Elderly peoples' experience of nursing care after a stroke: from a gender perspective

Title.  Elderly peoples' experience of nursing care after a stroke: from a gender perspective.
Aim.  This paper is a report of a study conducted to explore, from a gender perspective, older people's experiences of nursing care after a stroke.
Background.  Little attention has been given to gender differences in nursing care. The majority of people who have a stroke are older. Improving knowledge of the gender perspectives of older men and women regarding nursing care after stroke is crucial.
Method.  This was a qualitative study based on interviews with five women and five men between 66 and 75 years of age, who had received nursing care at a ward for stroke rehabilitation. The data were collected in 2006. Qualitative content analysis of the interviews was carried out.
Findings.  A main theme and five categories, all common to both men and women, were identified. The main theme, to promote recovery of the body, encompassed the categories. There were, however, gender differences in how the nursing care received was experienced. The ways patients experienced nursing care seemed to be linked with their lives as women and men before they had the stroke. Their perceptions are linked with their lives as women and men before they had their stroke. Both men and women will reclaim former abilities but what they perceive to be the goals of nursing care and rehabilitation may differ.
Conclusion.  Nurses need to increase their awareness and knowledge concerning the similarities and gender differences in the experiences and needs of older people, both men and women.     

Staying in 'the stream of life': rehabilitation of older people in their own homes following total hip replacement

Background.  According to World Health Organization (WHO), rehabilitation should be based on the person's entire situation with a focus on body functions, level of activity, participation and environment. But different types of investigations show an unclear concept of rehabilitation in professional nursing.
Aims and objectives.  This study aims to identify older persons' (≥75 years of age) experiences of the rehabilitation process after total hip replacement.
Design and methods.  Qualitative interviews were undertaken with six persons who were rehabilitated in their own homes following total hip replacement. The interviews were guided by Max van Manen's phenomenological methodology with its focus on the life world as described through patients' experience of time, space, body and interpersonal relations.
Results.  Staying in the stream of life confirmed the importance of the life world. What is essential in the rehabilitation process is to get back into everyday life as soon as possible and participate in activities which are meaningful and which are linked to being at home where 'you can be who you are'. The home is the framework for being in the stream of life, and it provides the centre of gravity for the people's welfare.
Conclusion.  Staying in the stream of life is about being the author of one's own meaningful life. It takes into account life phenomena embodied in the maintenance aspect of health care; dignity in relation to identity and integrity; and an understanding of the dialectical relation between frailty and strength.
Relevance to clinical practice.  Rather than focusing exclusively on patient participation and goal-directed activity, nursing actions should integrate life phenomena as key aspects of rehabilitation with older people in their own right.     

Hip fractures and cognitive state: patient outcomes and proxies' perceptions of the rehabilitation period

Background.  Numerous studies are available on hip fracture and rehabilitation outcomes, some mention dementia but very few from a family/proxy perspective.
Aim.  To investigate whether cognitive state influences the hip fracture patients' rehabilitation outcomes as well as the proxies' perceptions of the 6-month rehabilitation period.
Design.  A survey with structured and unstructured questions. Statistics and content analysis.
Methods.  The questionnaire was sent to 40 proxies of hip fracture patients with and without cognitive impairment, 32 replied. Statistics and content analysis were used to analyse the data.
Results.  In the cognitively impaired group, physical function decreased ( P  = 0.0241) as well as locomotion ( P  = 0.0005) compared to pre-fracture. This group mainly participated in rehabilitation sessions in institutions ( P  = 0.0001) and their main support came from nursing staff. The cognitively impaired group assessed the rehabilitation period as being of a much lower quality than the cognitively intact group ( P  = 0.0048). In the impaired group, hindrances to rehabilitation were low level of staffing, and lack of access to rehabilitation resources such as physiotherapists.
Conclusions and relevance for clinical practice.  Hip fracture patients are a dichotomous group and cognition is decisive for physical and social outcomes as well as type of rehabilitation support.     

