Direct Care Research Articles

Responding to the ongoing pandemic-related challenges of individuals with brain injury through the perspective of community-service in Canada: A qualitative study.

To investigate brain injury (BI) associations' perspectives regarding the impacts of the second year of the COVID-19 pandemic on individuals with BI and BI associations services across Canada. This qualitative descriptive study included 26 representatives of Canadian BI associations that participated in six online focus groups to discuss the effects of the second year of the pandemic on clients living with BI and on the provision of community services. Findings revealed three main themes: 1) ongoing pandemic-related challenges faced by clients living with BI, including worsening mental health and basic needs insecurities, difficulties faced by clients in adhering to safety measures, and ongoing technological issues; 2) ongoing adaptations to accommodate clients' needs, including offering tailored services, ensuring consistent and transparent safety measures, and providing hybrid services; and 3) developing a sustainable 'new normal' aligned with association mandates and resources by expanding networks and building resilience. The unfolding of the pandemic has brought increased challenges for people with BI and reinforced the need for adapted, clear, and accessible public health information to ensure the safety of vulnerable populations in times of crisis. It is essential to bolster community-based associations that provide direct care to people with BI.

AHP SO07 - Dietetic Outpatient Service to Patients undergoing Oesophagogastric (OG) Surgery for Cancer

Abstract Background Nutrition is a modifiable risk factor impacting surgical outcomes in OG cancer. Its key role influencing health related quality of life is emerging with improved survivorship. Guidelines depicting optimal timing and type of dietetic intervention for this patient group are unclear. In order to best direct dietetic care, optimise timing of nutritional interventions and understand demand for service it is important to reflect on current provision. This audit aimed to describe the dietetic outpatient service to patients undergoing OG Surgery for cancer in a national centre for treatment of oesophageal cancer. Method A retrospective review of dietetic records and statistics. Patients who underwent oesophagectomy (O), gastrectomy (G) or subtotal gastrectomy (STG) for cancer between May 2022- May 2023 were included. Results 63 patients were included: 38 O, 17 TG, 8 STG. 11 were seen by the dietitian at first visit to OG Clinic (9 O, 1 TG, 1 STG) – 6 had an elective feeding tube (FT) inserted for neoadjuvant treatment (5 O, 1 STG). 83% attended a surgical pre-assessment dietetic appointment (36 O, 14 TG, 2 STG). 86% were reviewed within 1 month post O or TG, 75% post STG. 258 dietetic interventions occurred in the first year post-op (median 3.5, range 0-14). 64% in the first 3 months(m) post op, 16% at 3-6m, 10% at 6-9m, 10% at 9-12m. Conclusion In this high nutritional risk group only 18% are assessed by a dietitian at first visit to UGI MDT clinic. There is a successful pathway for immediate peri-operative dietetic care in patients post O and TG. The pathway for STG is less well established. Dietetic interventions are concentrated in the first 3 months after surgery. There is no established protocol to support longer term nutritional needs into survivorship. To inform practice a measure of patient experience and needs would be useful, to explore best delivery format and access routes to future services.

Hierarchies of Actualization.

The concept of transforming power over to power with, the theme of this issue of Creative Nursing, comes from Riane Eisler's cultural transformation theory describing a continuum of domination and partnership along which cultures orient themselves. Hierarchies are important organizing principles in many systems; it is not their presence that is inhumane, but how they function. Domination systems display authoritarian rule in both the family and the state or tribe, with strict hierarchies of domination, and narratives that normalize domination and present the violence that maintains it as inevitable. Partnership systems are characterized by egalitarian structures in both the family and state or tribe, with hierarchies of actualization in which power is used to empower others rather than disempower, low levels of sanctioned violence (since it is not needed to maintain power), and narratives depicting mutual respect, accountability, and benefit as natural. All the articles in this issue of Creative Nursing depict empowerment: of patients, parents and other family members, foster parents, children from preschool age to near adulthood, providers of direct patient care at many levels in many areas, nurses seeking to publish their knowledge, and all people who seek to use language that demonstrates respect and value for all people while acknowledging the diverse cultures in which we abide.

