AIM:This study aimed to develop recommendations for acceptable physical and psychological clinical indicators of acute deterioration and strategies to support sustained adoption of an approach to detecting and responding to acute deterioration in long-term care. BACKGROUND:Previous studies have trialled programmes to reduce avoidable hospital transfers through early detection of acute deterioration in long-term care. However, variability in outcomes and implementation experiences highlights differences in the essential components of these approaches. DESIGN:Three-round Delphi process. METHODS:The Delphi process conducted between September 2022 and January 2023 included a 22-member Australian expert panel to elicit consensus and to generate recommendations. Delphi participants were asked to rate the potential items on a 9-point scale for level of importance (Part A), level of priority of action (Part B) and level of acceptability (Part C). The mean, standard deviation (SD) and I-CVI of each item were calculated. Clinical indicators with mean ≥ 7, I-CVI ≥ 0.78 were considered to have a good degree of agreement, appropriateness and relevance and were deemed acceptable for inclusion. RESULTS:Participants completed a two-part online survey in Round 1, and three-part surveys in Rounds 2 and 3. Round 1, Part A included 44 clinical indicators. On completion of Round 3, 36 items remained. Care pathways in response to acute deterioration (n = 20) were included in Part B. After Round 3, 17 care pathways remained. There was agreement in Part C that communication aides, education and mentor programmes were necessary as viable strategies to support sustained adoption. CONCLUSION:Detecting the early warning signs of acute deterioration will have significant outcomes for residents, staff and health care services.

Examine the quality of evidence relating to the association of routine inflammatory biomarkers neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and monocyte-lymphocyte ratio (MLR) with symptoms, treatment toxicities, and quality of life (QoL) in people with advanced cancer. Searches were conducted in MEDLINE, Embase, CINAHL and the Cochrane database to identify studies that investigated associations between NLR, PLR and MLR with symptoms, toxicities and QoL in people with advanced cancer. The evidence was graded as good, fair or poor through the application of the National Institute of Health (NIH) quality assessment tool. A narrative approach was used for data synthesis. Of the 38 studies reviewed, NLR was the most frequently investigated biomarker. Thirteen studies found no association between NLR and symptoms or treatment toxicities. Of the 25 that did, five provided good quality evidence linking NLR to immune-related adverse events (irAEs), chemotherapy-related haematological toxicities and insufficient oral intake. However, NLR cut-off values varied across studies. Ten studies reported an association between PLR and symptoms or treatment toxicities whilst six studies found no associations; one study found no association with MLR and symptoms or treatment toxicities. Further research is needed to establish specific cut-off values of NLR to increase the utility of this biomarker in clinical practice. PLR and MLR warrant further investigation for association with symptoms, treatment toxicities and QoL.

Palliative and supportive care provided in the home for individuals with heart failure and their carers can improve quality of life, reduce symptom burden and hospital admissions. However, enabling this care in accordance with what matters to individuals living with heart failure and their carers remains elusive. This research aimed to explore the experiences, perspectives and preferences of individuals with heart failure and their carers on home-based palliative and supportive care. A qualitative study using semi-structured interviews was conducted with individuals with heart failure and carers, recruited from two tertiary care hospitals in Queensland, Australia. A total of eleven individuals with heart failure and ten carers participated. Their age ranged between 40 and 84 years. Most participants were female (n = 14, 66.7