Relationship between the length of hospital stay after hip fracture surgery and ambulatory ability or mortality after discharge in Japan

Aim:  To examine whether the length of hospital stay after hip fracture surgery is related to patients' ambulatory ability or mortality after discharge.
Methods:  This is a retrospective observational study of patients who had undergone hip fracture surgery at one of three hospitals in Japan. The medical records of patients who were ≥65 years and who had hip fracture surgery within the past 2.5 years were reviewed regarding the demographics, treatments, and health outcomes during the hospital stay. A mail survey, asking about health outcomes after discharge, was sent to the study participants and/or their family members. The response rate of the survey was 70% ( n  = 149).
Results:  The patients who were discharged between 30 and 39 days after surgery had significantly lower current ambulatory ability, compared to the patients who stayed for ≥40 days, after adjusting for patient characteristics, treatments, and hospital. The patients who were discharged within 2 weeks after surgery and the patients who were discharged between 30 and 39 days after surgery had a significantly higher risk of mortality, compared to the patients who stayed in the hospital for ≥40 days, after adjustments were made.
Conclusions:  If patients are discharged to a rehabilitation hospital before they are totally recovered from surgery, the emphasis might be on their rehabilitation without adequate management of their comorbidities. Additional prospective studies are needed to determine the effects of a shorter length of hospital stay after hip fracture surgery on patient outcomes.     

Promoting self-management improves the health status of patients having peritoneal dialysis

Title.  Promoting self-management improves the health status of patients having peritoneal dialysis.
Aim.  This paper is a report of a study conducted to explore the effects of promoting self-management on the well-being of patients having peritoneal dialysis.
Background.  Peritoneal dialysis is a home-based treatment for end-stage renal disease. Promoting self-management has been shown to improve the health status of people with diabetes mellitus and other chronic diseases. However, little is known about the effects of self-management support for patients having peritoneal dialysis.
Method.  Thirty patients who had received peritoneal dialysis for at least 6 months and were clinically stable were enrolled in the study in 2006. A multidisciplinary team was built to support the patients' self-management. Various forms of education such as group discussion and individual consultation were used to improve patients' self-efficacy and all were followed up for 6 months. We compared the volume status, adequacy of dialysis, nutritional status, quality of life, rehabilitation status, self-management capacity and self-efficacy levels at baseline, 3 and 6 months after enrolment.
Results.  During follow-up, patients' urine volume and residual renal function decreased, while the adequacy of dialysis (Kt/v and Ccr) did not change. Volume status, quality of life and rehabilitation status all improved, whereas nutritional status did not deteriorate. Both self-management capacity and self-efficacy level increased statistically significantly.
Conclusion.  A team approach needs to be taken to achieve successful self-management in patients having peritoneal dialysis, as with other chronic disease treatments. Nurses should use multiple strategies based on self-efficacy theory to improve patients' self-efficacy levels and self-management capacities.     

Striving for independence: experiences and needs of service users with life limiting conditions

Title.  Striving for independence: experiences and needs of service users with lifelimiting conditions.
Aim.  This paper is a report of a study to explore what service users with a range of life-limiting conditions identify as their key experiences and needs generally and, specifically, from health and social care services.
Background.  Whilst internationally palliative care has a primary focus on service users who have cancer, there is growing evidence that those with non-cancer life-limiting conditions have similar palliative care needs. The literature has mainly been focused on independence, choice and control at an individual level, with wider influences on the maintenance or attainment of independence ignored.
Method.  A participatory approach was used in 2003–2004, with both the researcher and a group of service users working together in all stages of the study. Twenty-five participants in receipt of support from an acute hospital, primary care, social services and a hospice took part. Face-to-face individual interviews and small discussion groups were conducted and data were analysed thematically.
Findings.  Eight different but interconnected themes were identified. Independence/dependence was an overarching theme, with negotiation between independence and dependence being evident across all themes. This theme and the influence of health and social care services on the experience of living with life-limiting conditions are the focus of this paper.
Conclusion.  Palliative care and practitioners should focus on maximizing independence at both the individual and structural levels. How services for those with life-limiting conditions are provided and relationships with health and social care staff can directly impact on an individual's experience of independence, choice and control.     

