Surgical patients’information needs on discharge: Are they being met?

Increasingly patients are being encouraged to participate more in their health care. Patients are being discharged earlier; therefore their need for information may potentially increase if they are to be involved in their care. This study explored the information that patients received prior to their discharge and, through follow-up interviews after their return home, investigated the usefulness of the information provided. Only 11 of a total 20 patients (55%) routinely received discharge information. This information was not solicited and its content was ad hoc . Nine patients (45%) did not routinely receive discharge information. If these patients needed information they had to ask for it. Despite the lack of comprehensive discharge information for the 20 surgical patients, the majority of patients (75%) did not access services after discharge. Only one of the five patients who did seek advice was in need of further medical intervention. The remaining four required further information so that they could be reassured. These findings emphasize the need for further research on the type and extent of information required by patients on their return home so that they can effectively participate in their recovery.     

Supportive nursing care around breast cancer surgery: an evaluation of the 1997 status in The Netherlands

This study aimed to assess nurses' involvement in the supportive care of patients with recently diagnosed breast cancer in Dutch hospitals. A questionnaire used to evaluate various aspects of nursing care for breast cancer patients was sent to the surgical nursing teams in all 120 Dutch hospitals that provide surgical treatment for these patients. Nursing care was defined to be optimal if it met the following criteria: (a) Specialized nursing support is provided to all patients during admission and in the outpatient departments both before and after surgery. (b) A protocol is in place outlining standard nursing procedures for breast cancer patients. (c) Formal communication about each breast cancer patient exists between the nurses involved. On the basis of this definition, it was found that optimal nursing care was provided in only 6% of the hospitals. Nursing care fell short mainly in the outpatient setting. This shortcoming also was recognized by most respondents, and many were already planning improvements. Nurses had varying opinions about their responsibility to provide the patient with information about the disease and its treatment, and consensus was lacking. In summary, nursing care for newly diagnosed breast cancer patients in Dutch hospitals needs improvement, especially in the outpatient setting.     

Information provided to surgical patients versus information needed

The importance of providing preoperative information to patients has been reiterated in many research studies; however, the delivery is based on health care providers' view of what information should be included. An analysis of studies on the type of preoperative information given to patients confirms the lack of patient focus when delivering such information. In this study, a multifaceted approach was used to determine patients' and health care providers' perceptions about preoperative information. Importance was placed on information about the details of anesthesia by all three cohorts (ie, patients, nurses, physicians). A gap in information provided about the details of anesthesia and the OR environment was found. Further analysis seems to attribute the inadequate information received by patients to health care providers' misunderstanding regarding the information patients want. AORN J 77 (March 2003) 546-561.     

'No control whatsoever': end-of-life care on a medical teaching unit from the perspective of family members

BACKGROUND: In our institution, about one third of annual deaths occur on the general medical teaching unit. (MTU) The average patient dies on the MTU from non-malignant disease after 4 weeks in hospital, and approximately 20% of available beds on the MTU at any time are occupied by patients who will not survive to discharge, but quality of end-of-life care on the MTU is not routinely assessed. AIM: To identify areas for improvement in delivering high quality end-of-life care on the medical teaching unit. DESIGN: Qualitative study using semi-structured interviews. METHODS: Six months after the death of the patient, next of kin were sent a letter inviting participation; 75 family members were screened and 50 invitations were mailed out. Interviews were conducted in the home. Eliciting narratives and direct questioning about important aspects of end-of-life care were used. RESULTS: Six next of kin agreed to participate. All patients were described as seriously and chronically ill. None died of cancer. Deaths were not described as 'good', and some comments suggested that death was unexpected and not inevitable. There were few concerns about pain control or unnecessary suffering. Proactive efforts to provide prognostic information or end-of-life care were not described. Survival, not palliation, was of central importance. Consistent with this priority, satisfaction with care provided in the intensive care unit was high. Follow-up after death was desired, especially if autopsy results were available. DISCUSSION: Earlier discussions about treatment failure and end-of-life care, and the need for palliation, appear to be central to improving the quality of end-of-life care for patients dying on our medical teaching unit. Our results are consistent with other studies in this area.     

Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients

Compared with men, women report more pain and are at increased risk for having pain discounted or misattributed to psychological causes. Overweight individuals experience high rates of pain and may receive suboptimal care because of provider bias. Research suggests the social consequences of being overweight are worse for women than men, and that gender and weight uniquely and interactively affect pain experience and care. Healthy participants (n?=?616) viewed 6 videos of back pain patients (1 female and 1 male of normal weight, overweight, and obese categories) performing a functional task. Participants provided judgements/ratings regarding patient pain (intensity, interference, exaggeration), potential sources of patient pain (medical, psychological), and treatment recommendations (opioids, psychological therapy, seek workplace accommodations). Results suggest that the pain of normal and overweight women and obese men was discounted (judged as less intense, less interfering, more exaggerated, and less attributable to medical factors) and judged as less in need of treatment (treated with less opioids and workplace accommodations). Across all weight categories, women's pain was attributed more to psychological factors and was more likely to receive recommendations for psychological therapy than men's pain. These findings highlight the differential effect of patient weight on pain-related judgements about women and men.

Patients with cancer: their approaches to participation in treatment plan decisions

The aim of this study was to explore experiences of participation in treatment planning decisions from the perspective of patients recently treated for colorectal cancer. Ten patients were purposively selected and interviewed. Constant comparative analysis, the core concept of grounded theory, was used. The dimensions were developed and organized into the main theme of 'compliant participation in serious decisions', which was composed of the two variations: complying with participation; and complying without participation. Complying with participation was characterized by feelings of self-confidence and self-competence and by open dialogue between the participants, significant others and the physician. Complying without participation was characterized by participants' feelings of uncertainty and distress, and of being rushed into submitting to decisions without having time to reflect on the information provided or the opportunity to influence the treatment and care process. To participate (or choosing not to participate) builds on open and affirming dialogue, information and knowledge about the illness. Patient participation in treatment and care decision making is interpreted as a health promoting way of coping with illness.     

Standardized Nursing Diagnoses in an Electronic Health Record: Nursing Survey Results

PURPOSE. A survey was conducted to obtain feedback from registered nurses as end‐users of standardized nursing terminology for care planning in an electronic health record. Revisions to the care plan terminology were completed as part of an evidence‐based project by nurses at one facility. METHODS. The survey was conducted pre‐, post‐, and 2‐year post‐implementation to obtain feedback from the acute care registered nurses (RNs). FINDINGS. Nurses reported a more positive agreement with the changes at 6 months compared with baseline, which generally was found to be sustained in the 2‐year survey. Overall, the standardized terminology provided the nurses greater ease in their selection of nursing diagnoses and interventions in planning patient care, yet their reported satisfaction did not change. The survey identified several problematic areas related to nurses and care planning. Nurses reported less agreement with the statement about the care plans offering them the ability to determine the status of their patient's nursing care needs. They noted less agreement with statements of the care plan offering information on assessment of patient outcomes of nursing care. CONCLUSIONS. The patient plan of care in the electronic record is expected to offer nurses the ability to communicate the needs of the patient and assess outcomes of care. The survey findings indicate weaknesses warranting further exploration to identify changes needed to improve care planning documentation.     

Why Taiwanese hospice patients want to stay in hospital: health-care professionals’ beliefs and solutions

Patient-related barriers and their solution in the planning of discharge to palliative home care were investigated through a nationwide survey conducted in Taiwan. Of 250 questionnaires sent to palliative care workers at 15 hospices in Taiwan, 229 valid questionnaires (91.6%) were retrieved. Most of the respondents were nursing staff (72.5%) while only 38 were physicians (16.6%). Canonical correlation analysis was used to examine the association between the barriers and solutions, and revealed that the value of the first variate was 0.49 (P<0.05). The barriers and canonical loadings were: unable to manage emergent medical conditions (0.83), the quality of care in the hospital is better (0.74), and insufficient number of caregivers (0.72). The effective solutions that correlated significantly with the above factors were ranked as: to reassure the patient about the possibility of smooth readmission (0.84), to arrange palliative home care programs (0.68), and to educate family members on taking care of the patient at home (0.64). In conclusion, to solve patient-related barriers in the planning of the discharge of patients with terminal cancer, the results suggest that (1) health professionals involved in the care of patients with terminal cancer should have adequate knowledge of palliative care, particularly communication skills, (2) an effective referral system among general or oncology and palliative care units should be established, (3) inpatient care facilities and home-care programs should be provided, and (4) patients and families should be educated as to what may happen and how to manage these conditions at home and should be assured of the availability of medical help.     

Professional status and interprofessional collaboration: A view of massage therapy

Abstract

Interprofessional education (IPE) can be hindered by the lack of infrastructure required to support it. We developed a clinical IPE experience for medical and pharmacy students built upon an existing infrastructure. We created tools to orient students to IPE and had students participate in pharmacist-led and physician-led IPE clinics. Results from the surveys indicated that after participating in the IPE experience, there were no significant changes in attitudes toward interprofessional teamwork or attitudes toward different members of the healthcare team. Students found less value in tools outlining roles and responsibilities of team members, on-line modules about the other profession, and IPE group discussion. They placed more value on the actual clinical experience. Themes derived from analysis of open-ended survey questions reflected the value that students placed on interprofessional interaction in the setting of direct patient care.     

