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Exploring the concept of patient agitation in the intensive care unit.
Patient agitation in the intensive care unit is of widespread concern and linked to negative outcomes for patients, staff, and family members. There is currently no consensus on what constitutes agitation in the intensive care context, hindering effective and tailored prevention and management.
Concept Analysis.
Walker and Avant's eight-step concept analysis approach.
A comprehensive search was carried out in the databases MEDLINE, PsychINFO and CINAHL. A total of 32 papers published between 1992 and 2023 were included, reviewed, and analysed to explore definitions, attributes, antecedents and consequences of patient agitation.
Patient agitation in the intensive care unit is characterised by excessive motor activity, emotional tension, cognitive impairment, and disruption of care, often accompanied by aggression and changes in vital signs. Antecedents encompass critical illness, pharmacological agents and other drugs, physical and emotional discomfort, patient-specific characteristics and uncaring staff behaviours. Consequences of agitation range from treatment interruptions and poor patient outcomes to the psychological impact on patients, families, and staff.
Agitation in the intensive care unit is a complex issue which significantly impacts patient treatment and clinical outcomes. For healthcare professionals, patient agitation can contribute to high workloads and job dissatisfaction. Due to the complex nature of agitation, clinicians must consider multifaceted strategies and not rely on medication alone. Further research is needed to fully understand patient agitation in the ICU. Such understanding will support the development of improved strategies for preventing and managing the behaviours.
A clearer understanding of patient agitation supports the development of tailored interventions that improve patient care, guide ICU training, and inform future research.
This concept analysis was developed with input from a patient representative.
To explore the lived experience of young people aged 16–24 years diagnosed with melanoma and that of their significant other in England.
Interpretive phenomenological analysis.
Data were collected between August 2023 and January 2024 from one specialist cancer centre in England. Thirteen young people were approached, and 10 took part. Each young person was asked to nominate a significant other. Five nominated a significant other, and five nominated no one. Although interviews were offered face-to-face, virtual was the preferred method. In-depth semi-structured interviews were audio-recorded with the participant's consent. Interview data were transcribed verbatim and analysed.
The core conceptual thread woven throughout the findings was ‘It's like being on a rollercoaster,’ which is representative of the ups and downs of the treatment trajectory, often without the support of age-appropriate specialist care. Four superordinate themes were identified: ‘Is something wrong?’, ‘Suddenly it's serious’, ‘Out on a limb’ and ‘Finding our place’.
Although most young people were treated in a primary treatment centre for adults with cancer, their experience was challenging from route to diagnosis through their treatment and beyond. Few received age-appropriate care to support their physical, emotional, and social wellbeing to help them navigate the experience.
There is limited evidence exploring the experiences of teenagers and young adults living with melanoma or that of their significant other. This enriched understanding supports improvement of the care pathway and service delivery for these young people and their families.
One young person with lived experience was paid as a consultant to be part of the research team. He helped develop the grant application and research questions, data analysis, and writing this paper.
Explore state school nurse consultants' pivotal position during the COVID-19 pandemic to shape school policy and support frontline school nurses.
An inductive qualitative study.
Members of the National Association of State School Nurse Consultants in the United States participated in focus groups and a written survey from January to April 2023. Standard content analysis was used to identify patterns and themes. COREQ guidelines were followed.
Data from 14 participants revealed 5 themes and 29 subthemes: State School Nurse Consultants walk in two worlds, bridging health and education. They built collaboration and trust and functioned as interpreters and gatekeepers. State consultants were resources, advocates and supports for school nurses. They witnessed and experienced trauma. State consultants defined lessons learned and described how their national organisation supported them. Few sources describe state consultants' role from 2000 to 2022; therefore, this study fills a gap.
State consultants advocated for school nurses, students and school staff, whose needs were not well understood by public health or education leaders.
School nurses' workload increases exponentially in the absence of state consultants who provide resources to deliver effective and efficient school health services.
Policy leaders should recognise state school nurse consultants' intersectionality which strengthens the public health infrastructure, critical to meeting current and emerging public health challenges.
System-wide leadership at regional, state and national levels provides consistency in policy and programmes, reduces duplication of effort and potential error and ensures school nurses benefit from shared resources, problem-solving and support.
