Management and treatment of men affected by metastatic prostate cancer: evidence‐based recommendations for practice

Currently, 250 000 men are affected by prostate cancer in the UK. Clinical guidance is crucial for nurses involved in the care delivery for men with advanced prostate cancer and for their families to maximize their quality and quantity of life. It is essential that nurses understand how prostate cancer is diagnosed, can recognize signs of disease progression, are familiar with disease management, and can educate patients and manage any symptoms appropriately and effectively. Therefore, the aim of this paper is to review current evidence‐based guidelines in relation to care delivery for men with metastatic prostate cancer in order to optimize best supportive care. A literature review was conducted in a range of electronic databases (DARE, Cochrane, MEDLINE, BNI, PsychINFO, EMBASE and CIHAHL) to identify studies employing qualitative and/or quantitative methods. National (UK) and European clinical guidelines were also reviewed. Methodological evaluation was conducted and the evidence‐based recommendations were integrated in a narrative synthesis. Supportive care is a person‐centred approach to the provision of the necessary services for those living with or affected by cancer to meet their informational, spiritual, emotional, social or physical needs during diagnosis, treatment or follow‐up phases including issues of health promotion, survivorship, palliation and bereavement. A multidisciplinary and proactive approach to the management of men with metastatic prostate cancer ensures safe and effective supportive care delivery. Nurses involved in the care delivery for this patient group need to be aware of the complex physical and psychological supportive care needs, and evidence‐based management care plans to ensure a personalized and tailored support to optimize quality of life.     

Person‐centred care in the Indonesian health‐care system

Person‐centred care (PCC) is defined as the health‐care providers selecting and delivering interventions or treatments that are respectful of and responsive to the characteristics, needs, preferences and values of the individual person. This model of care puts the person at the centre of care delivery. The World Health Organization suggests that PCC is one of the essential dimensions of health care and as such is an important indicator of health‐care quality. However, how PCC is implemented differs between countries in response to local cultures, resources and consumer expectations of health care. This article discusses person‐centred care in the Indonesian health‐care system.     

Nurse middle managers contributions to patient‐centred care: A ‘managerial work’ analysis

Nurse middle managers are in an ideal position to facilitate patient‐centred care. However, their contribution is underexposed in literature due to difficulties to articulate this in practice. This paper explores how nurse middle managers contribute to patient‐centred care in hospitals. A combination of time‐use analysis and ethnographic work was used to disclose their contribution to patient‐centred care at a micro level. Sixteen nurse managers were shadowed for over 560 hours in four hospitals. Some nurse middle managers seldom contribute to patient‐centred care. Others are involved in direct patient care, but this does not result in patient‐centred practices. At one hospital, the nurse middle managers did contribute to patient‐centred care. Here balancing between “organizing work” and “caring work” is seen as a precondition for their patient‐centeredness. Other important themes are feedback mechanisms; place matters; with whom to talk and how to frame the issues at stake; and behavioral style. Both “hands‐on” and “heads‐on” caring work of nurse middle managers enhances their patient‐centeredness. This study is the first of its kind to obtain insight in the often difficult to articulate “doings” of nurse middle managers with regard to patient‐centred care through combining time‐use analysis with ethnographic work.     

Evidence‐based medicine: A cornerstone for clinical care but not for quality improvement

Quality improvement (QI) as a clinical improvement science has been criticized for failing to deliver broad patient outcome improvement and for being a top‐down regulatory and compliance construct. These critics have argued that the focus of QI should be on increasing adherence to clinical practice guidelines (CPGs) and, as a result, should be consolidated into research structures with the science of evidence‐based medicine (EBM) at the helm. We argue that EBM often overestimates the role of knowledge as the root cause of quality problems and focuses almost exclusively on the effectiveness of care while often neglecting the domains of safety, efficiency, patient‐centredness, and equity. Successfully addressing quality problems requires a much broader, systems‐based view of health‐care delivery. Although essential to clinical decision‐making and practice, EBM cannot act as the cornerstone of health system improvement.     

Development and testing of a patient‐centred care competency scale for hospital nurses

This study aimed to develop and test the psychometric soundness of a patient‐centred care competency (PCC) scale for hospital nurses. A cross‐sectional questionnaire survey was conducted among 594 nurses in two teaching hospitals (response rate 99.5%). Reliability and validity analyses were performed. The PCC scale consisted of 17 items divided into four subscales: respecting patients' perspectives (6 items), promoting patient involvement in care processes (5 items), providing for patient comfort (3 items) and advocating for patients (3 items). The Cronbach's alpha coefficient of the entire scale was 0.92, and those for the subscales were 0.85, 0.81, 0.84 and 0.80, respectively. Multitrait scaling analysis indicated that the four subscales had satisfactory convergent and discriminant validity. Significant correlations were found between total PCC scores and overall self‐ratings of patient‐centred care performance (r = 0.60, P < 0.001). The PCC scale was therefore determined to be a highly valid and reliable tool.     

