Fatigue in patients with chronic heart failure — A burden associated with emotional and symptom distress

Background

The relationship between experience of fatigue and emotional and symptom distress in chronic heart failure (CHF) needs to be thoroughly explored, because fatigue has major impact on daily activities in life.

Aims

The purpose was to examine the association between fatigue, as a multidimensional experience and anxiety, depression and symptom distress, and to explore the relationships between individual symptoms and the dimensions of fatigue in patients with CHF.

Methods

A consecutive sample of 112 patients with exacerbation of symptoms of CHF answered the Multidimensional Fatigue Inventory (MFI-20), the Hospital Depression and Anxiety (HAD) Scale and the Symptom Distress Scale (SDS).

Results

Anxiety was associated with mental fatigue, whereas depression was associated with reduction of activity, low motivation and decreased functioning. Physical fatigue was affected by symptom distress, with women reporting more distress than men. With exception of breathlessness, poor agreement was found between fatigue and the most intensive reported symptoms.

Conclusions

The relationship between emotional distress and the experience of fatigue in patients with CHF may have a devastating affect on the patient's ability to cope and manage daily activities, including self-care and adherence to recommended treatment.     

A qualitative study of mild to moderate psychological distress during pregnancy

Background

Psychological distress is common in the antenatal period. In England, psychological distress is classified as mild, moderate or severe but only those who suffer severe psychological distress are referred to the specialist mental health services. Those who suffer mild to moderate psychological distress are managed by the primary care services. However, little is know about the psychosocial experiences of pregnant women who suffer from mild-moderate psychological distress.

Objective

This study explored the experiences of pregnant women who self-reported mild to moderate psychological distress during antenatal care.

Design

A qualitative study. Data were collected using digitally recorded, face-to-face, semi-structured interviews. Data were analysed using framework analysis.

Setting

A large teaching maternity hospital in North West England.

Participants

Twenty-four pregnant women who self-reported mild to moderate psychological distress to their midwife during routine antenatal care.

Results

Three main themes emerged: the causes of, impact of, and ways of controlling self-reported mild to moderate psychological distress. A range of experiences caused psychological distress including past life and childbearing experiences, and current pregnancy concerns. Mild to moderate psychological distress took over the lives of these pregnant women. The strategies used to control mild to moderate psychological distress included both positive and negative coping elements.

Conclusions

Psychological distress that is categorised as mild to moderate can be extremely debilitating for pregnant women. Identification of these women in clinical practice is crucial so that effective interventions can be targeted appropriately. Screening criteria that has the efficacy to identify depression and anxiety is needed. We recommend that a multidisciplinary approach to the management of care is developed to address the range of experiences that pregnant women who suffer mild to moderate prenatal psychological distress may have.     

Effectiveness of case management among older adults with early symptoms of dementia and their primary informal caregivers: a randomized clinical trial

Background

It is believed that timely recognition and diagnosis of dementia is a pre-condition for improving care for both older adults with dementia and their informal caregivers. However, diagnosing dementia often occurs late in the disease. This means that a significant number of patients with early symptoms of dementia and their informal caregivers may lack appropriate care.

Objectives

To compare the effects of case management and usual care among community-dwelling older adults with early symptoms of dementia and their primary informal caregivers.

Design

Randomized controlled trial with measurements at baseline and after 6 and 12 months.

Setting

Primary care in West-Friesland, the Netherlands.

Participants

99 pairs of community-dwelling older adults with dementia symptoms (defined as abnormal screening for symptoms of dementia) and their primary informal caregivers.

Intervention

12 months of case management by district nurses for both older adults and informal caregivers versus usual care.

Measurements

Primary outcome: informal caregiver's sense of competence. Secondary outcomes: caregiver's quality of life, depressive symptoms, and burden, and patient's quality of life. Process measurements: intervention fidelity and caregiver's satisfaction with the quality of case management.

Results

Linear mixed model analyses showed no statistically significant and clinically relevant differences over time between the two groups. The process evaluation revealed that intervention fidelity could have been better. Meanwhile, informal caregivers were satisfied with the quality of case management.

Conclusion

This study shows no benefits of case management for older adults with dementia symptoms and their primary informal caregivers. One possible explanation is that case management, which has been recommended among diagnosed dementia patients, may not be beneficial if offered too early. However, on the other hand, it is possible that: (1) case management will be effective in this group if more fully implemented and adapted or aimed at informal caregivers who experience more severe distress and problems; (2) case management is beneficial but that it is not seen in the timeframe studied; (3) case management might have undetected small benefits. This has to be established.Trial registration ISCRTN83135728.     

Assessing the quality of sleep in Greek primary caregivers of patients with secondary progressive multiple sclerosis: a cross-sectional study

Context

Several studies have investigated the prevalence of sleep disorders in patients suffering from multiple sclerosis (MS) and have shown that up to 54% of patients may have significantly more sleep problems than the general population. To our knowledge, however, no data are available about the quality of sleep of the primary caregivers of patients with MS.

Objectives

The objectives of the current cross-sectional study were to assess the quality of sleep in Greek primary caregivers of patients with MS and to investigate its relationship with the degree of caregivers' emotional distress.

Methods

Twenty-two male and 13 female primary caregivers (mean age 47.3 ± 12.4 years) of an equal number of patients with MS, who consented to participate, completed the validated Greek version of the Pittsburgh Sleep Quality Index (PSQI) and the validated Greek version of the Hospital Anxiety and Depression Scale (HADS). Thirty-five age-, gender-, and education-matched healthy controls were used for comparisons.

