Alison Mary Mudge

Background: Many organizations in health and social services lack strong implementation and QI capacity, that is, the capability to effectively align practice with changing evidence and contexts and thereby continuously improve services and outcomes without external expert assistance. This study maps the characteristics of capacity building interventions (CBIs) aimed at developing generic implementation or quality improvement (QI) capacity, examines how their content aligns with implementation practice competencies, and how they are evaluated. Method: We followed the Joanna Briggs Institute scoping review methodology. Two searches (most recent 19/4/2024) were conducted in three databases. Empirical articles describing the development and implementation and/or evaluation of generic implementation or QI CBIs delivered to individuals, teams, and/or organizations in healthcare, public health, and social services were included. Data were analyzed using quantitative description and content analysis. Results: Data were extracted from 160 articles. Most CBIs were delivered in high-income countries ( n = 145, 91%), in healthcare settings ( n = 121, 76%), and to clinicians ( n = 74, 46%). CBIs usually target the individual level ( n = 63, 39%) or the individual and team levels ( n = 45, 28%). A combination of capacity-building strategies was generally used rather than a single strategy. Most content and activities aligned with analytical and planning competencies, with only a few emphasizing relational and emotional competencies, planning for sustainability, and knowledge brokering skills. Evaluations captured primarily self-reported reaction ( n = 98, 61%) and learning outcomes ( n = 83, 52%), with few assessing behaviors after active support ended ( n = 37, 23%) or results ( n = 45, 28%). Conclusion: CBIs aiming to build implementation or QI capacity vary substantially in their development, evaluation, and reporting, making knowledge synthesis and reproducibility difficult. Greater emphasis on relational, emotional, and sustainability competencies may help participants develop a more balanced skill set. Strategies to create organizational conditions and rigorous longitudinal evaluations are required to support and assess CBIs' long-term impact and skill sustainability.

Background: Many adults develop delirium in the community, prior to hospital admission. Yet the pathways leading to delirium in this setting and strategies for its prevention remain poorly understood. This scoping review aims to map existing literature on delirium prevention for adults in community settings, identifying who is considered at risk and how preventive strategies have been developed and implemented outside of acute care settings. Methods: Six online scientific databases were searched for original research written in English with no limits on date, with an objective to prevent delirium in adults (⩾18 years) in the community. Narrative synthesis was used to summarise study characteristics and outcomes. Delirium prevention components were analysed according to the “PINCHES ME Kindly” framework. Results: Of 7,845 records, four articles met the inclusion criteria describing three interventions and populations. All studies targeted older people following hospitalisation and offered a hospital-based multicomponent delirium prevention intervention post-discharge, delivered by multidisciplinary teams daily or an outreach nurse over structured sessions. The interventions comprised four to nine components, tailored to participants’ physical and medical needs. Conclusions: Evidence for delirium prevention in community settings remains limited and fragmented, with existing interventions appearing to be extensions of hospital based models without considering specific post-discharge or pre-admission risks. This may limit the potential for delirium prevention across the continuum of care.

Aim: To describe the point prevalence of cognitive impairment in hospitalised adults and evaluate the association with care needs and perceived risks of complications. Design: Multi‐site cross‐sectional study on a single day in May 2023. Methods: Trained clinician auditors screened adult inpatients in acute medical, surgical, oncology, geriatric, mental health, convalescent, and rehabilitation wards for cognitive impairment using the 4AT in seven healthcare facilities and recorded need for support with basic activities of daily living, incontinence, and perceived risks of complications (falls, pressure injuries, and malnutrition). Data were summarised and compared across 4AT categories, and the strength of association between 4AT and each outcome was estimated using multivariable regression models. Results: Data were available for 1145 inpatients on 68 wards (mean age 68 years [SD = 18], 583 [58.9%] female, 449 [39.2%] on acute medical units). Cognitive impairment (4AT of 1 or more) was identified in 482 (42.1%) participants. Participants with 4AT 1–3 had 2.0–3.6 times the odds of need for supervision or assistance with activities of daily living, while those with 4AT 4 or more had 2.9–5.3 times the odds of need for assistance. Conclusion: Cognitive impairment is very common in adult inpatients and is associated with significantly higher physical care needs. Implications for the Profession and Patient Care: Hospital care models must support staff to address the higher care needs in people with cognitive impairment to protect a large patient group from hospital‐acquired harm. Patient or Public Contribution: No patient or public contribution. Reporting Method: This study adheres to the STROBE reporting guidelines.