Populations are rapidly ageing. Advance Care Planning (ACP) is an important activity to help prepare for future healthcare needs. Little is known of the perceptions of the general public of the Asia-Pacific region in relation to these activities. Within the context of the Asia-Pacific region, this review aimed to explore awareness of, attitudes towards, experiences of, and the needs, wishes, and/or expectations related to ACP/Advance Directives (AD) of the general public. The systematic review protocol was registered with PROSPERO (December 17, 2023): CRD42023491109). PubMed, CINAHL, PsycINFO, Embase, and Emcare databases were searched 2013 to 2023 for primary research, of any design, that reported perspectives and experiences of the general adult public of the Asia-Pacific region relating to their awareness, attitudes, experience, and expectations of ACP/AD. The literature searches were updated in PubMed to 31 December 2025. Selected studies were quality appraised using the Mixed Methods Appraisal Tool. Findings were synthesised using Cochrane’s narrative synthesis approach. Out of 3,275 records retrieved, 14 studies were included in this review. This review found that awareness of ACP/AD among the general public in the Asia-Pacific region is relatively low and it was not uncommon for them to know nothing about substitute decision maker decision makers and other terms related to ACP/AD. While they believe ACP is necessary and important, only a minority have had previous discussions regarding ACP and the reported completion of AD was minimal. Various factors that influence people’s willingness to engage in ACP/AD were found, such as wanting legal parameters to protect patient autonomy. Expectations of medical professionals to have good communication skills when discussing ACP were highlighted as well as the need for legal parameters to support ADs. This review highlights that awareness of ACP/AD among the general public in the Asia-Pacific region is low. As proven by the small number of papers which informed this review, more robust studies are needed on various aspects of this topic in the context of the Asia-Pacific region. Such studies would inform the best ways to move forward in improving the awareness and knowledge of, and to improve attitudes towards, ACP/AD to ensure people’s treatment decisions are discussed, documented, respected and enacted.

This systematic review synthesises data relating to the effectiveness of behavioural interventions aimed at reducing alcohol consumption among people living with cancer. Five databases were systematically searched for randomised controlled trials (RCTs) published between January 2000 and April 2025 that reported behavioural interventions addressing alcohol consumption among people living with cancer. Evidence was assessed using the Cochrane Risk-of-Bias tool. Meta-analysis was not feasible due to substantial heterogeneity and few eligible studies. Instead, a TIDieR-guided narrative synthesis with vote-counting was performed. We conducted this systematic review according to the PRISMA 2020 statement. Eight RCTs (n = 1437) were included. Two trials targeted alcohol reduction, whereas the remaining six addressed alcohol use within broader multiple health-behaviour interventions. Alcohol intake was assessed via self-report using heterogeneous measures. At 2–3 months, all five reporting studies favoured the intervention (100

OBJECTIVES:To assess palliative care utilization, estimate duration of care, and identify predictors of care duration among general practitioner (GP)-referred patients following commencement of specialist palliative care. DESIGN:Multicenter retrospective cohort study. SETTING AND PARTICIPANTS:This study included patients with life-limiting illnesses referred by GPs between July 1, 2019, and June 30, 2024, and who received care from services registered with the Australian Palliative Care Outcomes Collaboration. METHODS:Two outcomes were assessed: (1) palliative care utilization (inpatient vs community) and (2) duration of palliative care, measured in days. Binary logistic regression identified factors associated with inpatient vs community palliative care utilization, and quantile regression identified predictors of palliative care duration from first admission to death. RESULTS:Of 25,124 GP-referred patients, 92.2% were admitted to community palliative care and 44.4% died during the study period. Most deaths (81.3%) occurred within 3 months of commencing specialist palliative care. Admission to inpatient care was more likely among patients with cancer and those experiencing distress from breathlessness, nausea, or psychological/spiritual problems, and less likely among those with higher functional status, older age, distress from appetite or fatigue, and family/carer problems. Among decedents, shorter duration of palliative care was associated with inpatient care, functional decline, distress from pain, breathlessness, and family/carer problems. CONCLUSIONS AND IMPLICATIONS:GP-referred patients were predominantly admitted to community-based palliative care, and most of them received specialist palliative care for a shorter duration than recommended. Future research in primary care, exploring needs-based referral models and referral acceptance, may support timely access and comprehensive care.

