A Web-Based Well-being Program for Health Care Workers (Thrive): Protocol for a Randomized Controlled Trial

BackgroundMental health has come to be understood as not merely the absence of mental illness but also the presence of mental well-being, and recent interventions have sought to increase well-being in various populations. A population that deserves particular attention is that of health care workers, whose occupations entail high levels of stress, especially given the ongoing COVID-19 pandemic. A neuroscience-based web-based well-being program for health care workers—the Thrive program—has been newly developed to promote habits and activities that contribute to brain health and overall mental well-being. ObjectiveThis paper describes the protocol for a randomized controlled trial whose objective is to evaluate the Thrive program in comparison with an active control condition to measure whether the program is effective at increasing well-being and decreasing symptoms of psychological distress in health care workers at a designated Australian hospital. MethodsThe trial will comprise two groups (intervention vs active control) and 4 measurement occasions over a 12-week period. A survey will be administered in each of weeks 0, 4, 8, and 12, and the well-being program will be delivered in weeks 1-7 (via web-based video presentations or digital pamphlets). Each of the 4 surveys will comprise a range of questionnaires to measure well-being, psychological distress, and other key variables. The planned analyses will estimate group-by-time interaction effects to test the hypothesis that mental health will increase over time in the intervention condition relative to the active control condition. ResultsThe Thrive program was delivered to a small number of wards at the hospital between February 2021 and July 2021, and it will be delivered to the remaining wards from October 2021 to December 2021. A power calculation has recommended a sample size of at least 200 participants in total. A linear mixed model will be used to estimate the interaction effects. ConclusionsThis trial seeks to evaluate a new web-based well-being program for health care workers at a major public hospital. It will contribute to the growing body of research on mental well-being and ways to promote it. Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12621000027819; https://tinyurl.com/58wwjut9 International Registered Report Identifier (IRRID)DERR1-10.2196/3400

Advanced practice nurses’ experiences of patient safety: a focus group study

Background: Patient harm from unsafe care is an increasingly global phenomenon leading to death or disability. Drawing on their expertise, Advanced Practice Nurses provide the opportunity to improve care quality and safety. Aim: To explore Nurse Practitioners and Clinical Nurse Consultants’ experiences in patient safety. Design: A qualitative design was used involving six audio-visually recorded focus group interviews. Participants working in an acute or community adult nursing speciality were involved. Methods: Twenty-eight Advanced Practice Nurses (female 82.1%, mean age 47.5 ± 10 years) were recruited by convenience and snowball sampling. After transcription of interview data, qualitative content analysis was conducted. Results: Six categories were identified: patient safety as the highest priority (1), special contribution to patient safety (2), patients/relatives role in safety (3), multidisciplinary team approach (4), government regulation in safety (5), and further needs to improve safety (6). Advanced Practice Nurses saw themselves as role models and leaders for other healthcare staff through their expertise and professional experience and thus able to see the bigger picture in health. They identified as change agents at the system-level due to their decision-making ability and multi-professional team connectivity. Conclusions: This study emphasises the key position of extended nursing roles and the need for future development of patient safety strategies in hospitals and community care. As influential leaders, Advanced Practice Nurses are best placed to identify improvements. They play a central role in guiding the multi-professional team, the patient and their family, educating nursing staff, and identifying and addressing system-wide safety gaps to improve patient safety

[In Press] Intensive care nurses' experiences with the new electronic medication administration record

Aim: To explore the experiences of Registered Nurses who administered medications to patients using the electronic medication administration record (eMAR) in Electronic Record for Intensive Care (eRIC) at one adult intensive care unit (ICU) in NSW, Australia. Design: The study research design used a qualitative descriptive exploratory approach that took place in two stages. Methods: Five participants attended one focus group followed by the observation of each participant as medications were administered to their assigned patient using the eMAR in eRIC. Results: From the data, three themes and one subtheme were identified. Themes included forcing nurses to work outside legal boundaries; patient safety; with a sub theme titled experiencing computer fatigue; and taking time away from the patient. To practise safely, nurses were required to implement workaround practices when using the new eMAR in ICU. Nurses also were concerned that the eMAR in eRIC took time away from the patient at the bedside and ‘added more screen time’ to their day

Intensive care nurses' experiences with the electronic medication administration record in eRIC

Introduction: Electronic medication administration record systems can overcome many issues associated with paper-based systems, yet can also give rise to new risks and challenges. Goals of such systems are to reduce medication errors, and improve patient safety. In today’s health care environment, medication administration is the most complex of all practices performed by nurses, particularly in the intensive care setting. Recently, a new electronic medication administration record (eMAR) was introduced to intensive care units across NSW. The eMAR was incorporated into the electronic information system eRIC, specifically designed for the intensive care environment. The aim of this study was to explore experiences of registered nurses working at one adult intensive care unit (ICU) with the eMAR in eRIC. Method: The study utilised a qualitative descriptive exploratory approach that took place in two stages, one focus group was conducted with five participants followed by the observation of each participant as medications were administered to their allocated patient. Results: From the focus group, three (3) themes and one subtheme emerged from the data. Themes included forcing nurses to work outside legal boundaries, time and patient safety, with a subtheme titled experiencing computer fatigue. Nurses were observed to move across ward spaces to obtain medications thus being forced to leave their patient under the care of another nurse working in the next ICU bay. Overall, nurses felt that the eMAR took time away from the patient at the bedside and ‘added more screen time’ to their day. To practise safely, ICU nurses were forced to implement workaround practices to resolve challenges that arose when using the new eMAR in ICU. Implications for Practice: This has potential legal implications for nurses’ registration and patient safety, should something go wrong. Changes need to be made to the eMAR system in eRIC to avoid adverse outcomes

