Abstract Background Non-allergy specialist healthcare workers removing low-risk penicillin allergy (penA) records, enabling patients to receive penicillin antibiotics, is safe but not common practice. We developed a behavioural change implementation intervention to support non-allergist healthcare workers to remove incorrect penA records from adult inpatients (penicillin allergy de-labelling; PADL). This study aimed to evaluate the effectiveness of the implementation intervention strategy and its impact on delabelling and antibiotic prescribing. Methods The implementation intervention was launched 10 th June 2024. This prospective, single centre, type 2 hybrid effectiveness-implementation study was evaluated using mixed methods: process evaluation, qualitative and quantitative study designs. The proportion of patients delabelled was measured. Antibiotics were grouped into the three WHO AWaRe categories with differences in antibiotic use between the de-labelled and non-de-labelled measured. Pearson chi-squared tests, Welch’s t-tests or Wilcoxon matched-pairs signed-rank tests were used. Results Between 10 th June and 13 th December 2024, the mean number of penicillin allergy records removed from the inpatient electronic prescribing system increased from 18.2/month pre-intervention to 42.7/month post intervention. Of 186 patients de-labelled with full data capture, the majority 126 (67.7%) were de-labelled by the antimicrobial pharmacists and the remainder by ward doctors or ward pharmacists across 21 clinical specialties. Antibiotic exposure, when grouped by WHO AwARe category, was not significantly different between de-labelled and not de-labelled groups. Of 138 patients with a penA record in their primary care records, there was evidence of communication with the GP to amend the primary care penA record for 94 (68.1%) patients of which 42 (44.7%) were actioned by GP surgeries. The PADL intervention was accepted by most patients, who considered hospital a safe place to be tested. Awareness of the PADL intervention was generally high across all healthcare workers. The PADL process was acceptable to all interviewed healthcare workers and aligned with staff roles and hospital processes but competing priorities were commonly cited as a barrier. Conclusions The PADL implementation intervention successfully increased non-specialist workforce PADL of low-risk patients. There is opportunity to further optimise PADL but competing priorities are a challenge. We found non-statistically significant impact of PADL on antibiotic use.

There are many circumstances where individuals with limited mobility are exposed to prolonged postures increasing the risk of pressure ulcers. Technologies have been developed to monitor posture, mobility and pressure exposure; however, their effectiveness in different clinical settings is unknown. The aim of this scoping review was to assess clinical studies using continuous pressure monitoring for the prevention and/or treatment of pressure ulcers. A scoping review of the literature was conducted using the PRISMA-ScR framework. Clinical-based studies were included which used continuous pressure monitoring for assessment and treatment over a minimum of a 2-h period. The outcomes included quantitative measures such as pressure distribution and mobility data, qualitative insights relating to patient comfort and acceptability, and the perceptions of healthcare staff regarding usability and clinical integration of the technology. Twenty-four studies were identified and included in the scoping review, conducted across eight countries spanning three continents. Most studies were undertaken in a hospital setting (67%, n = 16). Following review of the included papers, five core themes were identified: clinical outcomes, pressure metrics, posture and mobility, nurse feedback and patient experience. There was high heterogeneity in study design, outcome measures and different risk of bias limited the scope to synthesise the outcomes. Collectively, the studies indicate that CPM can enhance awareness of interface pressures, support clinical decision-making and inform repositioning strategies for individuals at risk of tissue damage. Reported benefits include greater staff confidence and patient engagement. However, consistent reductions in ulcer incidence have yet to be demonstrated, with larger trials with standardised outcomes required.

Frailty in community-dwelling individuals often leads to prolonged periods in bed or sitting, increasing their risk of pressure injury development. The Quality Improvement project 'Pressure Reduction through cOntinuous Monitoring In the community SEtting' (PROMISE) implemented the use of continuous pressure monitoring (CPM) to inform interventions. A secondary analysis of PROMISE data involving 17 patients was examined before and after the intervention. A novel algorithm using duration and magnitude of pressure signatures at the buttock area was estimated from the CPM data and an algorithm based on the sigmoid relationship between pressure and time was used to categorise risk pre- to post-intervention. The CPM intervention helped inform changes in support surface, posture and mobility advice. Duration and magnitude of pressure signatures revealed a high degree of inter-subject variability. At baseline 35% of (6/17) patients spent prolonged periods with potentially harmful interface pressures (high to very high exposure). Trends of improvements post-PROMISE intervention were observed, with 24% (4/17) in these higher exposure categories. This study demonstrated how CPM could be used to inform interventions for individuals living with pressure injuries in the community. An algorithm was used to understand trends in posture, mobility, and pressure exposure, showing some improvement pre- to post-intervention.