Associations Between Hearing Loss and Health-Related Costs: A Retrospective Population-Based Cohort Study

Purpose: Hearing loss (HL) is a leading cause of disability worldwide, but its health-related costs have been incompletely studied. Our objective was to examine the association between HL and direct health care costs and identify subgroups in which costs associated with HL are especially high. Method: This was a retrospective population-based cohort study of adults treated in a universal health care system between April 2008 and March 2019. HL was identified using administrative health data. We estimate health care costs in 2023 Canadian dollars, including costs for hospitalization, provider claims, ambulatory care visits, prescription medications, and long-term care (LTC). Results: Of 4,424,632 participants, 146,644 (3.3%) had HL. Participants with HL were older ( Mdn = 55 years [interquartile range: 43–68] vs. 35 years [24–50]) and had more comorbidities (1 [0–2] vs. 0 [0–1]) at baseline than participants without, whereas the likelihood of female sex, rural residence, and material deprivation were similar between groups with and without HL. Over median follow-up of 11.0 years, total age–sex adjusted annual health costs and each of its component costs were significantly higher in participants with HL compared to those without (annual total costs: $6,871, 95% confidence interval [CI] [$6,778, $6,962] vs. $4,716, 95% CI [$4,729, $4,763]). After full adjustment (a maximum of 29 comorbidities), annual costs remained significantly higher in participants with HL overall and for certain subcomponents (provider claims, ambulatory visits, and medications), whereas adjusted costs of hospitalization and LTC were lower among people with HL. The magnitude of the incremental costs among participants with HL was most pronounced for younger participants, men, or those with less comorbidity. Total projected annual direct health costs for Alberta residents with HL were $1.01 billion in 2023, of which $125 million (95% CI [$116, $135 million]) was attributable to HL specifically. Conclusions: Compared to those without HL, health costs were markedly higher among participants with HL, partially due to a higher burden of comorbidity. The relatively high population attributable costs of HL suggest that better prevention, recognition, and management of this condition could yield substantial economic benefits. Supplemental Material: https://doi.org/10.23641/asha.27353439

Clinical care ratios for, and tasks undertaken by, allied health professionals: A scoping review of the literature.

With the increasing demand on the global health system and the presence of persistent healthcare disparities, it becomes imperative to utilize the full potential of the healthcare workforce, including allied health professionals (AHPs). To date, no review has mapped the literature on clinical care ratios (CCRs) for AHPs. This information is vital in guiding future work-force planning to address healthcare issues such as understaffed and at capacity hospitals. This scoping review mapped available evidence to offer a comprehensive insight into current AHP CCRs, enabling evidence-based decision-making that ensures optimal care and enhanced system efficiency. The scoping review was undertaken using the 'Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews' (PRISMA-ScR). The search was conducted using Ovid (MEDLINE, Embase, Emcare, PsycINFO), CINAHL, the Cochrane Library, Scopus, PEDro, OTseeker and grey literature. Two reviewers independently screened records, following which data extraction was completed for the included studies. Descriptive synthesis was used to summarize the data. Of the 7670 records identified, 18 studies were included in this review. Whilst there was variability between AHPs on direct clinical time spent with patients, considerable amount of time was also spent on activities beyond direct clinical care. To offset this, literature highlights opportunities for allied health assistants and students to undertake tasks which would free-up AHPs to undertake more direct and higher-level tasks. However, limitations of findings (variability in measurement, lack of coverage of some professions) limits generalisability. While the literature highlights considerable variability in CCRs among different AHP disciplines, it does appear nearly a nearly a third of time spent by AHPs are on tasks that are beyond direct clinical care. Future research could explore new workforce models which would free-up AHPs to undertake more direct and higher-level tasks.

Advanced practice nursing in surgery: A scoping review of roles, responsibilities, and educational programs.

