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Flenady T, Connor J, Byrne AL, Massey D, Le Lagadec MD. The impact of mandated use early warning system tools on the development of nurses' higher-order thinking: A systematic review. J Clin Nurs 2024. [PMID: 38661093 DOI: 10.1111/jocn.17178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 03/17/2024] [Accepted: 04/07/2024] [Indexed: 04/26/2024]
Abstract
AIM Ascertain the impact of mandated use of early warning systems (EWSs) on the development of registered nurses' higher-order thinking. DESIGN A systematic literature review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Page et al., 2021). DATA SOURCES CINAHL, Medline, Embase, PyscInfo. REVIEW METHODS Eligible articles were quality appraised using the MMAT tool. Data extraction was conducted independently by four reviewers. Three investigators thematically analysed the data. RESULTS Our review found that EWSs can support or suppress the development of nurses' higher-order thinking. EWS supports the development of higher-order thinking in two ways; by confirming nurses' subjective clinical assessment of patients and/or by providing a rationale for the escalation of care. Of note, more experienced nurses expressed their view that junior nurses are inhibited from developing effective higher-order thinking due to reliance on the tool. CONCLUSION EWSs facilitate early identification of clinical deterioration in hospitalised patients. The impact of EWSs on the development of nurses' higher-order thinking is under-explored. We found that EWSs can support and suppress nurses' higher-order thinking. EWS as a supportive factor reinforces the development of nurses' heuristics, the mental shortcuts experienced clinicians call on when interpreting their subjective clinical assessment of patients. Conversely, EWS as a suppressive factor inhibits the development of nurses' higher-order thinking and heuristics, restricting the development of muscle memory regarding similar presentations they may encounter in the future. Clinicians' ability to refine and expand on their catalogue of heuristics is important as it endorses the future provision of safe and effective care for patients who present with similar physiological signs and symptoms. IMPACT This research impacts health services and education providers as EWS and nurses' development of higher-order thinking skills are essential aspects of delivering safe, quality care. NO PATIENT OR PUBLIC CONTRIBUTION This is a systematic review, and therefore, comprises no contribution from patients or the public.
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Affiliation(s)
- Tracy Flenady
- Central Queensland University, Rockhampton, Queensland, Australia
| | - Justine Connor
- Central Queensland University, Rockhampton, Queensland, Australia
| | - Amy-Louise Byrne
- Central Queensland University, Rockhampton, Queensland, Australia
| | - Deb Massey
- Edith Cowen University, Joondalup, Western Australia, Australia
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2
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Pann KJ, Ewers A. [Experience of nurses using the COVID-19 Early Warning Score in the care of COVID-19 patients: A qualitative study]. Pflege 2024. [PMID: 38592743 DOI: 10.1024/1012-5302/a000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Experience of nurses using the COVID-19 Early Warning Score in the care of COVID-19 patients: A qualitative study Abstract: Background: In all phases of the COVID-19 disease, patients are at risk of acute deterioration. In order to identify patients at risk at an early stage, the COVID-19-EWS Salzburg was implemented in April 2020 at the University Hospital Salzburg. So far, the applicability, practicability and relevance of the EWS for acute inpatient COVID-19 care are unknown. Aim: The aim of this qualitative study was to describe the relevance and practicability of the COVID-19-EWS Salzburg as a risk assessment tool for acute inpatient COVID-19 care, based on the experiences of the nursing staff. Methods: Nine semi-structured expert interviews were conducted with the nursing staff of the COVID-19 acute care unit. The data were analysed by qualitative content analysis. Results: Nurses described the EWS as relevant to practice because the score facilitates decision-making, increases patient safety, and enhances interprofessional communication. Both the Early Warning Score (EWS) and experience in caring for COVID-19 patients were found to be relevant for decision-making in the context of managing clinical deterioration. The score provided a sense of security in the care of COVID-19 patients, particularly to new and inexperienced nurses. Conclusion: The participating nurses describe the COVID-19-EWS Salzburg as a useful and practical risk assessment instrument, complementing clinical judgment. A need for adaptation concerning the parameters oxygen saturation and oxygen requirement was identified.