BACKGROUND:In the Philippines, rising stroke prevalence and healthcare inequalities present a concerning outlook. While acute stroke care is prioritised, rehabilitation remains undervalued. The experiences of healthcare providers who deliver stroke support are also under-researched. OBJECTIVE(S):Our study aimed to explore the experiences and needs of care providers across multiple regions of the Philippines to inform the development of stroke support initiatives and programmes. METHODS:Forming part of the Tulong, Ugnayan ng Lingap At gabaY (TULAY) project, a qualitative descriptive design involving semi-structured interviews was used. Care providers with professional or voluntary community healthcare service delivery roles were recruited. Data were analysed using reflexive thematic analysis. RESULTS:Seventeen participants across five regions were interviewed between June and September 2024. Three high-level themes were constructed: 1) inequitable stroke care and rehabilitation services, 2) barriers to the provision and access of stroke services and 3) desires, needs and opportunities for improvement. CONCLUSIONS:Traditionally multi-level (e.g. national, community) approaches offer solutions to enhancing stroke rehabilitation in the Philippines. However, due to the devolved healthcare system, community-based initiatives, cognisant of local contexts and built together with stroke survivors, offer a promising solution to improve the lives of Filipinos following stroke.

For many populations, access to nature stimulates positive physical and psychological health benefits. However, there is minimal evidence exploring these benefits for patients, visitors, and staff in intensive care units (ICUs). It is the proposition of this article that the health benefits seen from access to nature are a product of a temperamental trait, according to the biophilia reactivity hypothesis. For some individuals, this hypothesis may support humanization and optimization of the ICU environment. A clinically adapted model is proposed in which nature and access to natural spaces fits within the humanization work in the ICU. In addition, clinical guidance is offered to support clinical teams in integrating nature into their departments using the 4Ps approach: population engagement, planning and maintenance, patient safety, and postoccupancy evaluation.

AIM:To explore perceptions of healthcare professionals' psychological wellbeing at work and patients' experiences of care. DESIGN:Narrative interviews were undertaken as part of a wider experience-based co-design study. METHODS:Interviews were undertaken March to December 2022 with 19 participants (healthcare professionals n = 13 and patients n = 6) from a community hospital and analysed for emotional touchpoints using reflexive thematic analysis. RESULTS:Ten themes were synthesised into five categories: (1) What is psychological wellbeing at work? (2) Barriers to psychological wellbeing at work ('Misaligned NHS Culture' and 'Pressurised System'); (3) How negative psychological wellbeing at work impacts on staff and patients' experiences of care ('Staff Struggle to Survive' and 'Patients Suffer'); (4) Enablers of psychological wellbeing at work ('Nurturing Culture' and 'Teamwork'); and (5) How positive psychological wellbeing at work impacts staff and patients' experiences of care ('Staff Thrive' and 'Patients Benefit'). CONCLUSION:Poor psychological wellbeing negatively impacted healthcare professionals' health and their ability to provide care. In response, patients deliberately withheld requests for help, risking their recovery. Conversely, when psychological wellbeing was supported, staff provided more relational care with improved patient experience. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:A nurturing culture and teamwork are positive enablers of staff psychological wellbeing and can be used to improve staff and patients' experience. IMPACT:This is one of the first studies to demonstrate that patients modify their behaviour in response to perceptions of staff wellbeing, with implications for their recovery. REPORTING METHOD:COREQ. PATIENT OR PUBLIC CONTRIBUTION:Members of the public advised on the patient-facing materials and the overarching study design.