Background:Understanding how symptom outcomes vary by care setting helps optimize care.Aim:To compare trajectories of severe symptom distress in the final week of life across community and hospital settings.Design:This retrospective consecutive cohort study used point-of-care data from the Australian Palliative Care Outcomes Collaboration, which includes the Symptom Assessment Scale and Palliative Care Problem Severity Score. Mixed-effects logistic regression models were adjusted for clinical, demographic and temporal factors.Setting/Participants:Australian palliative care services (n = 165) contributed data for people who died between July 1, 2019, and June 30, 2024.Results:Of 141,691 patients,73.6% were inpatients; 61.0% had a cancer diagnosis. Severe symptom prevalence was generally low (<5%). After adjusting important factors, inpatients had higher relative odds of severe pain-related (aOR: 1.20, 95% CI: 1.10, 1.30) and breathing-related distress (aOR: 1.55, 95% CI: 1.40, 1.70) compared with community patients; the corresponding absolute risk differences (ARDs) were minimal (pain: +0.36 percentage points; breathing: +0.79 percentage points). Conversely, inpatients had lower relative odds of severe fatigue (aOR: 0.86, 95% CI: 0.79, 0.94) and insomnia (aOR: 0.74, 95% CI: 0.66, 0.84), with small ARDs (fatigue: -0.32; insomnia: -0.26). Over time, severe breathing-related distress increased significantly as death approached, while pain-related distress increased slightly. Inpatients were also less likely to experience family/carer issues (aOR: 0.78, 95% CI: 0.72-0.84), or other symptoms (aOR: 0.57, 95% CI: 0.53-0.61), with small ARDs (family/carer: -0.56; other symptoms: -0.26).Conclusions:While some relative differences were noted between settings, absolute differences were minimal, suggesting clinically comparable outcomes. These national data show that severity of symptoms in the two care settings are similar, reassuring patients, families, and health care professionals.

Acute inpatient care does not always align with the known palliative care needs and preferences of people with deteriorating health. The LEAHP (Listen, Empower and Act to improve Hospital Palliative care) bundle is a novel intervention combining collection and feedback of patient reported experience measures (PREMs), an understanding of context, co-design of a shared vision and facilitated clinician-led improvements in quality of care, for inpatients with palliative care needs. We describe the resource requirements for pilot implementation of the LEAHP bundle, and potential cost considerations for sustaining and spreading this initiative. A prospective costing analysis was conducted alongside a pre-post implementation study between May 2022 and Nov 2023 across three wards in a large hospital in Australia. A health service perspective was taken, with costs collected during the study period and valued in 2023 Australian dollars. Costs included Project Team and Clinical Team labour, as well as non-labour resources. Time-driven, activity-based costing methods were adopted, with implementation activities categorised using a modified Expert Recommendations for Implementing Change (ERIC) Framework headings. A scenario analysis explored cost reductions that would support sustaining and spreading of the initiative. The total average cost of implementing the LEAHP bundle for each ward over approximately 12 months was 37,019; consisting of26,289 (71

Optimising hospital care to align with what matters most for people living with advanced serious illness is a global priority area for improvement. Collection and feedback of patient reported experience measures (PREMs) is one potential method to inform improvements. This study used the integrated Promoting Action on Research implementation in Health Services (i-PARIHS) framework to inform the implementation of a complex intervention that included collection and feedback of PREM data and facilitation to empower ward-based quality improvements for inpatients with advanced serious illness. A single-site pre-post quality improvement study within a large Australian hospital. The intervention titled Listen, Empower and Act to improve Palliative care (‘LEAP’ bundle’) included three phases: ‘Listen’ – collecting and analysing patient (PREM) and clinician perspectives to understand current care experience and local context; ‘Empower’ – collating PREM feedback and facilitating local stakeholder engagement to identify and prioritise areas for improvement; and ‘Act’ – facilitating clinician led innovation development and implementation informed and monitored by continuing PREM collection and feedback. Intervention fidelity was summarised descriptively from field notes and meeting records. The primary effectiveness outcome was change in ‘very good’ experiences over time, reported from an eight-question validated PREM designed for inpatients with serious illness (consideRATE). Analysis used mixed binary logistic regression with time period as fixed effect and ward as random effect. The three participating wards completed the intervention with some adaptations, and each implemented different innovations. The proportion of ‘very good’ responses showed a statistically significant increase for all consideRATE questions in intervention periods 1–4 compared to period 0 (baseline). All questions except ‘attention to feelings’ (Q2) were significantly improved by the first measurement period, and all except ‘attention to affairs’ (Q6) remained significantly higher than baseline during the final measurement period. Implementation of the LEAP bundle led to improved palliative care experience within three wards in one large tertiary hospital setting. Listening to patients and empowering clinical teams to collectively reflect on data and lead change was crucial to study success and required skilled facilitation. Testing the sustainability, transferability and scalability of the intervention will be important next steps.

