Complex older patients represent about half of all acute public hospital admissions in Australia. People with dementia are a classic example of complex older patients, and have been identified to have higher rates of hospital-acquired complications. Complications contribute to poorer patient outcomes, and increase length of stay and cost to hospitals. The care for older people with dementia is complex, and this has been attributed to: their cognitive response to being hospitalised; their limited ability to self-care; and lack of nursing engagement with the family caregiver. Registered nurses can offer simultaneous assessment and intervention to prevent or mitigate hospital-acquired complications. However, it is known that when demand for nursing care exceeds supply, care is prioritised according to acute medical need. Consequently some basic but essential nursing care activities such as patient mobility, communication, skin care, hydration and nutrition are implicitly rationed. This paper offers a theoretical proposition of 'Failure to Maintain' as a conceptual framework to indicate implicit care rationing by nurses. Care rationing contributes to functional and cognitive decline of complex older patients, which then contributes to higher rates of hospital acquired complications. Four key hospital acquired complications: pressure injuries, pneumonia, urinary tract infections and delirium are proposed as measurable indicators of 'Failure to Maintain'. Hospital focus on throughput constrains nurses to privilege predictable, solvable and medically-related procedures and processes that will lead to efficient discharge over patient mobility, communication, skin care, hydration and nutrition. This privileging, also known as implicit rationing, is theoretically and physiologically associated with a rise in the incidence of complications such as pressure injuries, pneumonia, urinary tract infection, and delirium. Complex older patients, including those with dementia, are at higher risk of the complications, therefore should have higher delivery of prophylactic intervention (ie have higher care needs). 'Failure to Maintain' offers a conceptual framework that is inclusive of, and sensitive to, this vulnerable population. Implicit rationing is occurring and it likely contributes to functional and cognitive decline in complex older patients and hospital-acquired complications. However, the lack of patient functional ability data at admission and discharge for hospitalised patients, and lack of usable ward and hospital level nurse staffing and workload data makes it difficult to monitor, understand and improve quality of care. Current research in the fields of acute geriatrics and nursing work environments show promise through enabling multidisciplinary team communication, and facilitating clinical autonomy to provide patient focussed care, and avoid 'Failing to Maintain'. The research field of acute geriatrics can understand and act on the risk modification role of nurses, including controlling for nurse staffing and work env...

ObjectivesTo identify rates of potentially preventable complications for dementia patients compared with non-dementia patients.DesignRetrospective cohort design using hospital discharge data for dementia patients, case matched on sex, age, comorbidity and surgical status on a 1 : 4 ratio to non-dementia patients.SettingPublic hospital discharge data from the state of New South Wales, Australia for 2006/2007.Participants426 276 overnight hospital episodes for patients aged 50 and above (census sample).Main outcome measuresRates of preventable complications, with episode-level risk adjustment for 12 complications that are known to be sensitive to nursing care.ResultsControlling for age and comorbidities, surgical dementia patients had higher rates than non-dementia patients in seven of the 12 complications: urinary tract infections, pressure ulcers, delirium, pneumonia, physiological and metabolic derangement (all at p<0.0001), sepsis and failure to rescue (at p<0.05). Medical dementia patients also had higher rates of these complications than did non-dementia patients. The highest rates and highest relative risk for dementia patients compared with non-dementia patients, in both medical and surgical populations, were found in four common complications: urinary tract infections, pressure areas, pneumonia and delirium.ConclusionsCompared with non-dementia patients, hospitalised dementia patients have higher rates of potentially preventable complications that might be responsive to nursing interventions.

Engagement and participation in the clinical workplace are valuable for nursing students. Strategies to support learning in the workplace can be shared with students and clinicians. Further research to test the theoretical premises of the communities of practice framework in clinical nursing education is required.

Missed nursing care is care that is delayed, partially completed, or not completed at all. The aim of this overview of reviews was to identify the nursing care that is missed, the factors that influence missed nursing care and the outcomes from it. To be included, reviews had to use the systematic review process and focus on hospital care. Databases were searched from inception until August sixth, 2020. One author screened the papers and extracted data on included reviews and a second checked this. Two authors independently assessed the quality of the reviews. Seven reviews were included in this overview. Categories of care missed included: (a) communication and information sharing; (b) self‐management, autonomy, and education including care planning, discharge planning and decision; (c) fundamental physical care; and (d) emotional and psychological care including spiritual support. Factors associated with missed care were related to staffing levels and/or labor resources skill mix, material resources not being available, patient acuity and teamwork/communication. Outcomes of missed nursing care included: less/poorer quality of patient care, patient satisfaction, and nurses' job satisfaction, increased patient adverse events, and the organizational outcomes of increasing hospital length of stay and hospital readmission. In‐depth qualitative and mixed methods research is needed to better understand how nurses prioritize care and why care is missed. Longitudinal and experimental research is required to better clarify if these relationships between missed care and negative patient outcomes are likely cause and effect.

This study highlights the need to acknowledge the expertise of the carer, and their need for support. Enabling a smooth discharge from hospital and support to navigate care access in the community is paramount. These experiences provide insight into gaps in service provision and modifying existing services may lead to improved experiences.

In a 'communities of practice' model of clinical experience for students, there are benefits for staff as well as students. The implementation of this clinical model in residential aged care was relatively low in cost, a benefit in this sector and has the potential to address the critical issues of recruitment and retention.

This study explored how first year undergraduate nursing students learn in clinical placements as part of a program informed by Wenger's (1998) social theory of learning. Forty-nine written student narrative accounts of a learning experience were analysed and three triggers for learning were identified. The first trigger is that participation (or observation) of a task or procedure leads students into a complex, dramatic reading of nursing work. The second is that when students are personally (emotionally) confronted by the work, it presents a high challenge situation, recognized by students as a significant learning opportunity. The third trigger is encounters with different nurses assist students to construct an image of what they want to be as a nurse. These three triggers appear to align with Wenger's Communities of Practice constructs for identity, engagement, imagination, and alignment, and provides preliminary evidence supportive of the social theory of learning for nursing students on clinical placement.

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