The increasing complexity of the healthcare sector requires an evolution in nursing education to effectively manage care in complex and interdisciplinary contexts. This review aims to analyze the role of advanced practice nurse (APN) in the surgical context within hospital settings, detailing their functions and responsibilities. It also provides an overview of the main degrees and postgraduate training programs for specialization in perioperative management in major Western countries. This scoping review followed the Arksey-O'Malley framework and Joanna Briggs Institute methodology. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to ensure rigorous and transparent reporting. Among the 3663 records analyzed, 20 were included in this review. The role of the APN spans across the preoperative, intraoperative, and postoperative phases, encompassing follow-up care as leaders, mentors, and contributors to research. APNs play a pivotal role by offering direct and indirect patient care at each stage of the surgical journey. Acting as liaisons between the healthcare team and patients, APNs enhance healthcare delivery through personalized, coordinated care, while also fostering ongoing education and research in the field. APNs enhance surgical care by providing in-depth clinical assessments, education, and support throughout the treatment process. However, the lack of standardized regulatory frameworks in some countries limits the autonomy of APNs within the healthcare system, compromising their ability to address unmet health needs and engage in international collaboration. The findings underscore the need for standardized educational pathways, roles, responsibilities, and autonomy for APNs, facilitating better international collaboration and contributing to scientific research.

Pathologists Providing Direct Patient Care in Thoracic Transplant: Same Objective, Different Scope.

Cardiac and pulmonary allograft recipients represent a unique population, frequently interacting with support groups and exhibiting intense curiosity about their pathology. Like other solid organ transplant patients, they have enduring and frequent interaction with the laboratory for routine allograft surveillance. To address patient requests to understand what happens to their explanted organ and to better understand their disease while simultaneously improving awareness of pathologists' role in their continuing care. At routine follow-up appointments, transplant nurse coordinators offer each allograft recipient the opportunity to interact with a pathologist in our "On My Path" program. Organ viewing occurs in a private setting, in a specialized room. Relevant pathology is discussed, and questions are answered, with documentation in the medical record. The patient is subsequently gifted a 3-dimensional model of their explanted organ. Transplant coordinators were surveyed for their feedback on the experience. One hundred fifty-eight interactions have been documented (2017-2022), including patients who underwent cardiac transplant (96, 61%), single or bilateral lung transplant (54, 34%), or combination lung and heart transplant (8, 5%). Transplant coordinators reported an increase in patient understanding of their disease and emotional closure related to the disease through the On My Path program. Pathologists providing direct patient care is a feasible model that addresses currently unmet desires of the transplant population to better understand their pathology. Providing a 3-dimensional model helps to empower patients and drives satisfaction. These interactions also improve awareness about pathology as a discipline and its importance in the continued care of transplant recipients.

Paediatric palliative care in Aotearoa New Zealand-current state and future direction.

This paper seeks to explore the current state of paediatric palliative care in Aotearoa New Zealand. The low priority afforded to paediatric palliative care for more than two decades has had a significant impact on service provision, education and research within this specialty. As a result, provision of specialist paediatric palliative care to children with serious illness and their whānau (family, including extended family) is inequitable and vastly inadequate. This paper considers the consequences of having limited access to specialist palliative care for children and whānau, and outlines what is required for both service development and current priorities for research.

Development and Validation of the Midwifery Interventions Classification for a Salutogenic Approach to Maternity Care: A Delphi Study

Background/Objectives: This study aims to develop and validate a Midwifery Interventions Classification (MIC), which is an evidence-based, standardized taxonomy and classification of core midwifery interventions based on a salutogenic perspective for maternity care. Methods: This study described the consensus process up to the results regarding the validation of the MIC through a two-round Delphi survey involving three panels of stakeholders: Midwives, Healthcare Researchers, and Maternity Service Users. Results: The resulting MIC comprises 135 core midwifery interventions classified into Direct Midwifery care (n = 101 interventions), Indirect Midwifery Care (n = 52 interventions), and Community Midwifery Care (n = 13 interventions), reaching an overall consensus rate among experts equal to 87%. These interventions were, therefore, adapted specifically for the Italian midwifery care context, with potential for international transferability, implementation, and scalability. Conclusions: The MIC is pivotal to boosting quality improvement, education, and comparable data collection for research, sustaining midwives’ role in promoting optimal health for women, newborns, and families at large.