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Affiliation(s)
- Kathrin Julia Pann
- Koordination Klinische Pflegewissenschaft und -forschung, Pflegedirektion, Universitätsklinikum Salzburg, Österreich
- Masterstudiengang Pflegewissenschaft, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Andre Ewers
- Koordination Klinische Pflegewissenschaft und -forschung, Pflegedirektion, Universitätsklinikum Salzburg, Österreich
- Masterstudiengang Pflegewissenschaft, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
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3
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Alhmoud B, Bonicci T, Patel R, Melley D, Hicks L, Banerjee A. Implementation of a digital early warning score (NEWS2) in a cardiac specialist and general hospital settings in the COVID-19 pandemic: a qualitative study. BMJ Open Qual 2023; 12:bmjoq-2022-001986. [PMID: 36914225 PMCID: PMC10015673 DOI: 10.1136/bmjoq-2022-001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVES To evaluate implementation of digital National Early Warning Score 2 (NEWS2) in a cardiac care setting and a general hospital setting in the COVID-19 pandemic. DESIGN Thematic analysis of qualitative semistructured interviews using the non-adoption, abandonment, scale-up, spread, sustainability framework with purposefully sampled nurses and managers, as well as online surveys from March to December 2021. SETTINGS Specialist cardiac hospital (St Bartholomew's Hospital) and general teaching hospital (University College London Hospital, UCLH). PARTICIPANTS Eleven nurses and managers from cardiology, cardiac surgery, oncology and intensive care wards (St Bartholomew's) and medical, haematology and intensive care wards (UCLH) were interviewed and 67 were surveyed online. RESULTS Three main themes emerged: (1) implementing NEWS2 challenges and supports; (2) value of NEWS2 to alarm, escalate and during the pandemic; and (3) digitalisation: electronic health record (EHR) integration and automation. The value of NEWS2 was partly positive in escalation, yet there were concerns by nurses who undervalued NEWS2 particularly in cardiac care. Challenges, like clinicians' behaviours, lack of resources and training and the perception of NEWS2 value, limit the success of this implementation. Changes in guidelines in the pandemic have led to overlooking NEWS2. EHR integration and automated monitoring are improvement solutions that are not fully employed yet. CONCLUSION Whether in specialist or general medical settings, the health professionals implementing early warning score in healthcare face cultural and system-related challenges to adopting NEWS2 and digital solutions. The validity of NEWS2 in specialised settings and complex conditions is not yet apparent and requires comprehensive validation. EHR integration and automation are powerful tools to facilitate NEWS2 if its principles are reviewed and rectified, and resources and training are accessible. Further examination of implementation from the cultural and automation domains is needed.
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Affiliation(s)
- Baneen Alhmoud
- Institute of Health Informatics, University College London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Timothy Bonicci
- Institute of Health Informatics, University College London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Riyaz Patel
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | | | | | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK .,University College London Hospitals NHS Foundation Trust, London, UK
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Langkjaer CS, Bundgaard K, Bunkenborg G, Nielsen PB, Iversen KK, Bestle MH, Bove DG. How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: A fieldwork study. J Adv Nurs 2023; 79:789-797. [PMID: 36541263 PMCID: PMC10107488 DOI: 10.1111/jan.15547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/02/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
AIM To explore and describe how the National Early Warning Score (NEWS) and Individual Early Warning Score (I-EWS) are used and how they support nurses' patient risk assessment practice. DESIGN A qualitative observational fieldwork study drawing on ethnographical principles was performed in six hospitals in two regions of Denmark in 2019. METHODS Data were generated from participant observations and informal interviews with 32 nurses across 15 different wards in the hospitals. A total of 180 h of participant observation was performed. The observations lasted between 1.5 and 8 h and were conducted during day or evening shifts. RESULTS NEWS and I-EWS supported nurses' observations of patients, providing useful knowledge for planning patient care, and prompting critical thinking. However, the risk assessment task was sometimes delegated to less experienced staff members, such as nursing students and healthcare assistants. The Early Warning Score (EWS) systems were often adapted by nurses according to contextual aspects, such as the culture of the speciality in which the nurses worked and their levels of competency. In some situations, I-EWS had the effect of enhancing nurse autonomy and responsibility for decision-making in relation to patient care. CONCLUSIONS EWS systems support nurses' patient risk assessment practice, providing useful information. I-EWS makes it easier to factor the heterogeneity of patients and the clinical situation into the risk assessments. The delegation of risk assessment to other, less experienced staff members pose a risk to patient safety, which needs to be addressed in the ongoing debate regarding the shortage of nurses. IMPACT The findings of this study can help ward nurses, hospital managers and policymakers to develop and improve strategies for improved person-centred nursing care.