Queer challenges to evidence‐based practice

This paper aims to queer evidence‐based practice by troubling the concepts of evidence, knowledge and mental illness. The evidence‐based narrative that emerged within biomedicine has dominated health care. The biomedical notion of ‘evidence’ has been critiqued extensively and is seen as exclusive and limiting, and even though the social constructionist paradigm attempts to challenge the authority of biomedicine to legitimate what constitutes acceptable evidence or knowledge for those experiencing mental illness, biomedical notions of evidence appear to remain relatively intact. Queer theory offers theoretical tools to disrupt biomedical norms and challenges biomedical normativity to indicate how marginalisation occurs when normative truths about mental health classify those who differ from the norm as ‘ill’ or ‘disordered’. Queer theory's emphasis on normativity serves the political aim to subvert marginalisation and bring about radical social and material change. Reference will be made to mental health subjects within each discourse by indicating how the body acts as a vehicle for knowing. Deleuzian notions of the rhizome are used as metaphor to suggest a relational approach to knowledge that does away with either/or positions in either biomedical, or queer knowledge to arrive at a both/and position where the biomedical, constructionist and queer are interrelated and entangled in needing the other for their own evolution. However, queer does not ask for assimilation but celebrates difference by remaining outside to disrupt that which is easily overlooked, assumed to be natural or represented as the norm. The task of queer knowledge is to do justice to the lives lived in the name of evidence‐based practice and demands that we consider the relations of power where knowledge is produced. This pursuit creates different knowledge spaces where we identify new intersections that allow for socially just understandings of knowing or evidence to emerge.     

How evidence‐based medicine is failing due to biased trials and selective publication

Evidence‐based medicine (EBM) was announced in the early 1990s as a ‘new paradigm’ for improving patient care. Yet there is currently little evidence that EBM has achieved its aim. Since its introduction, health care costs have increased while there remains a lack of high‐quality evidence suggesting EBM has resulted in substantial population‐level health gains. In this paper we suggest that EBM's potential for improving patients' health care has been thwarted by bias in the choice of hypotheses tested, manipulation of study design and selective publication. Evidence for these flaws is clearest in industry‐funded studies. We argue EBM's indiscriminate acceptance of industry‐generated ‘evidence’ is akin to letting politicians count their own votes. Given that most intervention studies are industry funded, this is a serious problem for the overall evidence base. Clinical decisions based on such evidence are likely to be misinformed, with patients given less effective, harmful or more expensive treatments. More investment in independent research is urgently required. Independent bodies, informed democratically, need to set research priorities. We also propose that evidence rating schemes are formally modified so research with conflict of interest bias is explicitly downgraded in value.     

Observations of nursing staff compliance to a checklist for person‐centred handovers – a quality improvement project

Nursing shift‐to‐shift handovers are important as they impact the care quality indicators such as safety, patient satisfaction and continuity. However, nurses’ handovers have also been criticised and described as unstructured and ineffective. To improve the handovers and involve patients and their loved ones in the process, a person‐centred handover (PCH) model performed at bedside has been developed and tested at Karolinska University Hospital, Sweden. This study reports on the nursing staffs’ compliance to a checklist used for the newly introduced PCH model. A total of 43 PCH sessions were observed at two acute care wards, using a structured observation protocol. None of the observed handover sessions included all the 13 PCH checklist subcomponents. The checklist was used in 18 (44%) of the observed handover sessions. A statistically significant higher number of subcomponents were observed when the nurses used the PCH checklist (6.4 vs. 4.5 subcomponents, p < 0.05). The mean time spent on each PCH was 6 minutes. In 56% of the sessions, the patients were observed to actively participate in the handover. Overall, the nursing staffs’ compliance to the PCH checklist needs to be improved. The observations suggest that training on communication‐oriented tasks would be beneficial to establish a person‐centred handover process.     

The Tri‐focal model of care: Advancing the teaching‐nursing home concept

Providing residential aged care is challenging because of the complexity of residents’ health status, difficulties recruiting and retaining skilled staff, and financial and regulatory constraints. This paper discusses some of these challenges and describes an innovative model of care, termed ‘The Tri‐focal model of care’. This model was developed based on the concepts of ‘partnership‐centred care’, ‘positive work environment’ and the need for evidence‐based practice to underpin all aspects of care. It is envisaged that the implementation of this model will provide a rich learning environment that advances the teaching‐nursing home concept and the quality of residential aged care.     

Evidence‐based medicine meets person‐centred care: a collaborative perspective on the relationship

In a recent list‐serve, the way forward for evidence‐based medicine was discussed. The purpose of this paper was to share the reflections and multiple perspectives discussed in this peer‐to‐peer encounter and to invite the reader to think with a mind for positive change in the practice of health care. Let us begin with a simple question. What if we dared to look at evidence‐based medicine (EBM) and informed shared decision making like two wheels on a bike? They both need to be full of substance, well connected, lubricated and working in balance, propelled and guided by a competent driver, with good vision to get the bike where we want it to go. We need all the tools in the toolkit for the bike to stay operational and to meet the needs of the driver. By the same rationale, evidence alone is necessary but not sufficient for decision making; values are necessary and if neglected, may default to feelings based on social pressures and peer influence. Medical decisions, even shared ones, lack focus without evidence and application. Just as a bike may need a tune up from time to time to maintain optimal performance, EBM may benefit from a tune up where we challenge ourselves to move away from general assumptions and traditions and instead think clearly about the issues we face and how to ask well‐formed, specific questions to get the answers to meet the needs we face in health care.     