Importance: An improved understanding of the organizational influences on adult in-hospital mobility is essential to develop and sustain interventions to prevent functional decline. Objective: The objective was to map contemporary evidence about organizational barriers and enablers of adult patient mobility in general acute hospital units, the participants reporting these barriers and enablers, and how mobility was defined. Data Sources: A systematic search was conducted in Embase, Emcare, EBSCO Cumulative Index to Nursing and Allied Health Literature Complete, Cochrane Library, Joanna Briggs Institute, MEDLINE, ProQuest (Health Research Premium Collection), PsycINFO, Scopus and Web of Science for studies published in English from January 2013 to October 2024 inclusive. Study selection: Based on eligibility criteria, 2 reviewers independently screened title/abstracts and full texts. Data extraction and synthesis: Two reviewers independently extracted study characteristics and mobility definitions. Organizational barriers and enablers of mobility were mapped to the Consolidated Framework for Implementation Research 2.0 outer (community and jurisdiction) and inner setting (hospital) domains. Main outcomes: Fifty-one studies were included (45 primary studies and 6 reviews). Fourteen studies reported organizational barriers and enablers of mobility in the outer setting. All 51 studies reported inner setting mobility barriers and enablers, mostly related to infrastructure, culture, and available resources. Most participants were patients or health professionals providing direct patient care. Few studies defined mobility, and definitions were inconsistent. Conclusions and relevance: Studies reported many organizational barriers and enablers of mobility at the hospital level, with far fewer reported at the community and jurisdiction level. Few studies reported the perspectives of health service leadership, and investigating their perspective may provide greater insights to address these barriers. Consistent definitions of mobility could enable progress in research and practice. Greater insights into community and jurisdictional barriers and enablers of mobility from the perspective of health care leaders are required to address organizational barriers.

Background: Hospital mealtimes are complex, and older adults are at high risk of inadequate food and fluid intake, which contributes to poorer hospital outcomes. Interventions to improve mealtimes and mealtime care should consider patient perspectives. This multi‐site study aims to describe the eating and drinking experiences and perceptions of older adults admitted to 12 hospitals across Queensland, Australia. Methods: Mixed‐method study analyzing structured interviews with older inpatients (aged 65 years and older) collected within the Eat Walk Engage quality improvement program in 20 acute medical and surgical wards in 12 publicly funded hospitals (2019–20). Interviews were undertaken by trained staff and included patient perspectives, barriers, enablers, and suggestions related to eating and drinking in hospital. Qualitative data were coded using the Theoretical Domains Framework (TDF) and synthesized to create overarching belief statements. Results: Two hundred interviews were analyzed. Nearly all (98%) patients described eating and drinking in hospital as important. Eighteen belief statements were generated across the seven most indexed TDF domains. Patients recognized eating and drinking as important to their strength and recovery and generally appreciated the quality and options in hospital food. However, they experienced multi‐level challenges: at a personal level (e.g., reduced appetite, symptoms, and physical impairments); with mealtime care (e.g., lack of assistance and uncomfortable positioning); and from the broader hospital system (e.g., inflexible meal timing and meal sizes). Several enabling factors were identified, including self‐motivation, encouragement and assistance from staff and family, greater choice around food, and familiar and simple foods. Conclusions: Eating and drinking in hospital is complex for older patients. Improvement solutions should be multi‐faceted and multi‐disciplinary to provide effective person‐centered nutrition care.