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Affiliation(s)
- Caroline S Langkjaer
- Department of Emergency Medicine, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Karin Bundgaard
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Clinic for Neuro-, Head- and Orthopaedic Diseases, Aalborg University Hospital, Aalborg, Denmark.,Department of Public Health, Nursing, Health Faculty, Aarhus University, Aarhus C, Denmark
| | - Gitte Bunkenborg
- Department of Anesthesiology, Copenhagen University Hospital - Holbaek, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense C, Denmark
| | - Pernille B Nielsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Dorthe G Bove
- University College Absalon, Centre for Nursing, Roskilde, Denmark
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Burke C, Conway Y. Factors that influence hospital nurses' escalation of patient care in response to their early warning score: A qualitative evidence synthesis. J Clin Nurs 2022; 32:1885-1934. [PMID: 35338540 DOI: 10.1111/jocn.16233] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Early Warning Score (EWS) is a validated tool that has improved patient outcomes internationally. This scoring system is used within the hospital setting to identify potentially deteriorating patients, thus expediting referral to appropriate medical personnel. It is increasingly recognised that there are other influencing factors along with EWS, which impact on nurses' decisions to escalate care. AIM The aim of this review was to identify and synthesise data from qualitative studies, which examined factors influencing nurses' escalation of care in response to patients' EWS. METHODS The systematic search strategy and eligibility criteria were guided by the SPIDER (Sample Phenomenon of Interest Design Evaluation Type of Research) framework. Eleven databases and five grey literature databases were searched. Titles and abstracts were independently screened in line with pre-established inclusion and exclusion criteria using the cloud-based platform, Rayyan. The selected studies underwent quality appraisal using CASP (Critical Appraisal Skills Programme, 2017, https://www.casp-uk.net/casp-toolschecklists) and subsequently synthesised using Thomas and Harden's thematic analysis approach. GRADE-CERQual (Grading of Recommendations Assessment Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in results. The EQUATOR listed guideline ENTREQ (Tong et al., 2012, BMC Medical Research Methodology, 12) was used to synthesise and report findings. RESULTS Eighteen studies from seven countries including 235 nurses were identified. Following synthesis, four analytical themes were generated with eighteen derived consequent findings. The four themes identified were as follows: 1) Marrying nurses' clinical judgement with EWS 2) SMART communication 3) EWS Protocol: Blessing and a Curse 5) Hospital Domain. CONCLUSION Nurses strive to find balance by simultaneously navigating within the boundaries of both the EWS protocol and the hospital domain. They view the EWS as a valid essential component in the system but one that does not give a definitive answer and absolute direction. They value the protocols' ability to identify deteriorating patients and convey the seriousness of a situation to their multidisciplinary colleagues but also find it somewhat restrictive and frustrating and wish to have credence given to their own intuition and clinical judgement.
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Affiliation(s)
- Catherine Burke
- St Johns Hospital Urgent Care Center St Johns Hospital St Johns Square, Limerick, Ireland
| | - Yvonne Conway
- Department of Nursing, Health Sciences and Integrated Care, Galway Mayo Institute of Technology, Galway, Ireland
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Mølgaard RR, Jørgensen L, Christensen EF, Grønkjaer M, Voldbjerg SL. Ambivalence in nurses' use of the early warning score: A focussed ethnography in a hospital setting. J Adv Nurs 2021; 78:1461-1472. [PMID: 34841561 DOI: 10.1111/jan.15118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/12/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
AIM This study describes and explores the influences in registered nurses' use of early warning scores to support clinical decisions in a hospital setting. DESIGN A focussed ethnography allowed for the investigation of registered nurses' clinical practices in two wards in a Danish University Hospital. The study adhered to the 'Standards for Reporting Qualitative Research'. METHODS Participant observation and ethnographic interviews were conducted from March 2019 to August 2019. Ten registered nurses were observed and interviewed, and four physicians were interviewed. Data were analysed using LeCompte and Schensul's ethnographic analysis. FINDINGS The findings show the registered nurses' ambivalence towards the early warning score as a decision support system. Early warning score monitoring created a space for registered nurses to identify and initiate optimized care. However, when early warning scores contradicted registered nurses' clinical judgments, the latter were given priority in decisions even though elevated scores were not always accounted for in the situation. Moreover, we found unspoken expectations in the collaboration between physicians and registered nurses, which influenced the registered nurses' workloads and decisions regarding early warning scores. CONCLUSION Registered nurses' clinical judgment is essential to clinical decisions on the care and safety of patients if used combined with the early warning score. Interprofessional collaboration between registered nurses and physicians about the early warning score is challenged. Future research may address this challenge to explore how it should be operated as a collaboration tool. IMPACT The study adds knowledge to the evidence base of registered nurses' use of early warning score and the advantages and challenges associated with the use of these scoring systems. The study may provide valuable knowledge for the future development of policies or implementation strategies.