Empowering Dementia Communication via Virtual Reality AI-Driven Simulations

The use of effective communication skills is essential for direct care workers to provide quality care for persons living with dementia (PLWD) in long-term service and support settings (LTSS). However, direct care workers often report feeling unprepared, lacking competence in care, and fear interacting with PLWD. This proof-of-concept study proposes Virtual reality Communication Training Optimizing Real-world Interactions (VICTORI) intervention, aiming to develop and evaluate the usability, acceptability, and preliminary effectiveness of virtual reality (VR) simulated communication training for direct care workers using artificial intelligence (AI)-generated patients with dementia. Care-related and social communication scenarios in dementia care will be developed, based on current literature, our validated communication instrument, and AI technology. Six modules consisting of pre-briefing, simulation facilitation, and de-briefing will be developed, refined, and evaluated based on an advisory board of experts and direct care workers’ quantitative and qualitative feedback. To test the usability, acceptability, and effectiveness of the VICTORI intervention, we will use a single group pre- and post-test intervention design, integrating quantitative measures and qualitative semi-structured interviews in this mixed-methods study. Thirty direct care workers will be recruited at two LTSS in North Texas. Direct care workers will participate in six VR-AI simulation commu-nication training sessions that include communication with AI-generated patients, real-time feedback, and detailed evaluation of communication behaviors. Each simulation will be recorded to further evaluate the partici-pant’s communication skills using the Dyadic Communi-cation Observational coding scheme in Dementia care (DCODE). Additionally, participants' potential side effects during VR simulation will be assessed using continuous physiological data and self-reported questionnaires at each simulation session. Communication knowledge and com-petence in dementia care will be assessed before and after training using self-reported questionnaires. Direct care workers will also be interviewed to assess acceptability and satisfaction with the VICTORI training. This proposal will introduce innovative training methods that leverage AI technology into communication training in dementia care. Objective assessments, including AI-based feedback, physiological data, and observational assessments, ensure the reliability and validity of the data to evaluate plausibility of VICTORI intervention.

Considerations for emergency department virtual triage.

Health leaders are increasingly interested in harnessing Artificial Intelligence (AI) to remotely conduct virtual triage for Emergency Department (ED) patients. This study explores equity considerations and patient attitudes to virtual triage in a Canadian ED. A cross-sectional study surveyed 150 ED patients, with 32 additional patients interviewed in-depth. Descriptive statistics and qualitative descriptive methodology were employed. 84.7% of patients would consider virtual triage. 71.3% were comfortable following advice to seek alternate care, including their General Practitioner or virtual ED. Approximately 38.2% of patients >60years would require assistance using virtual triage, with confidence in using technology to direct care decreasing with age. Thematic analysis revealed five key themes: value of decision support; care access expectations; technological literacy demographics; trust in AI; and confidentiality. In conclusion, virtual triage is a viable and promising tool if barriers to technological literacy are addressed, and tools are endorsed by health providers and patients.

The reality of nursing time: how nurses spend their shifts.

Nurse staffing levels are increasingly challenged while pressures on healthcare systems are rising. There is a clear need to optimise efficiency in healthcare delivery in order to deliver safe, effective and quality health care. To understand how nurses working shifts spend their time and explore opportunities to improve efficiency in care delivery. A time-motion study was conducted on three acute care wards in a district general hospital in West Wales; 13 nurses were observed over 14 shifts, each activity undertaken was recorded in real time. In all, 109 hours were observed. Approximately half of nurses' time is spent delivering direct patient care, with medications administration taking the majority of time. A number of recommendations are made involving processes and workforce modelling with the aim of improving efficiency and safety. Further research would be required to assess the impact of their introduction.