Background: A composite outcome of hospital-associated complications of older people (HAC-OP; comprising functional decline, delirium, incontinence, falls, and pressure injuries) has been proposed as an outcome measure reflecting quality of acute hospital care. Estimating HAC-OP from routinely collected administrative data could facilitate the rapid and standardized evaluation of interventions in the clinical setting, thereby supporting the development, improvement, and wider implementation of effective interventions. Objective: This study aimed to create a Diagnosis Procedure Combination (DPC) data version of the HAC-OP measure (HAC-OP-DPC) and demonstrate its predictive validity by assessing its associations with hospital length of stay (LOS) and discharge destination. Methods: This retrospective cohort study acquired DPC data (routinely collected administrative data) from a general acute care hospital in Tokyo, Japan. We included data from index hospitalizations for patients aged ≥65 years hospitalized for ≥3 days and discharged between July 2016 and March 2021. HAC-OP-DPC were identified using diagnostic codes for functional decline, incontinence, delirium, pressure injury, and falls occurring during the index hospitalization. Generalized linear regression models were used to examine the associations between HAC-OP-DPC and LOS, and logistic regression models were used to examine the associations between HAC-OP-DPC and discharge to other hospitals and long-term care facilities (LTCFs). Results: Among 15,278 patients, 3610 (23.6%) patients had coding evidence of one or more HAC-OP-DPC (1: 18.8% and ≥2: 4.8%). Using “no HAC-OP-DPC” as the reference category, the analysis showed a significant and graded association with longer LOS (adjusted risk ratio for patients with one HAC-OP-DPC 1.29, 95% CI 1.25-1.33; adjusted risk ratio for ≥2 HAC-OP-DPC 1.97, 95% CI 1.87-2.08), discharge to another hospital (adjusted odds ratio [AOR] for one HAC-OP-DPC 2.36, 95% CI 2.10-2.65; AOR for ≥2 HAC-OP-DPC 6.96, 95% CI 5.81-8.35), and discharge to LTCFs (AOR for one HAC-OP-DPC 1.35, 95% CI 1.09-1.67; AOR for ≥2 HAC-OP-DPC 1.68, 95% CI 1.18-2.39). Each individual HAC-OP was also significantly associated with longer LOS and discharge to another hospital, but only delirium was associated with discharge to LTCF. Conclusions: This study demonstrated the predictive validity of the HAC-OP-DPC measure for longer LOS and discharge to other hospitals and LTCFs. To attain a more robust understanding of these relationships, additional studies are needed to verify our findings in other hospitals and regions. The clinical implementation of HAC-OP-DPC, which is identified using routinely collected administrative data, could support the evaluation of integrated interventions aimed at optimizing inpatient care for older adults.

Background: Geographical isolation compounds limited access to healthcare services and skilled workforce for the provision of rural aged care. Residents have complex chronic disease management and end‐of‐life care needs. An undersupply of general medical practitioners due to retirement, attrition or unfilled training places in Australia has impacted recruitment to rural areas. Nurse practitioners have been identified as a potential solution. Aim: To describe and explore the inner (local and organisational) and outer (wider health system) contexts of healthcare, from the perspective of care staff and residents' families. This, in turn, aims to inform the planned implementation of a nurse practitioner model, in several aged care facilities, operating within rural and remote settings, in Queensland Australia. Design: A convergent mixed methods design. Methods: Qualitative data were collected, in 2022–2023, using semistructured interviews with staff focusing on role, knowledge development, workplace culture and care relationships with local community. Resident's family's perspectives were obtained as a secondary analysis of organisational feedback data. Quantitative data were collected from direct care workers using the Alberta Context Tool for Long‐Term Care. Data were analysed according to type and integrated. Results: Relational care for residents and families is highly valued but provision of quality is challenging where time‐poor staff are perceived to be doing the best they can. Scarce local healthcare services make it difficult to meet resident healthcare needs. Despite the supportive organisational culture, evolving policy requirements have impacted already difficult staff recruitment in rural settings. Conclusion: Identifying contextual needs of organisations in readiness for change highlights geographical and sectoral nuances influencing any future implementation. As government policy changes to improve the older adult care sector, rural and remote facilities are forced to increasingly adapt. Implications for the Profession: Context‐specific needs extend far beyond a nurse practitioner providing additional expertise in care provision. Impact Statements: What problem did the study address? Nurse practitioners have been successfully implemented into residential aged care facilities in metropolitan and major regional centres but translating this role into rural and remote Australia requires being cognisant of the needs, unique challenges and context of this setting. What were the main findings? In an organisational culture of support, the importance of staff providing relational care and having connection with older adult residents and families was a central driver. It was challenging for staff to meet complex care requirements in the absence of local healthcare options and support. Time pressures, from inadequate staffing and changing structural aged care sector, force the prioritising of care requirements. Where and on whom will the research have an impact? Older adults, policy makers and aged care providers will benefit from understanding the context of rural and remote settings, particularly in identifying potential solutions when there are gaps in primary and secondary healthcare. Reporting Method: The GRAMMS checklist was followed in reporting of this study. Patient or Public Contribution: Two lived experience consumers were involved as research team members. One was involved during the development and submission of the funding application and another during project activities including data collection and analysis and the development of publications.