Individuals undergoing chemotherapy experience a range of symptoms that can significantly impact their quality of life and treatment outcomes; the prevalence and severity of which can change across their treatment journey. This study aimed to identify and describe the longitudinal symptom experience during the first four months of chemotherapy administration across a range of cancer diagnoses. A prospective longitudinal cohort study was conducted at a cancer centre in Queensland, Australia. Monthly surveys assessed symptoms, distress, and quality of life across 4 months of chemotherapy. A total of 252 participants completed baseline surveys (mean age 61 ± 12.3 years; 65

OBJECTIVE:To investigate how the presence of multiple parties during paediatric palliative care encounters influences involvement of child patients. METHODS:This mixed-methods observational study analysed 60 video recorded routine clinical encounters within three paediatric palliative care services in Australia. These were classified using a coding scheme that was iteratively developed using conversation analysis methods. Coded data were analysed statistically, with qualitative conversation analysis methods used to explore statistical findings. RESULTS:Statistical analysis of coded data indicated that child involvement increased when more adults were present during an encounter. The number and role of adults present were associated with child involvement. Clinicians were most involved with child patients when there were at least two clinicians present. Clinician involvement with child patients peaked when multiple clinicians were present and when there was only one adult family member present. When multiple family members were present, the likelihood that children would respond to attempts by adults to involve them increased. CONCLUSIONS:Including multiple clinicians and family members in paediatric palliative care encounters is associated with increased involvement of child patients. PRACTICE IMPLICATIONS:To foster optimal conditions for the involvement of children, multiple clinicians and - where possible - multiple family members should be present during clinical encounters.

BACKGROUND:Nurse retention and wellbeing have reached alarmingly low levels in recent years and health systems globally are searching for large-scale systemic solutions to reduce nurse burnout, improve wellbeing, and increase job satisfaction and retention while simultaneously enhancing patient care quality and safety. OBJECTIVE:To evaluate whether a minimum nurse staffing policy intervention in Queensland Australia improved nurse wellbeing, intentions to leave employment, and patient safety. METHODS:This is a quasi-experimental intervention study in which we compared nurse outcomes, patient safety measures, quality of care indicators, and operational failures among 27 hospitals subject to a minimum nurse staffing policy (i.e. intervention hospitals) and 41 hospitals not subject to the policy (i.e. comparison hospitals) at two points in time: prior to implementation of the policy (i.e. baseline) and two years after implementation (i.e. post-implementation). Percentages of nurses with unfavorable outcomes and unfavorable ratings of quality of care and patient safety are reported for intervention and comparison hospitals at baseline and post-implementation of the staffing policy. Fixed effects logistic regression models evaluated the interaction between the intervention effect and the post-implementation period to report the impact of the staffing policy on outcomes. RESULTS:The minimum nurse staffing policy intervention was associated with improvements in staffing, nurse wellbeing and job outcomes, and quality of care and patient safety in the intervention hospitals. Nurses in intervention hospitals had 24 % lower odds of high burnout (OR 0.76, 95 % CI 0.61-0.94, p < 0.05) and 27 % lower odds of job dissatisfaction (OR 0.73, 95 % CI 0.59-0.91, p < 0.01) at post-implementation relative to the baseline; no statistically significant differences in these outcomes were found among comparison hospitals. Job dissatisfaction with workload, professional development, autonomy at work, and work schedule all declined significantly in intervention hospitals and worsened over time in comparison hospitals. Nurse work environment scores improved in the intervention hospitals and worsened in the comparison hospitals. Quality of care, patient safety, and operational failures markedly improved in the intervention hospitals and generally worsened in the comparison hospitals. CONCLUSIONS:The quasi-experimental study design gives policymakers and hospital administrators strong confidence that minimum nurse staffing policy interventions can result in more favorable work environments for nurses, better job outcomes including lower nurse burnout and job dissatisfaction, and improvements in quality of care and safety for patients.