Effects of single- and double-shift work on hand and cognitive functions in nurses.

This study aims to examine the influence of single and double-shift work schedules on hand function and cognitive capacities, specifically working memory, attention, and response time in nurses. Shift work, particularly in extended formats, is known to affect various physical and cognitive functions critical to nursing duties. Understanding these impacts is vital for managing nurse schedules to minimize health risks and maximize performance. With an increase in demands on healthcare systems, nurses often endure prolonged working hours, which may impair their cognitive and manual abilities, thereby affecting patient care quality. This study involved 45 nurses aged 20-40 years from shift-oriented units providing direct patient care. Hand function was assessed using the Nine-Hole Peg Test (9-HPT). Cognitive functions such as working memory, attention, and response time were evaluated using the digit span task and the Stroop test, respectively. Two-way analysis of variance (ANOVA) was used for statistical analysis, assessing the interactions of time and shift type, with a significance level set at p<0.05. The results revealed significant changes in all tested variables between pre- and post-shift assessments and between single and double-shift conditions. Notably, the double-shift work significantly exacerbated declines in all measured functions. These findings suggest that double shifts may intensify the deterioration of essential nursing skills, potentially compromising patient care. This study underscores the detrimental effects of extended shift work on nurses' cognitive and manual functions. These insights should guide healthcare institutions in revising nurse scheduling practices to safeguard their well-being and maintain high standards of patient care.

Impact of a 2-week flipped classroom virtual neurology clerkship versus a traditional 4-week rotation on NBME shelf exam scores

ObjectiveThere is conflicting evidence whether decreased clerkship duration is associated with reduced NBME shelf examination performance. We hypothesized that scores would remain stable for students in a shortened 2-week flipped classroom-based virtual rotation as compared to the traditional 4-week Neurology clerkship.BackgroundThere is conflicting evidence whether decreased clerkship duration is associated with reduced NBME shelf examination performance. We hypothesized that Neurology shelf exam scores would remain stable for students in a shortened 2-week flipped classroom-based virtual rotation as compared to the traditional 4-week Neurology clerkship with direct patient care supplemented by didactics.MethodsThis is a retrospective observational cohort study. In April 2020, the neurology clerkship at Rutgers Robert Wood Johnson Medical School switched from a traditional 4-week in-person clinical rotation supplemented by didactics to a 2-week flipped classroom-based virtual-only curriculum decoupled from a supplementary 2-week in-person clinical rotation to be completed later. Students were offered the opportunity to test after the 2-week virtual curriculum. NBME shelf scores for these “exam before clinical rotation” (EBC) students over the final quarter of the academic year 2019–2020 were compared to those of the “exam after clinical” (EAC) students undergoing the 4-week traditional rotation from July 2018 to March 2020.Results321 students completed the shelf exam between July 2018 and June 2020, of which 284 students comprised the EAC cohort and 37 students, the EBC cohort. Mean scores did not differ between the EBC and EAC cohorts (81.8 ± 6.7 versus 81.8 ± 6.5, p = 0.96). Additional analyses showed no significant differences in the performance of EBC students as compared to the EAC students that tested within the same academic year 2019–2020 or within the matched quarter of the prior academic year 2018–2019, and students completing the virtual rotation who delayed testing after the clinical experience.ConclusionsTesting after a 2-week flipped classroom-based virtual curriculum in Neurology without additional clinical training did not negatively affect neurology NBME shelf scores. Decoupling clinical experiences from knowledge acquisition and the evaluation of that knowledge base by means of NBME shelf examination is not likely to disadvantage learners with respect to shelf examination performance.

Type 1 Diabetes in care homes: A practical guide on management.