Respiratory hygiene in the emergency department.

The emergency department (ED) is an essential component of the public health response plan for control of acute respiratory infectious threats. Effective respiratory hygiene in the ED is imperative to limit the spread of dangerous respiratory pathogens, including influenza, severe acute respiratory syndrome, avian influenza, and bioterrorism agents, particularly given that these agents may not be immediately identifiable. Sustaining effective respiratory control measures is especially challenging in the ED because of patient crowding, inadequate staffing and resources, and ever-increasing numbers of immunocompromised patients. Threat of contagion exists not only for ED patients but also for visitors, health care workers, and inpatient populations. Potential physical sites for respiratory disease transmission extend from out-of-hospital care, to triage, waiting room, ED treatment area, and the hospital at large. This article presents a summary of the most current information available in the literature about respiratory hygiene in the ED, including administrative, patient, and legal issues. Wherever possible, specific recommendations and references to practical information from the Centers for Disease Control and Prevention are provided. The "Administrative Issues" section describes coordination with public health departments, procedures for effective facility planning, and measures for health care worker protection (education, staffing optimization, and vaccination). The patient care section addresses the potentially infected ED patient, including emergency medical services concerns, triage planning, and patient transport. "Legal Issues" discusses the interplay between public safety and patient privacy. Emergency physicians play a critical role in early identification, treatment, and containment of potentially lethal respiratory pathogens. This brief synopsis should help clinicians and administrators understand, develop, and implement appropriate policies and procedures to address respiratory hygiene in the ED.     

Knowledge of,and participation in,advance care planning: A cross-sectional study of acute and critical care nurses’ perceptions

BackgroundNurses have a core role in facilitating discussions and enacting decisions about end-of-life issues for patients in hospitals. Nurses’ own knowledge and attitudes may influence whether they engage in meaningful end-of-life conversations with patients.AimsTo determine in a sample of nurses working in acute and critical care hospital wards:1) their knowledge of advance care planning, including the authority of substitute decision-makers and legal validity of advance directives;2) their own participation in advance care planning decision-making practices; and3) associations between nurses’ socio-demographic characteristics; clinical expertise; and knowledge and behaviour in relation to advance care planning practices.DesignQuestionnaire-based, cross-sectional study.Setting and participantsThe study was conducted with 181 registered and enrolled nurses employed in acute and critical care wards of three metropolitan hospitals in Australia.ResultsNurses were least knowledgeable about items relating to the authority of medical (56%) and financial (42%) substitute decision-makers. Few nurses had prepared advance directives (10%) or appointed medical (23%) or financial (27%) decision-makers, when compared to discussing end-of-life wishes (53%) or organ donation (75%). Overall, 15% of nurses had not engaged in any advance care planning practices. Nurses who had cared for 11–30 dying patients in the last six months were more likely to have an increased knowledge score. Older nurses were more likely to participate in a greater number of advance care planning practices and an increase in shifts worked per week led to a significant decrease in nurses’ participation.ConclusionNurses have a key role in providing advice and engaging dying patients and their families in advance care planning practices. Nurses’ own knowledge and rates of participation are low. Further education and support is needed to ensure that nurses have an accurate knowledge of advance care planning practices, including how, when and with whom wishes should be discussed and can be enacted.     

Bringing change-of-shift report to the bedside: a patient- and family-centered approach

Change-of-shift report is the time when responsibility and accountability for the care of a patient is transferred from one nurse to another. The communication that ensues during this process is linked to both patient safety and continuity of care giving. While many nurses already recognize the value of bringing report to the patient's bedside and have practiced in this manner, this remains relatively uncommon. Typically, nurse change-of-shift report has occurred at a nurses' station, conference room, or hallway and may be face to face, audio-taped, recorded on a telephone service, or in a written format. When report is given away from the bedside, the opportunity to visualize the patient and include the patient and family in an exchange of information and care planning is lost. Yet, patients and families, also stewards of patient safety, are given an opportunity to hear and participate in the exchange of information when report is brought to the bedside. Welcoming patients and families into the report process may be a new and challenging process for nursing staff.     

Factors affecting physician participation in a state Medicaid program.