BACKGROUND:Stroke is a leading cause of disability and mortality in the Philippines, where access to formal rehabilitation services is limited. There is a lack of research on the lived experiences of people with stroke and their household carers across diverse urban and rural settings. OBJECTIVE:To explore the experiences, challenges and support needs of people with stroke and their household carers throughout the Philippines, and to inform the co-design of a community-based stroke support programme. METHODS:A descriptive qualitative design was used. Semi-structured interviews were conducted with 24 people with stroke and 20 household carers across six sites in Luzon, Visayas and Mindanao. Interviews were enriched by auto-photography and visual elicitation. Data were analysed thematically using an interpretivist approach, through collaborative analysis by UK- and Philippine-based researchers. RESULTS:Four key themes were identified: (1) Multidimensional burden of stroke for people with stroke and household carers, including physical, psychological, social and financial impacts; (2) Cultural management and coping practices, emphasising the central role of family, use of traditional therapies and adaptive strategies, rooted in cultural values such as 'pagtitiis' (resilience and endurance) and 'utang na loob' (reciprocal obligation); (3) Knowledge and awareness of stroke and rehabilitation, revealing significant gaps and reliance on personal experience and informal information sources; and (4) Stroke care and rehabilitation needs, challenges, and recommendations, showing limited service availability and geographical and financial barriers, particularly in rural areas, alongside a strong desire for accessible, community-based support. CONCLUSION:Culturally relevant, gender-sensitive and accessible community-based stroke support and education programmes are urgently needed in the Philippines to address unmet needs and inequities in immediate and longer-term care. PATIENT OR PUBLIC CONTRIBUTION:A PPIE group consisting of people with stroke and other physical disabilities and carers reviewed the study protocol, interview topic guides and participant-facing documents and provided feedback on initial themes.

PURPOSE:Stroke imposes significant burden on informal caregivers (ICs) in the Philippines, yet factors associated with caregiver strain remain unclear. This study examined sociodemographic and caregiving factors associated with burden among stroke ICs. MATERIALS AND METHODS:A cross-sectional survey of 462 Filipino ICs collected sociodemographic characteristics, caregiver responsibilities and strain using the Modified Caregiver Strain Index-Filipino (MCSI-F). Data were analyzed using chi-square tests and ordinal logistic regression. RESULTS:Caregivers were predominantly female (75.3%), spouses/partners (47.8%), and economically disadvantaged (66.9%). Median MCSI-F score was 22 (IQR = 8), indicating no burden, while 11.9% reported severe strain. In the multivariable ordinal logistic regression model, work interference showed the strongest adjusted association with higher burden severity (aOR = 5.38, p < 0.001), followed by spousal relationship (aOR = 2.10, p = 0.028); male sex was protective (aOR = 0.34, p < 0.001), and providing <1 h/day of care (vs. >6 h/day) was associated with lower burden (aOR = 0.17, p = 0.004). Age, income, employment status, education, religion, and urban-rural residence were not significant after adjustment. Parallel lines held (p = 0.765), and Nagelkerke's R2 was 0.231. CONCLUSIONS:Filipino stroke ICs experience substantial strain primarily driven by work interference and intensive caregiving hours, with spouses and female caregivers disproportionately affected. Interventions should prioritize employment support for female spouses providing prolonged daily care.Implications for rehabilitationInformal caregivers of stroke survivors in the Philippines experience substantial burden, particularly when caregiving interferes with employment and requires intensive daily commitment.Female spouses providing prolonged daily care represent a particularly vulnerable group requiring targeted support from rehabilitation services.Rehabilitation teams should routinely assess caregiver work disruption and daily care hours as part of comprehensive stroke care planning.Employment-focused interventions, such as flexible appointment scheduling and liaison with employers, should be integrated into community-based rehabilitation programs to reduce work-care conflict.Rehabilitation professionals should prioritize training family caregivers in strategies that promote survivor independence and reduce intensive care demands over time.

ABSTRACT:This article explores the development and utility of the PIECE (Practice/Problem of interest, Intervention/Implementation, Evaluation, Context, and Engagement) planning and question framework as a structured approach for planning and conducting evidence implementation projects. Traditionally, the PICO model has been used as a guiding framework for formulating clinical questions and structuring systematic reviews; however, the elements of PICO do not suit the unique requirements of evidence implementation projects in real-world settings. Each element of PIECE addresses a critical component of implementation: selecting a problem grounded in evidence, choosing effective interventions, defining evaluation metrics, assessing contextual factors, and engaging relevant stakeholders. Through examples of successful JBI implementation projects, we illustrate how PIECE can be used to conceptualize and execute implementation efforts. The proposed framework provides a structured yet flexible roadmap, allowing health care teams to initiate and sustain meaningful improvements. PIECE supports the planning phase of implementation projects, fostering better alignment with organizational goals and greater stakeholder engagement. As implementation science continues to evolve, PIECE offers a grounded approach for clinicians seeking to embed evidence into daily practice.