Introduction Breast cancer is the most commonly diagnosed cancer among women worldwide. Survivors often experience physical and psychological effects arising from breast cancer and its treatment, which can last months and years, adversely impacting quality of life. As the number of early breast cancer survivors increases, models of specialist-led follow-up care in hospital settings are not sustainable and evidence suggests that they may not meet survivors’ needs. Nurse-enabled, shared-care, follow-up models between cancer specialist and primary care teams have potential to address this need.Methods and analysis The proposed research is a multicentre, prospective, pragmatic, stepped-wedge cluster-randomised trial designed to test the effectiveness and implementation of IBIS-Survivorship, a follow-up care model for patients with early breast cancer who have completed primary treatment. The IBIS-Survivorship intervention involves a nurse-led consultation, development of a Survivorship Care Plan and case-conferencing between a breast care nurse and the patient’s primary care provider. This study seeks to recruit 1079 breast cancer survivors across six cancer centres (clusters) in Australia. Health-related quality of life at 12 months assessed by the Functional Assessment of Cancer Therapy - Breast Cancer questionnaire will be the primary endpoint, along with a range of patient-reported outcomes, safety indicators and cost-effectiveness measures as secondary endpoints. General and generalised linear mixed models will be used to assess the effectiveness of the intervention versus usual care. Implementation and process outcomes will be assessed using the Reach Effectiveness Adoption Implementation Maintenance framework.Ethics and dissemination Ethical approval was provided by the Metro South Hospital and Health Service Human Research Ethics Committee (HREC/2020/QMS/59892) and reciprocally across the other five trial sites under National Mutual Acceptance arrangements. Results will be disseminated through peer-reviewed academic journal publications and presentations at national and international conferences.Trial registration Australia and New Zealand Clinical Trials Registry (ANZCTR) Trial ID: ACTRN12621000188831.

Population ageing and rising levels of non-communicable diseases are increasing the number of people living with and dying from advanced serious illnesses globally. Many of these people are hospitalised more than once in their last year of life. While there is sound evidence on what patients and their families require for safe and high-quality hospital palliative care, enabling this remains a challenge. This study aimed to understand the clinician, team, and organisational-level barriers and enablers to integrating good palliative care into acute care. An exploratory-descriptive, qualitative study involving semi-structured interviews and practical thematic analysis was conducted. Medical, nursing and allied health disciplines were recruited from three wards (cancer care, mixed general medicine/renal and mixed general medicine/respiratory) within a large Australian metropolitan hospital. Eighty-eight interviews (nursing (n = 39); medicine (n = 24); allied health (n = 25)) were undertaken, with a median duration of 25.5 min (range 5 to 55 min). Most participants were female (n = 73, 83