National Association of State School Nurse Consultants leaders instigated the study and approved the design and open-ended questions. Preliminary findings were shared with members at a national online meeting and feedback affirmed that the results resonated with their experiences.
To explain how government policies affected decision-making on Nurse Practitioner and Physician Assistant employment and training within Dutch healthcare organisations, and how organisational and sectoral circumstances were influential.
An online, cross-sectional survey study.
A literature- and interview-based program theory was tested using surveys. Respondents from hospital care, (nursing) home care, primary care, and intellectual disability services were recruited using convenience sampling. Data analysis used descriptive statistics and inferential tests. Open-ended responses were analysed using thematic synthesis techniques. Survey results were clustered to assess verification, falsification, or refinement of program theory elements.
A total of 568 experts in hiring and training healthcare professionals participated. Respondents indicated that most government policies promoted employment and training. Organisational and sectoral circumstances caused significant variations in Nurse Practitioner and Physician Assistant deployment across healthcare sectors, shaping how decision-makers interpreted and acted on government policies. Specific circumstances within primary care hampered deployment.
Government policies stimulated training and employment by: (1) removing practice restrictions (scope of practice expansion, legal acknowledgment), (2) facilitating cost-effective training and deployment (training grants, billing options), (3) providing sectoral knowledge on deployment, training, and healthcare outcomes (funding research and a sectoral knowledge center), and (4) establishing sectoral agreements (on apprenticeships). Organisational and sectoral circumstances significantly influenced outcomes. Key circumstances included flanking policies, stakeholder support, labor market capacity, healthcare demand, organisational resources and aims, and type of decision-makers (medical doctor or manager/director). Familiarity with the professions stimulated deployment.
The refined and verified program theory supports designing effective skill-mix policies and facilitating Nurse Practitioner and Physician Assistant employment and training. Tailoring skill-mix policies can optimise outcomes. This offers opportunities for governments, healthcare funders, organisations, and professionals to contribute to healthcare quality, cost efficiency, and patient satisfaction.
Healthcare professionals were part of the study population.
Commentary on:Michelson KA, Rees CA, Florin TA, et al. Emergency department volume and delayed diagnosis of serious pediatric conditions. JAMA Pediatr. 2024;178:362–8. doi:10.1001/jamapediatrics.2023.6672
Implications for practice and research Low-paediatric-volume emergency departments (EDs) can increase paediatric readiness by improving diagnostic tools, expanding paediatric expertise (eg teleconsultation) and using electronic clinical decision support. Further research is needed to examine the costs and effectiveness of specific interventions to improve readiness in low-volume paediatric EDs.
Children sometimes have subtle illness presentations and symptom overlap with non-serious conditions.
Commentary on: Halstead S, Cao C, Høgnason Mohr G, et al. Prevalence of multimorbidity in people with and without severe mental illness: a systematic review and meta-analysis. Lancet Psychiatry. 2024;11(6):431–42.
Implications for practice and research Multimorbidity is highly prevalent in adults with severe mental illness and should be a key consideration when assessing these patients. Future research should explore key moderating factors for the prevalence of physical multimorbidity in adults with severe mental illness.
The term severe mental illness (SMI) refers to individuals with psychological conditions so profound that they significantly hinder their capacity to perform functional and occupational activities, with schizophrenia and bipolar disorder often being classified as SMIs.
Commentary on: Danne et al. Association Between Treatment Adherence and Continuous Glucose Monitoring Outcomes in People With Diabetes Using Smart Insulin Pens in a Real-World Setting. Diabetes Care. 2024.47 (6),:995-1003
Implications for practice and research Healthcare providers should emphasise consistent insulin adherence for people with diabetes, as even a few missed doses can worsen overall glycaemia. Future research should identify barriers to consistent usage of insulin and develop strategies to enable patients’ adherence, such as increasing patient engagement with smart insulin pens and continuous glucose monitoring systems.
Diabetes is a widespread chronic disease, with steadily rising prevalence in most countries. In 2019, the global prevalence of diabetes was estimated at 9.3%, affecting 463 million people. This figure is projected to rise to 10.2% by 2030 and 10.9% by 2045.