‘All the King's horses …’: the problematical fate of born‐again evidence‐based medicine: commentary on Greenhalgh,T., Snow,R., Ryan,S., Rees,S., and Salisbury,H. (2015) six ‘biases’ against patients and carers in evidence‐based medicine. BioMed Central Medicine, 13:200

The phrase ‘evidence‐based medicine (EBM)' is being used by both EBM advocates and adversaries to broadly denote the production and use of clinical research throughout the healthcare system. Recently, this trend was joined by a call for a general expansion and rebirth of EBM to encompass a diverse range of healthcare activities otherwise corresponding to person‐centred care. The call asserts that EBM is to blame for anti‐patient biases within clinical practice and in policy and public health domains. Effective critique of either EBM or of the healthcare system requires that EBM itself be properly identified as a research literacy movement that grew out of clinical epidemiology of the 1970's and 1980's. We demonstrate the ineffectiveness of inappropriately targeted critiques of healthcare under the banner of born‐again EBM. We identify the strengths and weaknesses of EBM as an educational movement drawing on the concept of literacy associated with the Brazilian educator Paolo Freire. We consider the relationship of EBM to clinical epidemiology and conclude that it cannot fruitfully divorce itself from the latter. We briefly consider existing precedents for philosophically sound conceptual platforms for advocacy of person‐centred healthcare and broad based critique of the healthcare system including relationship‐centred care. We conclude that traditional EBM, as a framework for research literacy training of both clinicians and policy makers, must continue to play a subsidiary role within an expanding patient‐centred healthcare system and that advocacy efforts on behalf of patient voice and engagement are best pursued unencumbered by subsidiary agendas.     

Implementation of evidence‐based health care using action research: An emancipatory approach

The aim of the study is to discuss the emancipatory approach to action research as an appropriate methodology for workers' meaningful implementation of evidence‐based health care. Implementation of evidence‐based health care using action research is well supported by the literature. There are various approaches to action research, and they are coherent with the objectives and methods elected to develop the investigation. It is not clear which approach of action research is responsible for meaningful worker engagement in changing praxis. This is a discussion paper based on our experiences and supported by literature on collective health. Health care is defined as a social praxis, dependent upon the capitalist mode of production in which health workers engage themselves in a labour process that has negative (as alienation) as well as positive (as creativity) meanings. Emancipatory changes of social praxis through implementation of evidence‐based health care require that participants understand the positive and negative meanings of their work and engage health workers in a conscious and intentional collaborative educational process. Implementation of evidence‐based health care through emancipatory action research is capable of overcoming alienation and changing social practice through a participatory meaningful process of knowledge translation.     

A systematic review of instruments measuring patients′ perceptions of patient‐centred nursing care

This systematic review identified and evaluated instruments measuring patients' perceptions of patient‐centred nursing care. Of 2629 studies reviewed, 12 were eligible for inclusion. Four instruments were reported: The Individualized Care Scale, the Client‐Centred Care Questionnaire, the Oncology patients' Perceptions of the Quality of Nursing Care Scale and the Smoliner scale. These instruments cover themes addressing patient participation and the clinician–patient relationship. Instruments were shown to have satisfactory psychometric properties, although not all were adequately assessed. More research is needed regarding test–retest reliability, convergent and discriminant validity, validity with known groups and structural validity using confirmatory factor analysis.     

Patient‐centred care through a broader lens: Supporting patient autonomy alongside moral deliberation

Patient‐centred care (PCC) is an essential component of high‐quality healthcare and shared decision‐making is its cornerstone. Yet, integrating the principles of PCC into healthcare practice is not always straightforward and shared decision‐making can be complicated and ethically demanding. While ethicists and academics routinely debate moral aspects of clinical care, such discussion among clinicians is less overt. In this paper, we use Emmanuel et al.’s deliberative model to provide a practical framework for considering ethical aspects of PCC and shared decision‐making. The model encourages us to appreciate PCC through a broader lens and consider patient autonomy alongside other moral obligations such as justice and the equitable distribution of finite resources. The model can be used by healthcare providers, patients and caregivers to facilitate dialogue and moral deliberation regarding the merit of their preferences and values; in this way, individualised care can be delivered without compromising other important ethical obligations.     

Using holistic interpretive synthesis to create practice‐relevant guidance for person‐centred fundamental care delivered by nurses

Nursing policy and healthcare reform are focusing on two, interconnected areas: person‐centred care and fundamental care. Each initiative emphasises a positive nurse–patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse–patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice‐relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse–patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse–patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person‐centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.