Objective: Poor interdisciplinary team communication is a known barrier to increasing inpatient mobility. Understanding why and how clinicians from different disciplines communicate about mobility would help inform communication improvements. This qualitative interview study aimed to describe and explore clinician perceptions about written mobility communication and perceived barriers and enablers to this communication. Methods: A rapid deductive qualitative approach was used to efficiently capture information for local improvement. Clinicians (physical therapists, nurses, physicians, and occupational therapists) working on 3 internal medicine wards in a metropolitan teaching hospital in Brisbane, Australia were purposefully sampled and invited to participate in individual interviews. Questions were based on the Consolidated Framework for Implementation Research. Interviews were recorded, transcribed, and analyzed using deductive and inductive thematic methods. Results: From 17 interviews, key themes identified that written communication about patient mobility is important and valued by clinicians; clinicians learn documentation on the job, often from physical therapists; clinicians are not aware of organizational responsibility for mobility communication; multiple purposes for written communication contribute to multiple locations and inconsistency; and clinicians perceive that improvement would require a multidisciplinary and multilevel approach. Suggestions for improvement included the use of a common language, consistent use of existing bedside communication tools, and clearer responsibility for written communication about mobility. Conclusion: Written communication about patient mobility was valued by clinicians, and a range of barriers to effective interdisciplinary communication was identified. Clear professional roles and responsibility for written mobility communication are important. Suggestions for improvement included an interdisciplinary language supported by multidisciplinary education and organizational governance. Impact: Written communication about patient mobility is recognized as critical to safe, high-quality hospital care. Our findings suggest that successful mobility communication improvements must involve multiple disciplines and include clear organizational governance to support staff training, clear role responsibilities, and quality monitoring. Lay summary: This study found that staff on a medical ward think writing about mobility is important for patient and staff safety. Having clear roles and responsibilities for writing about mobility is important and consistency may be improved through education and training.

Aims: This scoping review aimed to identify and map the available information on the nutrition care process in older adults with delirium to analyse and summarise key concepts, and gaps, including the barriers and enablers to providing nutrition care for this group.Design: Scoping review.Methods: This review was conducted in accordance with the JBI methodology for scoping reviews. Published and grey sources in English were considered.Data sources: Databases searched were CINAHL, Medline, Embase, JBI Evidence‐based Practice, Scopus, ProQuest and Google. The initial search was conducted from October 2021 to March 2022 and repeated in October 2023.Results: The database search identified 1561 articles, 186 underwent full‐text review and 17 articles were included. The grey literature search identified eight articles. Malnutrition and delirium were identified as mutually reinforcing, and nutrition strategies were included as part of multicomponent interventions for delirium management. There was no mention of barriers or enablers to nutrition care and minimal descriptive or empirical data available to guide nutrition care processes in this group.Conclusion: This scoping review revealed a need for further research into nutrition care processes in older patients with delirium, in particular the barriers and enablers, to inform appropriate management strategies in this vulnerable group.Implications for the profession and patient care: Providing nutrition care for older patients with delirium is important and further practical guidance could help patients, healthcare staff and families.Impact: This scoping review yielded instructive data suggesting that delirium is an important risk factor for malnutrition and vice versa, which leads to poor patient and health service outcomes.Reporting method: This scoping review adhered to relevant EQUATOR guidelines and used the Preferred Reporting Items For Systematic Reviews and Meta‐Analyses Extension for Scoping Reviews (PRISMA‐ScR).Patient of public contribution: No patient or public contribution.