Background and objectives:Penicillin allergy (penA) records prevent first-line penicillin antibiotic use, but more than 90% are incorrect after formal testing and can be removed ('de-labelled'). We developed an implementation intervention package that supports a multi-professional non-allergy workforce to deliver penicillin allergy de-labelling (PADL) in a UK hospital. To explore the experiences of doctors, nurses, pharmacists and medicines optimization pharmacy technicians (MOPTs) of the implementation intervention package. Methods:Process evaluation utilizing semi-structured interviews with doctors, nurses, pharmacists and MOPTs with a target sample size of 20. Inductive reflexive thematic analysis was used to analyse the data. Results:Fifteen interviews were conducted between 7 November 2024 and 25 March 2025 with six doctors, five pharmacists and four MOPTs. PADL aligned well with the medicine's reconciliation process, the process of accurately listing a person's current medicines, which meant it better aligned with pharmacists' and MOPTs' roles than doctors' roles. Healthcare worker (HCW) confidence to deliver PADL remained low among some doctors and pharmacists, but all reported that with time and support PADL would embed. Competing priorities in an inadequately resourced healthcare setting made PADL challenging. Professional bodies formally defining PADL as a core role for their HCWs would increase engagement with PADL. The PADL champion role was identified as key to the implementation of PADL. Conclusions:Competing priorities were limiting PADL engagement and as such PADL needs to be a core part of a HCW's role for it to be prioritized. The champion is required to support PADL as a shared responsibility and needs to be available until the process is embedded into ways of working.

There is increasing evidence to suggest that physical activity can slow Parkinson’s progression. There is also increasing interest in non-pharmacological interventions to alleviate Parkinson’s symptoms. This scoping review aimed to map and describe the evidence for interventions that promote physical activity in people with newly diagnosed Parkinson’s. Studies conducted since 2011, on adults with Parkinson’s (≥ 18 years), investigating the effects of non-pharmacological interventions to promote physical activity and/or exercise were considered. Interventions needed to be conducted in healthcare or healthcare-related settings for people within 5 years of Parkinson’s diagnosis. Published or unpublished full-text articles since 2011 were searched in November 2023, using online focused, broad, and grey literature databases. JBI scoping review methodology was used and results presented in table format accompanied by a narrative review. A total of 22 articles with a variety of research designs were included with 14 randomized trials, one single-site, prospective, single-arm study, two retrospective cohort studies, one case series, two case reports, and two qualitative reports. Many studies (n = 7) were conducted in outpatient clinics with the majority of interventions (n = 17) involving physiotherapists. Interventions varied widely, including aerobic exercise, balance exercise, dance, and yoga. The duration of intervention varied from 4 weeks to 8 years. Dosage of interventions varied widely from 30 to 90 min, and from twice weekly to seven times weekly. Several different outcome measures related to physical activity levels and/or physical fitness were used. The most frequent clinician/researcher reported outcome measure was the 6-min walk test (in nine studies) and the most frequently used participant/patient reported outcome measure was the 39-item Parkinson’s Disease Questionnaire (PDQ-39) (also in nine studies). The review showed limited research in identifiable cohorts with newly diagnosed Parkinson’s. Sample sizes were predominantly small. In all but one study, authors interpreted their results as favoring interventions to promote physical activity for people with newly diagnosed Parkinson’s. All authors recommended further studies. There is a need for more research with larger sample sizes and standardized reporting to inform the evidence base for interventions that promote physical activity in people with newly diagnosed Parkinson’s. https://pearl.plymouth.ac.uk/ ( http://hdl.handle.net/10026.1/20098 )