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Affiliation(s)
- Rikke R Mølgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Nursing, University College of Northern Denmark, Hjorring, Denmark
| | - Lone Jørgensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Clinic for Surgery and Cancer Treatment, Aalborg University Hospital, Aalborg, Denmark
| | - Erika F Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Center for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Grønkjaer
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Siri L Voldbjerg
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Nursing, University College of Northern Denmark, Hjorring, Denmark
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Langkjaer CS, Bove DG, Nielsen PB, Iversen KK, Bestle MH, Bunkenborg G. Nurses' Experiences and Perceptions of two Early Warning Score systems to Identify Patient Deterioration-A Focus Group Study. Nurs Open 2021; 8:1788-1796. [PMID: 33638617 PMCID: PMC8186715 DOI: 10.1002/nop2.821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/29/2020] [Accepted: 01/31/2021] [Indexed: 11/07/2022] Open
Abstract
AIMS To explore Registered Nurses' experiences and perceptions with National Early Warning Score and Individual Early Warning Score to identify patient deterioration. DESIGN A qualitative exploratory design. METHODS Six focus groups were conducted at six Danish hospitals from February to June 2019. Registered Nurses from both medical, surgical and emergency departments participated. The focus groups were analysed using content analysis. RESULTS One theme and four categories were identified. Theme: Meaningful in identifying patient deterioration but causing frustration due to lack of flexibility. Categories: (a) Inter-professional collaboration strengthened through the use of Early Warning Score systems, (b) Enhanced professional development and communication among nurses when using Early Warning Score systems, (c) Detecting patient deterioration by integrating nurses' clinical gaze with Early Warning Score systems and (d) Modification and fear of making mistakes when using Early Warning Score systems.
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Affiliation(s)
- Caroline S. Langkjaer
- Department of Emergency MedicineNordsjaellands HospitalUniversity of CopenhagenHilleroedDenmark
| | - Dorthe G. Bove
- Department of Emergency MedicineNordsjaellands HospitalUniversity of CopenhagenHilleroedDenmark
| | - Pernille B. Nielsen
- Department of CardiologyHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
- Department of Emergency MedicineHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
| | - Kasper K. Iversen
- Department of CardiologyHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
- Department of Emergency MedicineHerlev and Gentofte HospitalUniversity of CopenhagenHerlevDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Morten H. Bestle
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
- Department of Anaesthesiology and Intensive careNordsjaellands HospitalUniversity of CopenhagenHilleroedDenmark
| | - Gitte Bunkenborg
- Department of AnesthesiologyHolbaek HospitalHolbaekDenmark
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
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9
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Burdeu G, Lowe G, Rasmussen B, Considine J. Clinical cues used by nurses to recognize changes in patients' clinical states: A systematic review. Nurs Health Sci 2020; 23:9-28. [PMID: 32969179 DOI: 10.1111/nhs.12778] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/18/2020] [Accepted: 09/20/2020] [Indexed: 01/04/2023]
Abstract
The aim of this systematic review was to examine the clinical cues used by acute care nurses to recognize changes in clinical states of adult medical and surgical patients that occurred as usual consequence of acute illness and treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist were followed. Four databases and reference lists of included studies were searched: from 1,049 studies, 38 were included. There were 26 subjective and 147 objective cues identified; only 6% of all cues described improvements in patients' clinical states. The most common clinical cues used were heart rate, blood pressure and temperature. Many studies (n = 31) focused on only one element of assessment, such as physiological stability, pain, or cognition. There was a paucity of studies detailing the complexity of acute care nurses' assessment practices as they would occur in clinical practice and a disproportionate focus on the objective assessment of deterioration. Studies are needed to understand the full breadth of cues acute care nurses use to recognize clinical change that includes both improvement and deterioration.
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Affiliation(s)
- Gabrielle Burdeu
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, Victoria, Australia
| | - Grainne Lowe
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Bodil Rasmussen
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research- Western Health Partnership, Sunshine, Victoria, Australia.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Victoria, Australia.,Faculty of Health Sciences University of Southern Denmark, Victoria, Australia
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, Victoria, Australia
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