12099 Background: The MOST-S26 is a patient-reported outcome measure that complements follow-up after first-line treatment for ovarian cancer (OC). MOST-S26 enables assessment of physical and psychological symptoms, and well-being. A randomized trial was conducted to evaluate nurse-led follow-up for OC via telehealth using the MOST-S26 to structure consultations vs routine hospital follow-up (ACTRN12620000332921). A qualitative sub-study assessed acceptability of the intervention from patient and nurse perspectives. Methods: Semi-structured interviews via video or telephone explored experiences of receiving or delivering nurse-led follow-up. Patients that participated in at least two nurse-led follow-up appointments were eligible. Study nurses delivering the intervention were interviewed at the end of the trial. Interviews were recorded, transcribed and coded using a Framework Approach following five stages: familiarisation, developing a thematic framework, indexing, charting, mapping and interpretation. Results: From June 2021, 38 patients were enrolled at 6 Australian sites. The trial closed to acrual in April 2024. Twenty-one participants were interviewed (15 women with OC and 6 study nurses). Analysis identified 3 overarching themes: (1) key patient-centred benefits (convenience and flexibility; providing a sense of connection and feeling cared for; enabling personalised, holistic care and prompt management of symptoms; providing dedicated space for patients’ to freely express experiences and emotions); (2) challenges to delivery from nurses’ perspectives (emotional impact of patients' cancers recurring; lack of referral pathways; inability to observe physical cues; difficulties establishing rapport; and, lack of suitability for all patients e.g. non-English speaking or patients with low literacy); and, (3) Nurse views on usefulness of MOST-S26 to support consultations (provides a useful tool to guide consultations/referrals, detect recurrence, track symptoms over time, flag symptoms for discussion, and, helps patients’ reflect on their symptoms). Conclusions: Results confirmed acceptability of this type of follow-up for both OC patients and nurses. Both reported several benefits compared with standard hospital-based follow-up. Challenges that should be considered prior to routine implementation of this follow-up model included: the need to provide support to nurses to cope with the emotional impact of patients’ cancers recurring; developing clear referral pathways for symptom management; and considering the characteristics of patients most and least suitable for this type of follow-up. Clinical trial information: ACTRN12620000332921 .

The Multinational Association for Supportive Care (MASCC) recently published its Supportive Care 2030 Movement with the aims of developing consensus about shared, equitable and translatable ambitions to drive excellence in and outline the desired state of supportive cancer care by 2030. In response to the publication of the ambition statements, the major oncology nursing organizations launched a collaboration in June 2024 with the aim of achieving global nursing excellence and leadership within the wider interdisciplinary model of supportive cancer care. This editorial presents our collective response to the ambitions set by the Supportive Care 2030 Movement. We believe that the 13 ambitions can realistically be achieved only if five prerequisites are in place that put oncology nursing at the forefront of any relevant endeavor.

BACKGROUND:Despite significant advances in the availability and quality of palliative care globally, health economics research to understand the value of palliative care in Australian settings remains scarce. To address knowledge gaps and foster evidence-informed policy, funding and practice, this paper presents a consensus-driven research agenda for the health economics of palliative care in Australia. METHODS:A panel of 27 Australian experts was convened, including health economists, palliative care clinicians/researchers, policy makers/government officials, and representatives from the national peak body for palliative care. Panel members completed a survey, participated in a forum and collectively drafted the research agenda. RESULTS:The panel recommended 16 health economics research priorities across four key areas: (1) person-centred outcomes; (2) costs; (3) economic evaluation; and (4) data and metrics. Specific priorities included: comprehensively capturing the benefits of palliative care for people with life-limiting illnesses and their informal carers; understanding the diversity of preferences for palliative care across the population; capturing informal caring costs within economic evaluations; embedding economic evaluation within clinical trials and health services studies; and quantifying the extent and location of unmet palliative care needs. CONCLUSIONS:This paper outlines high-priority research actions to generate the economic evidence required for appropriate funding and resource allocation in palliative care. The research agenda serves as a strategic tool to help researchers address gaps without duplicating efforts. By focusing on these priorities, we aim to support the development of more effective, equitable and sustainable palliative care services across Australia.