Background Delirium is a severe neuropsychiatric clinical state, presenting as acute cognitive deficits, altered levels of consciousness, inattention and psychotic episodes. Critically ill patients requiring invasive mechanical ventilation (IMV) have the highest risk of developing delirium in the intensive care unit (ICU). Best practice guidelines recommend a bundle of care to prevent delirium in the ICU. This includes early mobilisation interventions. However, these recommendations are based upon preliminary evidence. The FRECycl-D trial is a mixed-methods randomised controlled trial. The trial aims to investigate the feasibility of early (within 48-hours of IMV) in-bed cycling to reduce delirium in the ICU. This process evaluation will assess important implementation outcomes of the FRECycl-D trial. Methods A mixed-methods process evaluation of the FRECycl-D trial. Acceptability of the intervention and delirium outcomes will be explored using semi-structured qualitative interviews with trial intervention participants, their relatives and carers. Interviews will be carried out across the course of the 18-month trial recruitment period. The sample size will be guided by data adequacy. Reflexive thematic analysis will be conducted and themes linked to the Theoretical Domains Framework. Fidelity will be assessed at 6,9, and 18 months using descriptive data and integrated with the qualitative interview data. Conclusion Evaluation of the implementation outcomes will provide an explanation of the FRECycl-D trial results, highlight key areas for improving outcomes and inform decision makers in the implementation of a larger powered trial.

Objectives To develop a behavioural intervention package to support non-allergist healthcare workers (HCWs) to remove incorrect penA records from medical and surgical adult inpatients. This paper describes the development of the penicillin allergy de-labelling (PADL) intervention and the implementation intervention that will support non-allergist-delivered PADL.Design We combined evidence-based, theory-based and person-based approaches. Qualitative research with healthcare professionals and patients explored barriers and enablers to implementation of the proposed PADL pathway. Key intervention design objectives and the key features of the implementation intervention required to achieve each objective were then developed and captured as guiding principles. We produced a logic model, integrating the theoretical domains framework to identify the behavioural influences on PADL and the behaviour change wheel to show how the implementation intervention is hypothesised to address the target behaviours. The implementation intervention package was then reviewed by stakeholders and topic experts for further refinement and optimisation. Finally, we outline how the implementation intervention will be evaluated.Setting Single-centre District General Hospital in the SW England servicing a rural community of 575 000 people without local allergy services.Results HCWs reported PADL needed to be structured, standardised, evidence based and supported by hospital approved guidelines with easy to access patient information leaflets, supported by a sustained programme of education and training with named PADL leaders and visible PADL champions. Patients wanted a good explanation of the benefits and risks of testing and the benefits of having their ‘penA’ record removed. The identified HCW target behaviours were: taking a penA allergy focused history and to risk assess the patient’s penA history; to then either de-label the patient on history alone (direct de-label; DDL) or prescribe a direct oral challenge (DOC) dose; to perform baseline and post-test observations and counsel the patient on the risks of penA records and on the risks and the benefits of PADL. We identified barriers to target behaviours that we considered both important and modifiable, which included: lack of confidence in taking a penA focused history, PADL not viewed as a priority, low confidence with differentiating low-risk and high-risk penA histories, concerns about the safety of DOC, a requirement for senior support for nurses to deliver the observations and senior support for the other HCWs to deliver PADL, access to an expert for advice when required, a lack of PADL champions to promote PADL, and PADL not being supported by the organisation. The identified patient target behaviours were acceptance of the opportunity to be de-labelled via either DDL or DOC and willingness to take penicillin when prescribed. We developed intervention components to target the HCW and patient target behaviours which included: Education, expert advice made available from Infection specialists, a named PADL champion, hospital endorsed PADL guideline with necessary tools to enable PADL and patient information leaflets. The implementation intervention was further optimised through workshops with PADL researchers and stakeholders. The Consolidated Framework for Implementation Research outcome addendum was used to define both implementation intervention and PADL intervention outcomes.Conclusions We have developed a theory-based and stakeholder-developed implementation intervention to support inpatient PADL delivered by a multiprofession workforce. The intervention will be tested in a single hospital and scalability explored.