Assessment and communication excellence for safe patient outcomes (ACCELERATE): A stepped-wedge cluster randomised trial protocol

Background: Nurses play a major role in patient safety. Poor nursing assessment and communication practices are associated with higher incidence of the adverse events of undetected deterioration, falls, and pressure injuries. Despite widespread adoption of patient safety systems, occurrence of these events continues. Aim: To implement and evaluate the feasibility and effectiveness of an organisational ward-level intervention to facilitate comprehensive systematic assessment and improved communication in clinical handover to reduce medical emergency team calls; unplanned Intensive Care Unit admissions; falls; and pressure injuries. Design: A stepped-wedge cluster randomised trial sequentially implemented over 12 months. Methods: Evidence-based implementation strategies will be employed to support implementation of an intervention focusing on comprehensive systematic patient assessment and improved nurse bedside clinical handover and multidisciplinary communication involving the patient. These are – intervention tailoring to individual wards through barrier and enabler identification; action plans; education; clinical champions; outreach visits; facilitation; clinician engagement; and reminders. Primary outcome measures will be a composite of Medical Emergency Team calls and unplanned intensive care unit admissions for deterioration. Secondary outcomes will be all categories of inpatient falls; stage 2–4 pressure injuries; nurse-reported perceptions of: teamwork; safety culture, and engagement; and patient-reported experience measures of receiving safe and patient-centred care. An a priori process evaluation will determine factors influencing intervention uptake and inform strategies for future upscale and spread. Discussion: This feasibility trial will provide evidence regarding the use of systematic comprehensive patient assessment, combined with clinical handover re-design involving patients, to reduce clinical deterioration, falls and pressure injuries

Pre-implementation context and implementation approach for a nursing and midwifery clinician researcher career pathway: A qualitative study

Aim: To describe the pre-implementation context and implementation approach, for a clinician researcher career pathway. Background: Clinician researchers across all health disciplines are emerging to radically influence practice change and improve patient outcomes. Yet, to date, there are limited clinician researcher career pathways embedded in clinical practice for nurses and midwives. Methods: A qualitative descriptive design was used. Data Sources: Data were collected from four online focus groups and four interviews of health consumers, nursing and midwifery clinicians, and nursing unit managers (N = 20) between July 2022 and September 2023. Results: Thematic and content analysis identified themes/categories relating to: Research in health professionals\u27 roles and nursing and midwifery, and Research activity and culture (context); with implementation approaches within coherence, cognitive participation, collective action and reflexive monitoring (Normalization Process Theory). Conclusions: The Pathway was perceived to meet organizational objectives with the potential to create significant cultural change in nursing and midwifery. Backfilling of protected research time was essential. Implications for the Profession and/or Patient Care: The Pathway was seen as an instrument to empower staff, foster staff retention and extend research opportunities to every nurse and midwife, while improving patient experiences and outcomes. Impact: Clinicians, consumers and managers fully supported the implementation of clinician researchers with this Pathway. The Pathway could engage all clinicians in evidence-based practice with a clinician researcher leader, effect practice change with colleagues and enhance patient outcomes. Reporting Method: This study adheres to relevant EQUATOR guidelines using the COREG checklist. Patient or Public Contribution: Health consumers involved in this research as participants, did not contribute to the design or conduct of the study, analysis or interpretation of the data, or in the preparation of the manuscript

The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation

Abstract Background Nurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients’ bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost–benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries. Methods A stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses’ education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and ‘Code Blue’ calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses’ perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses’ and medical officers’ perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost–benefit analysis and post-trial process evaluation will also be undertaken. Discussion If effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally. Trial registration Australian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022

Different factors limit early‐ and late‐season windows of opportunity for monarch development

Abstract Seasonal windows of opportunity are intervals within a year that provide improved prospects for growth, survival, or reproduction. However, few studies have sufficient temporal resolution to examine how multiple factors combine to constrain the seasonal timing and extent of developmental opportunities. Here, we document seasonal changes in milkweed (Asclepias fascicularis)–monarch (Danaus plexippus) interactions with high resolution throughout the last three breeding seasons prior to a precipitous single‐year decline in the western monarch population. Our results show early‐ and late‐season windows of opportunity for monarch recruitment that were constrained by different combinations of factors. Early‐season windows of opportunity were characterized by high egg densities and low survival on a select subset of host plants, consistent with the hypothesis that early‐spring migrant female monarchs select earlier‐emerging plants to balance a seasonal trade‐off between increasing host plant quantity and decreasing host plant quality. Late‐season windows of opportunity were coincident with the initiation of host plant senescence, and caterpillar success was negatively correlated with heatwave exposure, consistent with the hypothesis that late‐season windows were constrained by plant defense traits and thermal stress. Throughout this study, climatic and microclimatic variations played a foundational role in the timing and success of monarch developmental windows by affecting bottom‐up, top‐down, and abiotic limitations. More exposed microclimates were associated with higher developmental success during cooler conditions, and more shaded microclimates were associated with higher developmental success during warmer conditions, suggesting that habitat heterogeneity could buffer the effects of climatic variation. Together, these findings show an important dimension of seasonal change in milkweed–monarch interactions and illustrate how different biotic and abiotic factors can limit the developmental success of monarchs across the breeding season. These results also suggest the potential for seasonal sequences of favorable or unfavorable conditions across the breeding range to strongly affect monarch population dynamics