AIM:To explore multidisciplinary clinical, academic, policy and governance stakeholders' perceptions of enablers and barriers to implementing designated registered nurse prescribing in Australia, using a systems-thinking approach. DESIGN:A two-phase explorative study using a systems-thinking lens to investigate complex health-system interdependencies. METHODS:Fifty-three participants were recruited from all Australian states and territories, including registered nurses, nurse practitioners, pharmacists, medical practitioners and health-service planners. Phase 1 involved interviews and focus groups conducted between February 2024 and April 2024 (n = 45), analysed using deductive content analysis, guided by the Sustainability of Innovation Framework. Phase 2 was a face-to-face workshop conducted in August 2024 (n = 28), with data from participant discussions and observer field notes analysed inductively and refined through reflexive dialogue. Reflexive analysis of the findings allowed the construction of recommendations for implementation in various healthcare contexts. RESULTS:In Phase 1, participants representing all Australian jurisdictions and healthcare contexts identified that successful adoption of designated registered nurse prescribing is contingent upon several interrelated system components. These interconnected factors influence each other within the broader healthcare system and serve as the focus for Phase 2. In Phase 2, participants reported context-specific service models, stakeholder engagement, financial support, clear messaging and workforce/organisational readiness for new models of care and service delivery were recognised as dynamic interrelated elements. Three overarching themes for successful implementation were generated: The Standard-just one piece of the puzzle. Harnessing collective capability. Shared wisdom for success. CONCLUSION:National implementation of registered nurse prescribing requires consistent but context-responsive reforms. A systems-thinking approach underscores the need for whole-of-system strategies, acknowledging interdependencies and avoiding rapid, unplanned implementation. This study highlights that sustainable adoption of registered nurse prescribing in Australia depends on recognising system interdependencies and their dynamic nature. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:Designated registered nurse prescribing has the potential to improve timely access to medicines and enhance patient-centred care when implemented with whole-of-system support. This study provides key systems-level recommendations to guide policymakers and healthcare services to successfully implement designated registered nurse prescribing across various settings. IMPACT:This study highlights key stakeholders' perspectives, providing valuable insights on the essential elements required for the successful adoption of this expanded practice. Broad systems-level recommendations are offered to guide policymakers and healthcare services to successfully implement designated prescribing across various settings, taking into account the complexity of the healthcare system. REPORTING METHOD:Consolidated criteria for reporting qualitative research guidelines. PATIENT OR PUBLIC CONTRIBUTION:This study did not include patient or public involvement in its design, conduct or reporting. REGISTRATION:Not registered.

AIM:This study aimed to identify diverse ways nonspeaking and speaking children are involved in clinical encounters. METHODS:The study analysed video recordings of paediatric palliative care encounters in Australia. Conversation analytic coding methods were used to identify embodied (e.g., gesture) and vocal (e.g., grunting) modes of interaction used by all children and lexical verbalisations (i.e., words) used by speaking children. Analysis focused on interactions between children and adults (both family members and clinicians). RESULTS:A total of 38 child patients (seven speaking, 31 nonspeaking), 56 family members and 50 clinicians participated across 60 video-recorded encounters with the child patient present. Analysis identified 1737 spates (i.e., periods) of interaction with child patients. Nonspeaking children were involved in a median of 38.0 spates of involvement per hour and speaking children in a median of 58.7 spates per hour. Observed practices of nonspeaking and speaking children included adult clinicians and family members doing something with a child without speaking, identifying the child as a recipient of some action, assessing the child, telling the child something, and physically tending to the child with verbal commentary. Clinicians and adult family members more often initiated spates of involvement (62.9%) than children themselves and were more responsive to spates initiated by nonspeaking children (89.6%) than speaking children (79.3%). CONCLUSIONS:This study demonstrates how children-including nonspeaking children-are regularly involved in clinical encounters. The study findings indicate a need to avoid exclusively focusing on verbal communication, to appreciate the diverse ways that children can be involved in clinical encounters about them.