Background:Delirium is a severe neuropsychiatric clinical state presenting as an acute onset of cognitive deficits. Patients receiving invasive mechanical ventilation (IMV), have the highest incidence (50%-80%) of delirium amongst patients admitted to intensive care units. Preliminary data indicates that early mobilisation is associated with reduced delirium in critically ill patients. However, definitive evidence is lacking. Current practice varies due to many barriers to patients, who require IMV, receiving early mobilisation interventions. In-bed cycling may address some of these barriers. This research aims to evaluate the feasibility and acceptability of early in-bed cycling to reduce delirium in critically ill patients. Methods:This multi-site feasibility randomised controlled trial will evaluate early (⩽48 h following IMV), in-bed cycling as a method of early mobilisation, to reduce delirium. Eighty-four participants will be randomised across three sites in a 1:1 ratio, to receive either early in-bed cycling in addition to usual care or usual care alone. The primary outcome is feasibility (recruitment, retention, intervention fidelity). Secondary outcomes include different methods of measuring delirium, physical function, length of stay, ventilator free days, sedation free days, Richmond Agitation Sedation Scale, adverse events and mortality. Descriptive statistical analyses will be conducted. Hypothesis testing will be used for exploratory analysis of the mechanistic sub-study outcomes. An embedded qualitative interview study will evaluate the acceptability of this research. Conclusion:This trial has been prospectively registered (ISRCTN74277350) and received full ethical approval (REC reference: 24/SC/0096). The trial opened to recruitment in July 2024. Recruitment will take place across 18-months.

OBJECTIVES:This study aimed to illustrate the state of stroke care and rehabilitation in the Philippines through the perspectives of local government officials, policymakers, and organisational leaders. It sought to identify challenges, opportunities, and recommendations for improving stroke policies and services across different administrative levels. METHODS:Mixed-methods approach involving a structured survey of 131 local government officials and in-depth interviews with eight key stakeholders. Survey participants included Department of Health (DoH) officials, local chief executives, policymakers, Local Government Unit (LGU) employees, and representatives from non-government agencies. Interviewees comprised leads and managers from the DoH and representatives from organisations including the Philippine Academy of Rehabilitation Medicine (PARM), Physicians for Peace Philippines, and the Philippine Council for Health Research and Development (PCHRD). Quantitative survey data were analysed using descriptive statistics and qualitative interview data were thematically analysed, then the two types of data were triangulated and organised by theme. RESULTS:Findings revealed significant gaps in funding, healthcare infrastructure, and policy implementation. Challenges included inadequate facilities, lack of qualified staff, financial barriers, and regional disparities in service provision. Survey and interview participants emphasised the need for increased government support, comprehensive policies, and community-based rehabilitation (CBR) programmes. Improving stroke survivors' quality of life was ranked as the most critical aspect of rehabilitation programmes. CONCLUSIONS:The study highlights the critical need for more equitable and accessible stroke care and rehabilitation in the Philippines. This can be facilitated by sustained government support, inter-agency collaboration, community engagement, and the implementation of holistic, evidence-based, and cost-effective CBR initiatives.

Interprofessional collaboration (IPC) is crucial for the safe provision of maternity care. However, IPC is poorly understood in the maternity care context, and the role of the childbearing woman within this collaboration remains unclear. The Labouring Together study used a mixed method, multi-site case study design to explore IPC and decision-making with women from the perspectives of maternity health care professionals (HCP). Case studies included a range of maternity models of care in metropolitan and regional settings in Australia. Cross-sectional surveys were used to investigate organizational context and HCPs' attitudes toward collaboration. Experiences and perceptions of collaboration and decision-making were explored using in-depth semi-structured interviews. A conceptual framework "Experience of collaboration: Working together to get the best outcomes" was formed from the interview findings, with major themes of "Organisation of care: working together for the organisation" and "Partnering in care: working together with women." Individual-level behaviors were employed by HCP to transcend interprofessional tensions relating to IPC. Entrenched organizational and policy-level barriers to effective IPC were identified; and whilst participants agreed that women should have autonomy with decision-making, most identified barriers at multiple levels to achieving this ideal.