Health research aims to improve people’s health by understanding the best ways to diagnose and treat conditions, and understand people’s responses to health problems and health promotion initiatives. Quantitative research, and more specifically randomised controlled trials (RCTs), aims to establish if an intervention works, for example testing the effectiveness of a new drug, using statistical analysis. In contrast, qualitative research focuses on understanding a situation, for example people’s experiences, perspectives and behaviours. Qualitative research can enhance RCTs by ensuring a more complete understanding of the factors that influence the acceptability of a new intervention and how it might be implemented in practice. A previous article in this series outlined how process evaluation embedded within RCTs can help understand how and why an intervention works.
Commentary on: Chauhan A, Newman B, Manias E, et al. Creating safer cancer care with ethnic minority patients: A qualitative analysis of the experiences of cancer service staff. Health Expect. 2024 Jan 30;27(1):e13979.
Implementing culturally competent communication strategies, including interpreters and culturally adapted materials, can enhance patient safety and engagement. Further studies are needed to evaluate the effectiveness of communication tools and strategies in improving safety outcomes for ethnic minority patients with cancer.
This qualitative study explores the experiences of healthcare staff in creating safer cancer care environments for ethnic minority patients. People from ethnic minority groups, who face an increased risk of safety events, often encounter barriers such as language and cultural differences.
Interpretative phenomenological analysis (IPA) is a widely recognised and well-established method of qualitative inquiry designed to explore personal experience in detail, focusing on participants’ understandings and sense-making.
IPA was developed in the mid-1990s by Jonathan Smith and emerged out of health psychology, and since the early 2000s has increasingly been adopted by nursing and health researchers more generally. At the time of writing, a Google Scholar search of the terms ‘interpretative phenomenological analysis’ and ‘nursing’ yielded more than 35 000 results. IPA is primarily interested in undertaking...
Commentary on: Vanzella LM, Cotie LM, Flores-Hukom M, Marzolini S, Konidis R, Ghisi GLM. Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study. J Cardiovasc Nurs. Published online January 5, 2024.
Implications for practice and research The use of theoretical models integrating well-recognised techniques (eg, goal setting, action planning, telemonitoring, individual assessment/tailoring) to guide virtual cardiac rehabilitation (CR) is essential. Apart from teleconferencing, using advanced wearable devices, analytics and artificial intelligence techniques may improve personalised exercise and educational content capacity of future virtual CR studies.
Cardiac rehabilitation (CR) is a recommended treatment for patients with cardiovascular disease (CVDs), given the rising number of cardiac incidents due to ageing population and modern lifestyles.
Commentary on: Women’s caesarean section preferences: a multicounty cross-sectional survey in low- and middle-income countries by Etcheverry et al. 2024;132.
Implications for practice and research Pregnant women in low- and middle-income countries should be counselled about the benefits and risks of both caesarean sections and vaginal deliveries to facilitate informed choices, the most suitable opportunity being antenatal clinic visits. Further studies are needed to explore decision aids in order to help women and doctors make informed shared decisions regarding the mode of delivery.
Caesarean section (CS) rates are rising globally from 7% in 1990 to 21% in 2018.
Commentary on: Timmins KA, Hales TG, Macfarlane GJ, et al. Childhood maltreatment and chronic ‘all over’ body pain in adulthood: a counterfactual analysis using UK Biobank. Pain. Published Online First: 15 November 2024. doi: 10.1097/j.pain.0000000000003457
Implications for practice and research Healthcare providers should routinely screen for childhood maltreatment in patients with chronic pain and integrate targeted mental health interventions. Future research should prioritise longitudinal studies to establish clearer interactions between childhood maltreatment, mental health, adult stressors and chronic pain development.
Adverse childhood experiences (ACEs), including maltreatment (abuse, neglect) and household challenges, have been identified as risk factors for various health conditions in adulthood.
Commentary on: Van Hecke A, et al. Development of a competency framework for advanced practice nurses: a co-design process. J Adv Nurs 2024; 1-13. doi.org/10.1111/jan.16174
Implications for practice and research A CanMEDS-derived APN (Advanced Practice Nurse) competency framework informs APNs’ personal and professional development and guides APNs’ practices within educational and healthcare settings in Belgium. Further research is required to validate this competency framework and determine its usability in education and practice.
Advanced practice nursing (APN) refers to an expanded scope of practice beyond the generalist level to provide direct healthcare services, including prevention, diagnosis, therapeutics and illness management.
