Among eligible patients, 80%–99% met criteria for each GDMT drug class, yet only 29% received quadruple therapy at discharge in 2022. Prescription rates for ACEi/ARB/ARNI (67%), beta-blockers (89%), MRAs (40%), and SGLT2 inhibitors (46%) remained suboptimal despite high eligibility. At discharge, over 90% of patients on ACEi/ARB/ARNI and beta-blockers received ≤50% of target doses. By 6 months, prescription rates declined by 16% for ACEi/ARB/ARNI, 26% for beta-blockers and 7% for MRAs, while SGLT2 inhibitor use increased. Older age (OR 0.97, 95% CI 0.96 to 0.98) and chronic kidney disease stage 3a–4 (OR 0.65 to 0.04) were associated with lower odds of receiving quadruple therapy, while significant institutional variation was observed.
Despite high eligibility, uptake and optimisation of GDMT remain poor in Singapore, with substantial treatment gaps driven by underprescription, inadequate dosing and discontinuation. Interventions targeting clinician awareness, postdischarge support and institutional practice variation may improve adherence to guideline-recommended therapy.
Effective communication is essential between health professionals during surgical procedures for delivery of safe patient care. The influence of noise on communication during critical moments of surgery and on communication failures is unclear.
To examine communication events among health professionals in the operating room and investigate the influence of noise on communication.
Non-participatory observations were undertaken of communication between health professionals during surgical procedures while simultaneously measuring sound pressure levels. Audio visual recording was used to document communication events, ensuring data accuracy. A generalised linear mixed model was used to examine relationships between various explanatory variables and the presence of at least one communication failure. The STROBE checklist guided the reporting of this paper.
A representative range of procedures was observed from diverse surgical specialties (N = 80). Observations comprised 2274 communication events; communication failures were observed in 24% and repeated communication was observed in 25% of all communication events. The mean maximum sound pressure levels were 64.9 dB[A] for communication events, 64.5 dB[A] for communication failures and 65.5 dB[A] for repeats. The type of surgical procedure, the emergence from anaesthesia compared to other phases of surgery, communication related to the surgical safety checklist, communication related to the surgical count, the presence of multitasking, and the use of surgical facemasks, were associated with the presence of at least one communication failure.
This research identified the inherent risks and occurrence of communication failure in noisy operating room environments where health professionals are undertaking complex cognitive tasks and where effective communication is essential to ensure patient safety.
This study did not include patient or public involvement in its design, conduct, or reporting.
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