BACKGROUND:The results of rehabilitation clinical trials can be negatively affected by adherence to trial protocols. Adherence is multi-factorial, but studies often look at adherence factors separately. Therefore, a systematic review to appraise and synthesise the evidence is warranted to determine the barriers, facilitators and predictors associated with adherence to inpatient rehabilitation trial protocols, whether and how factors interact with one another, and how adherence to rehabilitation protocols can be optimised. METHODS:A mixed-methods systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Databases searched were PubMed (Ovid), EMBASE (Ovid), MEDLINE (Ovid), CINAHL (Ovid), PsycINFO (Ovid), Cochrane Library, Health Technology Assessment Database, Web of Science and grey literature up to April 2024. A cohesive, integrated methodology was employed, leveraging the Consolidated Framework for Implementation Research (CFIR) 2.0, to transform, synthesise and integrate data from various methodologies to address the review objectives. RESULTS:Twenty-seven studies met the inclusion criteria (randomised controlled trials, qualitative studies related to randomised controlled trials or mixed-methods). Most of the studies were in stroke (n = 17), but other studies included neurological, respiratory, cardiovascular, post-surgical, osteoarthritis and elderly medical. Multiple factors affecting adherence protocols were identified. Adherence was measured in various ways, and setting pre-specified adherence levels was uncommon. CONCLUSION:Adherence to inpatient rehabilitation trial protocols is multi-dimensional and multi-factorial. Consensus of adherence measurement and interpretation of adherence levels is needed to make meaningful comparisons between trials. A standardised approach, including adopting a traffic light system, would enable trialists to implement changes mid-trial or stop the trial to avoid research waste. Adopting approaches from behavioural science in the design and conduct of inpatient rehabilitation trials may overcome some of the behavioural barriers identified and optimise adherence for those delivering and receiving the intervention. REVIEW REGISTRATION:Prospective Register of Systematic Reviews, registration number CRD42021270121.

Aim To pragmatically investigate rectal emptying difficulty in women to identify if managing their symptoms with an innovative device is more effective and satisfactory than their usual care. Background Rectal emptying difficulty has a mostly unknown influence on women and frequently a hidden issue. Self-management alternatives are underappreciated. Despite the magnitude of the problem and its influence on women’s lives and healthcare, non-surgical alternatives have received little attention. Methods This cohort study of 35 female participants, recruited via secondary care outpatient clinics, used composite questionnaires before and after an 8-week intervention using the device. The questionnaire comprised of a quality of life instrument (International Consultation on Incontinence Questionnaire-Vaginal Symptoms and obstructed defaecation syndrome questionnaires), bowel diary recordings and participant feedback on using the device. Findings The device helped participants reduce the need to use their fingers (z= −2.844; p≤0.004) and offered participants improved lifestyle. There was significant reduction in difficulties to evacuate (p≤0.004), digitation to evacuate (p≤0.018), the feeling of incomplete evacuation (p≤0.002), straining to evacuate (p≤0.008) and lifestyle alteration (p≤0.046). The sense of incomplete emptying before and after using the device was significant (z= −2.646; p≤0.008), and feeling of being blocked improved (z= −3.317; p≤0.001). Stool consistency did not change. Medication to evacuate, returning to the toilet to evacuate and time needed showed no difference. Twenty-four participants (68.5%) completed the Patient Global Impression of Improvement question postintervention. Overall, 16 participants (66.7%) reported that the device was better than not using it. The results have clinical value, suggesting the device can assist women enhance their quality of life and improve physical symptoms associated with rectal emptying difficulties. Conclusions Most women with rectal emptying difficulty in this study found the device effective when compared with their usual care. Furthermore, it offers an additional conservative measure option within healthcare provision.

Background:Penicillin allergy (penA) records are common, but true penA is rare. PenA records are associated with broad spectrum antibiotic prescribing and negative patient outcomes. We developed a behavioural intervention package to support inpatient penicillin allergy de-labelling (PADL) delivered by a multi-profession non-allergist workforce to remove incorrect penA records from medical and surgical adult inpatients in a UK hospital. Aims:To explore the experiences, beliefs and concerns of patients who had been offered PADL. Methods:Semi-structured interviews to explore the views of patients admitted to a medical or surgical ward with a penA record and offered PADL between June 2024 and October 2024. Inductive reflexive thematic analysis was used to analyse the data. Results:Twenty patients were interviewed. Patients that believed their penA to be incorrect and those that described their index reaction as mild were more likely to agree to testing. Patients considered hospital a safe place to be tested. Some patients thought being acutely unwell was not a barrier to testing, whereas others preferred an outpatient setting once discharged from hospital. De-labelled patients described having a good explanation of the risks and benefits of PADL, were grateful for the opportunity and trusted the healthcare worker and the PADL process. Conclusion:PADL was well accepted by patients who described receiving a good explanation of the PADL process. Index reactions perceived as low severity (e.g. non-severe rashes) and/or doubtful of their penA (e.g. unaware they had a penA record) were more likely to accept PADL. Some who declined inpatient PADL would consider outpatient testing once recovered from their acute illness.