Commentary on: Kosola S, Mproa S, Holoapaine E. Smartphone use and well-being of adolescent girls: a population-based study. Arch Dis Child, 2024; 109: 576–581
Implications for practice and research Smartphone addiction may contribute to the increase in anxiety disorders in adolescent girls; peer engagement activities and tech-free zones may help reduce smartphone use. Providing support and advice relating to smartphone use for young people is everyone’s responsibility; solely relying on mental health services to address smartphone addiction is not realistic.
The prevalence of anxiety disorders, particularly in adolescent girls, is increasing; smartphone addiction is a potential causal factor. Kosola et al
This population-based study recruited over a thousand adolescent girls from 21 socially diverse schools who completed online...
Commentary on: Takashima, M et al. Pediatric Central Venous Access Device Lock Solutions: A Network Meta-analysis.
Chelating and antibiotic locks should be considered for prevention of central venous access device (CVAD)-associated bloodstream infection (BSI) in paediatric patients. Further research with larger sample sizes is necessary to gain a more accurate insight into the potential impact of lock solutions on the treatment of CVAD-associated BSI.
Central venous access devices (CVADs) are required by children to allow the safe delivery of intravenous therapies that must be delivered in the large central veins of the body. CVADs are associated with many complications such as infections, thrombosis and occlusions.
To pilot and evaluate the implementation of a structured Evidence-Based Rounds (EBR) education model in critical care.
A mixed data type design was used to evaluate Evidence-Based Rounds in a critical care setting. Structured observational data were captured and open-ended survey responses were submitted by attendees. Content analysis and descriptive statistics were used to analyse survey findings.
Seventeen rounds were completed between March 2023 and January 2024 with a total of n = 83 clinical staff members. From these, n = 55 staff completed and submitted evaluation surveys. Rounds were most frequently attended by nurses of all bandings including senior clinical nurses, support workers and student nurses. Evidence-Based Rounds were globally perceived as a positive and useful education strategy and staff were very willing to attend future sessions. Patient outcomes were not directly assessed and rounds specifically facilitated three outcomes: (1) helping staff apply evidence to practice, (2) building staff confidence in presenting clinical information and (3) supporting staff in identifying local improvements to patient care.
Evidence-Based Rounds are an adaptable effective model of bedside education within critical care. In our setting, staff perceived that this model facilitated the application of evidence in clinical practice and positively influenced feelings of confidence. Importantly, this education strategy empowered nurses to explore and identify improvements locally to patient care. Whilst this model offers a practical education approach to address some of the key critical care workforce issues, such as an expanding curriculum and loss of senior staff, it could also be widely adopted to other clinical areas.
Evidence-Based Rounds are perceived by staff as a successful bedside education model that facilitates nurses to apply evidence in practice. It is feasible that this strategy is a potentially sustainable, low-cost model for continuing professional development centred around routine clinical work.
No patient or public contribution.
To explore the associations of (1) shift-to-shift Nurse Perceived Adequacy of Staffing Scale (NPASS) scores and (2) the relative contribution of individual NPASS items to nurse-perceived quality of care (NPQoC) and job enjoyment.
Multihospital prospective observational study.
The study was conducted across 15 medical, surgical or acute admission hospital wards in three teaching hospitals in the Netherlands. Vocationally and bachelor-trained nurses conducted 1550 measurements of perceived adequacy of staffing using the NPASS, NPQoC and job enjoyment in 797 shifts. Multilevel models were used to assess associations between NPASS scores and NPASS items and the outcome variables.
Higher NPASS scores were significantly associated with improved NPQoC and job enjoyment. An increase in 1.0 point NPASS score leads to an increase of 0.97 points in NPQoC and 1.04 points in job enjoyment. Of the NPASS items, energy level, adherence to protocols and the opportunity for adequate breaks had the most positive effect on both outcomes.
Perceived adequacy of staffing as measured by the NPASS is highly relevant for improvements in both NPQoC and job enjoyment.
Decision-makers on nurse staffing should incorporate the NPASS in staffing methods to ensure adequate staffing and the associated benefits. Policies that ensure adequate breaks, adherence to protocols and maintenance of nurses' energy levels during the shift should be implemented with special attention.