Critical to policy planning for a program of national health insurance or a National Health Service is an understanding of the strengths and weaknesses of current federally-supported health programs. One program which has been subjected to criticism is Medicaid. A major problem facing Medicaid is the high proportion of physicians who refuse to participate in the program, thus preventing the target population from obtaining access to medical care. A telephone survey was conducted to assess the attitudes and behavior of a stratified random sample of physicians regarding their participation in a Medicaid program. Physicians were asked to identify major advantages and disadvantages of the program to individual patients, to society and to their medical practice. Non-participants were asked to identify the major reasons why they did not participate in the program. Medical specialty was the only significant demographic determinant of participation. Inadequate reimbursement, excessive paperwork, patient abuses of the program and bureaucratic complexity were among the most prominent factors contributing to nonparticipation. Implications of these findings are discussed with respect to the role of primary care providers' perceptions in the planning of future national health programs.     

Family participation in care to the critically ill: opinions of families and staff

Background Allowing family members to participate in the care of patients in intensive care units (ICUs) may improve the quality of their experience. No previous study has investigated opinions about family participation in ICUs.Methods Prospective multicenter survey in 78 ICUs (1,184 beds) in France involving 2,754 ICU caregivers and 544 family members of 357 consecutive patients. We determined opinions and experience about family participation in care; comprehension (of diagnosis, prognosis, and treatment) and satisfaction (Critical Care Family Needs Inventory) scores to assess the effectiveness of information to families and the Hospital Anxiety and Depression score for family members.Results Among caregivers 88.2% felt that participation in care should be offered to families. Only 33.4% of family members wanted to participate in care. Independent predictors of this desire fell into three groups: patient-related (SAPS II at ICU admission, OR 0.984); ICU stay length, OR 1.021), family-related (family member age, OR 0.97/year); family not of European descent, OR 0.294); previous ICU experience in the family, OR 1.59), and those related to emotional burden and effectiveness of information provided to family members (symptoms of depression in family members, OR 1.58); more time wanted for information, OR 1.06).Conclusions Most ICU caregivers are willing to invite family members to participate in patient care, but most family members would decline.Supported by a grant (AOR1004) from the Assistance Publique des Hôpitaux de Paris and the Direction Régionale de la Recherche Clinique. Affiliations of the authors are listed in the Appendix     

Documentation of medication management by graduate nurses in patient progress notes: a way forward for patient safety

Nursing documentation provides evidence of nurses' management, the patient response, and evaluation of care. The aim of the study was to examine how graduate nurses document their medication management in the progress notes. A prospective clinical audit of patient medication charts and the progress notes made by 12 graduate nurses was undertaken. Graduate nurses were also individually interviewed and asked clarifying questions about their medication management. Documentation was examined based on four areas: assessment, planning care, administration of medications, and evaluating outcomes of medications. Recorded information about assessment focused on cues of a biomedical rather than a psychosocial nature. Planning care involved non-specific documentation of discharge planning needs, and little information about communication with doctors, pharmacists, nurses, patients and next of kin. Administration of medications included details about the names of medications given to patients, but no information about medication education provided to patients during this time. Evaluation of outcomes of medication administration was poorly documented. Graduate nurses tended to focus on assessing medications before their administration without considering how the patient responded to treatment. Recommendations are proposed for improving the quality of graduate nurses' progress notes. These recommendations include implementing and evaluating protocols that link nurses' decision-making to documentation processes. Adopting a supportive multidisciplinary approach to quality improvement and providing education that emphasises written documentation of verbal communication are also recommended.     

Influence of interactional structure on patient’s participation during interprofessional discharge planning meetings in rehabilitation centers

ABSTRACT

Interprofessional practice has become increasingly important. In addition, patients are expected to participate more actively in health-care decisions. While comprehensive discharge planning has been shown to be effective, it is unclear how interactional structure influences patients’ participation during discharge planning meetings. The aims of this qualitative study were to examine the interactional structure of interprofessional meetings in two rehabilitation clinics and to identify patients’ types of communicative involvement (patient participation) during discharge planning meetings. Using an ethnomethodological approach and Conversation Analysis, 121 interprofessional meetings were video-recorded (19 hours of recordings). Twenty-five patients (30– 87 years) with neurological or musculoskeletal disorders and their teams were included. The findings revealed two types of meetings aimed at either (a) exchanging information with team members and patient (“information exchange meeting”) or (b) negotiating care plans with patients and the team. “Negotiation meetings” were often led by allied health professionals or nurses and were characterized by active patient participation. Those meetings offered patients an opportunity to give additional information rather than only ask questions. The discussion includes reflections on how interactional analysis can help understand the social organization of meetings and how patient participation can be enhanced in this context and concludes with practice implications.