Conectar
To explore multidisciplinary clinical, academic, policy and governance stakeholders' perceptions of enablers and barriers to implementing designated registered nurse prescribing in Australia, using a systems-thinking approach.
A two-phase explorative study using a systems-thinking lens to investigate complex health-system interdependencies.
Fifty-three participants were recruited from all Australian states and territories, including registered nurses, nurse practitioners, pharmacists, medical practitioners and health-service planners. Phase 1 involved interviews and focus groups conducted between February 2024 and April 2024 (n = 45), analysed using deductive content analysis, guided by the Sustainability of Innovation Framework. Phase 2 was a face-to-face workshop conducted in August 2024 (n = 28), with data from participant discussions and observer field notes analysed inductively and refined through reflexive dialogue. Reflexive analysis of the findings allowed the construction of recommendations for implementation in various healthcare contexts.
In Phase 1, participants representing all Australian jurisdictions and healthcare contexts identified that successful adoption of designated registered nurse prescribing is contingent upon several interrelated system components. These interconnected factors influence each other within the broader healthcare system and serve as the focus for Phase 2.
In Phase 2, participants reported context-specific service models, stakeholder engagement, financial support, clear messaging and workforce/organisational readiness for new models of care and service delivery were recognised as dynamic interrelated elements. Three overarching themes for successful implementation were generated: The Standard—just one piece of the puzzle. Harnessing collective capability. Shared wisdom for success.
National implementation of registered nurse prescribing requires consistent but context-responsive reforms. A systems-thinking approach underscores the need for whole-of-system strategies, acknowledging interdependencies and avoiding rapid, unplanned implementation. This study highlights that sustainable adoption of registered nurse prescribing in Australia depends on recognising system interdependencies and their dynamic nature.
Designated registered nurse prescribing has the potential to improve timely access to medicines and enhance patient-centred care when implemented with whole-of-system support.
This study provides key systems-level recommendations to guide policymakers and healthcare services to successfully implement designated registered nurse prescribing across various settings.
This study highlights key stakeholders' perspectives, providing valuable insights on the essential elements required for the successful adoption of this expanded practice.
Broad systems-level recommendations are offered to guide policymakers and healthcare services to successfully implement designated prescribing across various settings, taking into account the complexity of the healthcare system.
Consolidated criteria for reporting qualitative research guidelines.
This study did not include patient or public involvement in its design, conduct or reporting.
Not registered.
Transition of care from hospital is a period when the risks of medication errors and adverse events are high, with 50% of adults discharged having at least one medication-related problem. Pharmacist-led medication reviews can reduce medication errors and unplanned readmission when completed promptly post-discharge; however, they are underutilised. A Transition of Care Stewardship pharmacist has been proposed to facilitate and coordinate a patient’s discharge process and facilitate a timely post-discharge medication review. Access to pharmacist medication review in rural and regional areas can be limited. This protocol describes a randomised controlled trial (RCT) to determine whether a virtual Transition of Care Stewardship pharmacist reduces medication-related harm in rural and regional Australia.
Multicentre RCT involving patients at high risk of medication-related harm discharged from regional and rural hospitals to a domiciliary residence. Eligible patients must be aged≥18 years, admitted under a medical specialty, be discharged to a domiciliary setting, have a regular general practitioner (GP) or be willing to visit a GP or an Aboriginal Medical Service after discharge for medical follow-up, have a Medicare card and be at high risk of readmission. High risk of readmission is defined as either a previous admission to the hospital or Emergency Department (ED) presentation in the past 6 months AND≥three regular medications OR on at least ONE high-risk medication. A total of 922 participants will be recruited into the study. Enrolled participants will be randomised to the intervention or control (usual care). The intervention will include a virtual Transition Of Care Stewardship pharmacist to ensure that patients receive discharge medication reconciliation, medication counselling, medication list and communicate directly with primary care providers to facilitate a timely post-discharge medication review. Usual care will include informing the patient’s clinical inpatient treating team that the patient is at high risk of medication misadventure and may benefit from a post-discharge Home Medicines Review (a GP-referred pharmacist medication review funded by the Australian Government).
Data analysis will be performed on a modified intent-to-treat basis. The primary outcome assessed is a composite of a first unplanned medication-related hospitalisation or ED presentation within 30 days of hospital discharge. Comparisons between the intervention and usual care groups for the primary outcome will be made using a mixed-effects logistic regression model, adjusting for site-level clustering as a random effect.