The primary purpose of the original NAPCHD project was to develop a national Strategic Document of Diabetes Care for Care Homes which has now been completed and well received as a worthwhile, sustainable, and effective guidance for delivering quality diabetes care in the UK. A Working Group of NAPCHD was established to produce a Position Statement on type 1 diabetes in care homes since this area was recommended as a topic to further develop. There are currently limited data on the prevalence and clinical outcomes associated with type 1 diabetes in care homes and management policies have been non-existent in the UK. Communication among all key stakeholders involved in direct care of residents with type 1 diabetes is generally fragmented and lacks coordination. This is compounded by a slowly growing utilisation of diabetes technology and the absence of a standard/agreed community-based model of interdisciplinary collaboration. The Rationale and Objectives were defined prior to commencing the work and a work plan with individual tasks was initially set out. After multiple correspondences and Team calls over a period of 9 months, the Group successfully generated a first draft in October 2023. This draft was then finalised the following month and circulated among stakeholders for feedback. Nine chapters have been provided including minimum standards of diabetes care, insulin regimens, avoiding hospitalisation and discharge planning. A scheme for a community-based model of care for type 1 diabetes has been included. Eight key messages were developed. In addition, an Appendix has been created which includes key assessments such as nutritional assessment, detection of frailty, sick day rules and foot risk stratification (available online).

Organizational Rigidity and Demands: A Qualitative Study on Nursing Work in Complex Organizations

Background/Objectives: The nursing work environment is a critical element in healthcare delivery and a strong predictor of both patient and nurse outcomes. Understanding the complexity and multifaceted nature of this environment is essential for improving nursing practices and optimizing healthcare systems. This study aimed to gain insights into the perceived characteristics of the nursing work environment, considering it as a complex and multifaceted system. Methods: A qualitative research approach was employed, involving 42 semi-structured interviews with 43 nurses and managers from academic, teaching, and general hospitals in The Netherlands. Data were collected between July 2020 and August 2021 through convenience sampling. Thematic coding was conducted to identify key patterns and themes. Results: The findings revealed that nurses demonstrated flexibility and a strong commitment to high-quality care, despite grappling with rigorous organizational tasks and processes. Four key themes emerged: (1) direct patient care as a standard feature of nursing work; (2) nurses’ flexibility for hospital productivity; (3) interdependencies, which decrease autonomous nursing practices; and (4) organizational structures that determine how nurses can shape their work. Nurses found it difficult to balance direct care with broader tasks due to organizational rigidity, revealing a gap between ideal nursing practices and daily reality. Conclusions: This study highlighted the challenges within the nursing work environment, particularly in balancing direct care with organizational demands. Addressing this gap between ideal nursing practice and reality requires a systems approach. This includes autonomous practices, supportive management, and flexible structures, allowing nurses to shape their work and enhance job satisfaction and care quality.

“Every Day I was Crying about Something”: Lingering Effects of the COVID-19 Pandemic on People Working in Juvenile Prisons

Staff working in prison settings experience high rates of job-related stress which was amplified during the COVID-19 pandemic. Twenty staff members from a juvenile prison were interviewed to determine the unique mental health symptoms and stressors several years after initial shutdown procedures. Anxiety, PTSD symptoms, and sleep disturbances were reported; sometimes resulting in staff avoiding interactions with youth. Some positive aspects were noted, but overall, results indicated a continued need for mental health support and policy changes for staff. As noted by one participant, “If you don’t have the direct care staff, you don’t have a facility.”

Using normalisation process theory (NPT) to explore implementation of the maternal perinatal death surveillance and response (MPDSR) policy in Uganda: a reflection