Pulmonary rehabilitation: summary of an evidence-based guideline

Pulmonary rehabilitation has emerged as a standard of care for patients with chronic lung disease, based on a growing body of scientific evidence. Over recent decades, several organizations have championed pulmonary rehabilitation and developed comprehensive statements, practice guidelines, and evidence-based guidelines. Documenting the scientific evidence underlying clinical practice has been important in overcoming skepticism and convincing health professionals, health-care institutions, third-party payers, and regulatory agencies to support pulmonary rehabilitation programs. The literature on pulmonary rehabilitation has increased substantially and provided justification for including pulmonary rehabilitation in practice guidelines for chronic obstructive pulmonary disease and other chronic lung diseases. Therefore, the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation decided to update their 1997 guidelines with a systematic, evidence-based review of the literature since the previous review. The panel updated prior topics and recommendations and reviewed new topics. Recommendations were given for outcomes of comprehensive pulmonary rehabilitation programs, including lower-extremity exercise training, dyspnea, health-related quality of life, health-care utilization, survival, psychosocial outcomes, and long-term benefits. Additional topics include the duration of pulmonary rehabilitation, post-rehabilitation maintenance strategies, intensity of aerobic exercise training, strength training, anabolic drugs, upper-extremity training, inspiratory-muscle training, education, psychological and behavioral components, oxygen supplementation, noninvasive ventilation, nutrition supplementation, rehabilitation for patients with disorders other than chronic obstructive pulmonary disease, and future pulmonary rehabilitation research. These guidelines provide an excellent summary of the recent literature and further strengthen the scientific basis of pulmonary rehabilitation.     

The truth is in the eye of the beholder? Quality in rehabilitation from the patients' perspective

The definition of "good" quality in health research and quality management in health care and rehabilitation are primarily based on health professionals and their associations. But laypersons, patients, and participants in rehabilitation programmes, too, develop cognitive concepts about what defines good quality in health care. Until now systematic knowledge about the role of the patients' views on quality in rehabilitation is rare. Existing data demonstrate that patients report detailed ideas about indicators and preconditions of good quality of rehabilitative care. Patients' quality concepts differ in some aspect from the quality definitions of health care professionals. There is some evidence that patients' views on quality are a necessary extension and completion of programme evaluation and of quality management. They influence usage and selection of rehabilitation facilities and programme elements and probably patient satisfaction and long-term outcomes as well. Patients' ideas could contribute to gaining a deeper understanding of patients' needs. Here, patients are experts to define challenges for long-term improvements in health and health-related behavior with regard to everyday life and related resources and barriers. Taking patients' views on the quality of rehabilitation into account could help to adapt rehabilitation features, programmes and long-term offers more adequately to patients' needs. More systematic evidence is however needed as a basis for further developments in rehabilitation programmes.     

Case Study: The Challenges of Self-Management of Exacerbation of Pulmonary Symptoms

PURPOSE.  This case study demonstrates the signs and symptoms of pulmonary exacerbation and the challenges of self-management for a female veteran.
DATA SOURCES.  Data were obtained through the author's clinical practice in primary care nursing and research literature sources.
DATA SYNTHESIS.  The appropriate nursing diagnosis, nursing interventions, and patient outcomes were identified through the use of NANDA-International, the Nursing Interventions Classification, and the Nursing Outcomes Classification.
CONCLUSIONS.  This case study illustrates the appropriate nursing diagnosis, interventions, and outcomes pertinent to an individual with pulmonary exacerbations. It provides a framework for nurses in primary care when caring for individuals with pulmonary exacerbations.
IMPLICATIONS FOR NURSING PRACTICE.  Employing the NANDA-International standardized nursing diagnoses, the Nursing Interventions Classification and the Nursing Outcomes Classification provided the needed constructs for improving care for a patient that had pulmonary issues in a primary care setting.     

Barriers and facilitators to the achievement of community-focused public health nursing practice: a UK perspective

Aim  To explore the extent to which Community Health Nurses (CHN) engage in community-focused public health practice and the facilitators and barriers to such practice.
Background  The government promotes the role of nurses in public health. However, there is confusion as to what constitutes public health; a lack of support to move from individual and family-focused practice to community-focused practice; and, inconsistency of the use of titles.
Method  A 15% quota sample ( n  = 409), drawn from a population of 2668 CHNs, participated in a quantitative survey.
Results  Response rate was 67% ( n  = 275). Over half of CHN time was spent with individuals and families, community level activity accounting for only 18%. Only 9% of respondents had completed a community needs assessment. Education was key to the promotion of community-focused practice with collection of individual activity data a major barrier.
Conclusions  There is a gap between the rhetoric and reality of community public health nursing.
Implications for Nursing Management  Development of a shared vision of public health nursing and commissioning of education to meet public health priorities is essential. Furthermore, strengthening public health nurse leadership to foster innovative practice and methods of measuring public health nursing outcomes is required.