This study is approved to be conducted at the Western New South Wales Local Health District via the Research Ethics and Governance Information System (approval number: 2023/ETH00978). To ensure the needs of Aboriginal and Torres Strait Islander patients are appropriately addressed, ethics for this study were submitted and approved by the Aboriginal Health and Medical Research Council (approval number: 2148/23). Manuscripts resulting from this trial will be submitted to peer-reviewed journals. Results may also be disseminated at scientific conferences and meetings with key stakeholders.
ACTRN12623000727640.
Effective management of type 2 diabetes mellitus (T2DM) consists of lifestyle modification and therapy optimisation. While glycaemic monitoring can be used as a tool to guide these changes, this can be challenging with self-monitoring of blood glucose (SMBG). The FreeStyle Libre 3 (FSL3) is a real-time continuous glucose monitoring (CGM) system designed to replace SMBG. The evidence for the benefit of CGM in people with T2DM on non-intensive insulin regimens is limited. This study aims primarily to assess the glycaemic impact of FSL3 in people with suboptimally controlled T2DM treated with basal-only insulin regimens plus sodium-glucose cotransporter-2 (SGLT-2) inhibitor and/or glucagon-like peptide (GLP)-1 agonist.
This is an open-label, multicentre, parallel design, randomised (2:1) controlled trial. Recruitment has been offered across 24 clinical centres in the UK and nationally through self-referral. Adults with T2DM treated with basal-only insulin regimens plus SGLT-2 inhibitor and/or GLP-1 agonist and with screening HbA1c from ≥59 mmol/mol to ≤97 mmol/mol are included. Eligible participants will be randomised to either FSL3 (intervention) for 32 weeks or continuation of SMBG (control). The study is split into two phases, each of 16 weeks duration: phase 1 consisting of self-management with basal-insulin self-titration and phase 2 where additional therapies may be initiated. Control group participants may subsequently enter an optional extension phase to receive FSL3. The primary endpoint is the difference between treatment groups in mean change from baseline in HbA1c at 16 weeks. Secondary outcomes include HbA1c at 32 weeks, CGM-based metrics, therapy changes, physical activity levels and psychosocial measures. An economic evaluation for costs and patient outcomes will be undertaken.
The study was approved by the Health Research Authority, Health and Care Research Wales and the West Midlands-Edgbaston Research Ethics Committee (reference: 23/WM/0092). Study results will be disseminated in peer-reviewed journals.
Identifier assigned by the sponsor: ADC-UK-PMS-22057.
Revision D. Dated, 13 December 2024.
Delay in detecting acute deterioration in older adults in care homes is associated with avoidable hospitalizations and adverse outcomes, including premature death.
Underpinned by the Knowledge to Action Framework, this study aimed to understand the barriers and enablers to direct care staff detecting and responding to the early signs of acute deterioration in care home residents.
Online focus groups or interviews with regulated (registered and enrolled nurses) and unregulated (assistants in nursing and personal care workers) direct care staff from participating care homes were conducted. Homes were recruited using disproportionate stratified random sampling to include metropolitan, inner regional, and outer regional care homes. Interview and focus group recordings were transcribed verbatim and analyzed using inductive thematic analysis.
Eighty direct care staff (n = 48 regulated; n = 32 unregulated) from eight care homes participated. Fifteen focus groups (n = 7 unregulated staff, n = 8 regulated staff) and two interviews (n = 1 regulated staff, n = 1 unregulated staff) were conducted between July 2021 and October 2022. Four themes related to the barriers and enablers of detecting and responding to acute deterioration were generated: decision-making within the scope of practice; resource availability; streamlined communication; and teamwork.
Findings highlight the challenges direct care staff encounter in being able to detect early signs of acute deterioration and implement appropriate care pathways. Perceived barriers and enablers highlighted in this study need to be considered when developing and implementing programs to optimize the timely detection of, and response to, acute deterioration in care homes.
Workforce knowledge, experience, and confidence deficits are significant barriers to detecting acute deterioration, while the unique workforce mix in care homes poses additional challenges for the accurate detection of early signs of acute deterioration. Knowing the resident, working as a team, and valuing the contribution of aged care staff and families in managing acute deterioration are enablers to achieving better outcomes for residents experiencing acute deterioration.
FreshRSS 