BackgroundThe implementation of the maternal perinatal death surveillance and response (MPDSR) policy is among the envisaged strategies to reduce the high global burden of maternal and perinatal mortality and morbidity. However, implementation of this policy across various contexts is inconsistent. Theoretically informed approaches to process evaluation can support assessment the implementation of policy interventions such as MPDSR, particularly in understanding what the actors involved actually do. In this article, we reflect on how the normalisation process theory (NPT) was used to explore implementation of the MPDSR policy in Uganda. NPT is a sociological theory concerned with the social organisation of the work (implementation) of making practices routine elements of everyday life (embedding) and of sustaining embedded practices in their social contexts (integration).MethodsThis qualitative multiple case study conducted across eight districts in Uganda and among 10 health facilities (cases) representing four out of the seven levels of the Uganda health care system. NPT was utilised in several ways including informing the study design, structuring the data collection tools (semi-structured interview guides), providing an organising framework for analysis, interpreting and reporting of study findings as well as making recommendations. Study participants were purposely selected to reflect the range of actors involved in the policy implementation process. This included direct care providers located at each of the cases, the Ministry of Health and from agencies and professional associations. Data were collected using semi-structured, in-depth interviews and were inductively and deductively analysed using NPT constructs and subconstructs.Results and conclusionNPT served useful for process evaluation, particularly in identifying factors that contribute to variations in policy implementation. Considering the NPT focus on the agency of people involved in implementation, additional efforts are required to understand how recipients of the policy intervention influence how the intervention becomes embedded within the various contexts.

Positioning Ethics When Direct Patient Care is Prioritized: Experiences from Implementing Ethics Case Reflection Rounds in Childhood Cancer Care.

Caring for children with cancer involves complex ethical challenges. Ethics Case Reflection (ECR) rounds can be offered to support teams to reflect on challenges and what should be done in patient care. A training course, for facilitators of ECR rounds, has been offered to healthcare professionals (HCPs) in childhood cancer care by a Nordic working group on ethics. During/after the course, the trainees implemented and facilitated ECR rounds in their clinical setting. The aim was to explore the trainees' experiences of implementing ECR rounds in childhood cancer care. HCPs, who participated as trainees in the course, participated in 3 focus group interviews (n = 22) and 27 individual interviews (n = 17). Interview data were analysed concurrently with data collection following classic grounded theory. Positioning ethics is the core category in this study, used to resolve the main concern of doing ethics in a context where direct patient care is prioritized. Being able to take time for ethics reflections, not perceived as the key priority, was considered a luxury in the clinical setting. Strategies for positioning ethics include allying, promoting ethics reflection, scheduling ethics reflection, and identifying ethical dilemmas. These strategies can be more or less successful and vary in intensity. The prioritisation of direct patient care is not surprising, but polarisation between care and ethics needs to be questioned and ethics reflection need to be integrated in standard care. Ethical competence seems to be central in doing ethics and more knowledge on the promotion of ethical competence in practice and education is needed.

Beliefs and attitudes of PICU doctors and nurses on parental presence and open visiting policies: an Italian nationwide survey.

The aim of the study is to investigate doctors' and nurses' beliefs and attitudes towards family presence and open visiting policies in Pediatric Intensive Care Units (PICUs) in Italy. A multicentric nationwide study was carried out in all 30 Italian PICUs. All doctors and nurses were asked to complete the Italian version of the Beliefs and Attitudes toward Visitation in ICU Questionnaire (BAVIQ). The questionnaire consists of 20 questions on beliefs and 14 on attitudes towards visiting. The response rate was 89% (925 questionnaires), with 87% of nurses and 94% of doctors responding. Most respondents (85%) believed that visiting has a beneficial effect on the patient and that an open visiting policy can reduce parental anxiety (68%). However, nearly half the respondents believed that an open policy interferes with direct nursing care (45%) and makes them feel checked up on (49%). Multiple logistic regression conducted on the eight most representative items showed that factors associated with beliefs and attitudes opposing open visiting policies were: being a nurse, geographic area (working in PICUs in Central Italy or the South and Islands) and working in a cardiac surgery unit. Age showed a trend of younger professionals being more convinced that an open visiting policy can be beneficial for patients. Most healthcare professionals in Italian PICUs believe that an open visiting policy for families is beneficial for both the patient and his/her family. However, despite an overall positive attitude among PICU staff members, there is still some resistance in Italy, particularly among nurses and in cardiac surgery units.