This study provides supportive evidence for incorporating nurses' perceived adequacy of staffing, as measured by the NPASS, to ensure adequate staffing. This is crucial for nurse retention, and therefore vital to maintaining accessible healthcare given the global nursing shortages.
The STROBE checklist was used to conduct and describe the study.
This study did not include patient or public involvement in its design, conduct or reporting.
To explore the optimal timing of patient-reported outcome assessment, defined as the collection and use of patient-reported outcomes at clinically meaningful points such as before or during encounters, treatment initiation and follow-up, and to identify the facilitators and barriers to timely use.
A qualitative analysis of semi-structured interviews with healthcare professionals across diverse US health systems.
Thematic analysis was used to identify key themes related to the timing and implementation of patient-reported outcomes assessments. Interviews were analysed iteratively to develop a coding framework and synthesise overarching themes.
Fourteen healthcare professionals, including nurse practitioners, cardiologists and health informatics experts across seven U.S. health systems from academic and community hospitals, were interviewed in February 2024. Three major themes emerged: (1) value proposition of timely patient-reported outcome data collection (2) key facilitators for timely implementation and (3) multilevel barriers. The value proposition focused on the use of patient-reported outcomes for prevention and active disease management. Critical facilitators for the timely implementation of patient-reported outcomes included the involvement of research and clinical coordinators, strategies for pre-visit and on-site patient-reported outcome collection, the use of standardised templates within EHRs and the alignment of patient-reported outcome collection with patients' long-term treatment goals. Finally, multilevel barriers included time constraints, patient-level challenges (e.g., fatigue, literacy, language) and systemic issues (e.g., technical limitations, lack of reimbursement and unclear guidelines).
Timely collection and use of patient-reported outcomes is critical for improving symptom monitoring and supporting patient-centered clinical decision-making. However, multilevel barriers hinder consistent implementation across health care settings.
Integrating patient-reported outcomes into clinical workflows can improve the patient-centeredness of patient-healthcare professional interactions, and provide a more holistic picture of a patient's health status. Addressing barriers to patient-reported outcome implementation, including lack of time, poor health literacy and workflow integration barriers, is crucial for improving clinical outcomes.
This study adhered to the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist, in accordance with EQUATOR Network guidelines.
No patient or public involvement: This study did not include patient or public involvement in its design, conduct or reporting.
Limited literature has focused on people with cancers' preference for care providers in scenarios where trade-offs may have to be made.
To report the results of a comprehensive search and synthesis of discrete choice experiments or best-worst scaling studies (± willingness to pay estimates) in scenarios involving cancer nurses, with a focus on: (1) preferred care provider; and (2) relative importance of attributes of care provision for people with cancer.
A search was conducted across: CINAHL, Cochrane Central Register of Controlled Trials, EconLit, Medline, PsycINFO, Scopus, Web of Science Core Collection, and Google Scholar for discrete choice experiments published between January and July 2025. Data were extracted and appraised by two authors. Results were narratively synthesised.
Of 461 studies screened, 11 were included, published in Australia (n = 3), UK (n = 3), and China (n = 5) including people with breast (n = 4), gastric (n = 4), prostate (n = 1), or mixed cancers (n = 2). In six studies exploring scenarios of follow-up care (i.e., survivorship/surveillance), cancer medical specialists were the preferred care provider, followed by cancer nurses, and then general practitioners. In four of the five studies of supportive care scenarios (i.e., diet and exercise advice, anxiety and depression screening), cancer nurses were the preferred care provider, followed by allied health professionals, then cancer medical specialists. The highest WTP estimate was $US226.15 for a medical specialist to provide follow-up care. For supportive care, the highest WTP was $US137.52 for a cancer nurse to provide diet-based lifestyle advice post-treatment for breast cancer.
Cancer nurses are highly valued by people with cancer, particularly for supportive care provision. Opportunities exist for an increase in cancer nurse specialists with expanded scope of practice, to support the preference of people with cancer to have cancer medical specialists, or cancer nurse specialists provide expert cancer follow-up care.
Employees of a cancer patient advocacy group were involved in the design of the study, interpretation of the data, and the preparation of the manuscript. No patients were involved in this work. However, this systematic review prioritized patient voices by including studies that reported on the preferences of people with cancer.
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