Results

Caregivers experienced a higher degree of anxiety than depression. The mean score in the seven-item HADS-A subscale was 9.5 ± 4 (range 3-15) and the mean score in the seven-item HADS-D subscale was 7.1 ± 3.1 (range 2-14). The mean scores of caregivers on both HADS-A and HADS-D were significantly higher than those of controls (P < 0.001). The PSQI scoring demonstrated that 19 (54.3%) caregivers had poor sleep quality (cut-off value of >5). The mean values of caregivers for the PSQI were 6.0 ± 2.8 (range 2-12) compared with controls, who scored at a significantly lower level (1.5 ± 0.8; P < 0.001). Poor quality of sleep was significantly correlated with increased levels of anxiety (r = 0.392; P = 0.02) and depression (r = 0.424; P = 0.01). Among the PSQI components, the sleep duration and sleep latency were mostly influenced by the degree of emotional distress.

Conclusion

A significant proportion of primary caregivers of MS patients experience poor sleep quality. The degree of their emotional distress appears to significantly influence their quality of sleep. Appropriate psychopharmacological interventions may be required for those individuals.     

Relationships of Fear, Anxiety, and Depression With Physical Function in Patients With Knee Osteoarthritis

Scopaz KA, Piva SR, Wisniewski S, Fitzgerald GK. Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis.

Objectives

To explore whether the psychologic variables anxiety, depression, and fear-avoidance beliefs, and interactions between these variables, are associated with physical function in patients with knee osteoarthritis (OA). We hypothesized lower levels of function would be related to higher anxiety, higher depression, and higher fear-avoidance beliefs, and that high levels of 2 of these factors simultaneously might interact to have a greater adverse effect on physical function.

Design

Cross-sectional, correlational design.

Setting

Institutional practice.

Participants

Subjects included patients with knee OA (N=182; age, mean ± SD, 63.9±8.8y; 122 women).

Interventions

Not applicable.

Main Outcome Measures

Self-report measures of function included the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, the Lower Extremity Function Scale (LEFS), and the Knee Outcome Survey-Activity of Daily Living Scale. The Get Up and Go test was used as a physical performance measure of function. Self-report measures for psychologic variables included the Beck Anxiety Inventory, the Center for Epidemiological Studies Depression Scale, and the Fear Avoidance Belief Questionnaire-Physical Activity Scale modified for the knee.

Results

Higher anxiety was related to poorer function on the WOMAC physical function. Both high anxiety and fear-avoidance beliefs were related to poorer function on the LEFS and Knee Outcome Survey-Activity of Daily Living Scale. There was no association between the psychologic variables and the Get Up and Go test. The anxiety × depression interaction was associated with the LEFS.

Conclusions

Anxiety and fear-avoidance beliefs are associated with self-report measures of function in patients with knee OA. Depression may influence scores on the LEFS under conditions of low anxiety.     

Relationship of Preinjury Caregiver and Family Functioning to Community Integration in Adults With Traumatic Brain Injury

Sady MD, Sander AM, Clark AN, Sherer M, Nakase-Richardson R, Malec JF. Relationship of preinjury caregiver and family functioning to community integration in adults with traumatic brain injury.

Objective

To investigate the relationship of preinjury caregiver and family functioning to community integration outcomes in persons with traumatic brain injury (TBI).

Design

Inception cohort.

Setting

Three TBI Model Systems inpatient rehabilitation facilities.

Participants

Persons with TBI (N=141) and their caregivers admitted to inpatient rehabilitation and followed up at 1 to 2 years after injury.

Interventions

Not applicable.

Main Outcome Measures

Community Integration Questionnaire and the Social and Occupation scales of the Craig Handicap Assessment and Reporting Technique.

Results

There were significant interactions of several preinjury caregiver and family variables with injury severity. For persons with complicated mild/moderate injury, better family functioning was associated with greater home integration, and less caregiver distress was associated with better social integration. For persons with severe injuries, greater caregiver perceived social support was associated with better outcomes in productivity and social integration.

Conclusions

Preinjury caregiver and family characteristics interact with injury severity to affect outcomes in persons with injury. Research on outcomes should include measures of caregiver and family functioning. Early interventions targeted toward decreasing caregiver distress, increasing support, and improving family functioning may have a positive impact on later outcomes.     

Relatives' Criticism Influences Adjustment and Outcome After Traumatic Brain Injury

Weddell RA. Relatives' criticism influences adjustment and outcome after traumatic brain injury.

Objectives

To apply some of the methods developed to study the effects of relatives' expressed emotion (EE) on psychiatric relapse rates and to test the prediction that relatives' criticism and psychiatric distress would be associated with outcome and emotional distress after traumatic brain injury (TBI).

Design

Retrospective cohort design with correlational analyses of quantitative and qualitative measures of TBI outcomes.

Setting

The author interviewed participants in the hospital. The research assistant interviewed close relatives at home.

Participants

Participants and relatives (N=78) were interviewed 34.3±15.2 months (mean ± SD) after a severe TBI.

Interventions

None.

Main Outcome Measures

Dependent variables in a series of hierarchical linear regression models were participants' scores on the Zung Depression Scale, Spielberger Trait Anxiety Inventory, State-Trait Anger Expression Inventory, an Anger Towards Relative questionnaire constructed for this study, and Extended Glasgow Outcome Scores. Participant-independent variables were social class, posttraumatic amnesia, Wechsler Memory Scale-Delayed Recall score, WAIS-R intelligence quotient, and a short version of the Smell Identification Test. Relative independent variables were the number of critical comments directed toward participants in the interview and psychiatric distress as measured by the General Health Questionnaire.

Results

The contributions of variance associated with relative independent variables (predominantly criticism) were significant in stage 2 of most hierarchical regression analyses after the adjustments for variance associated with participant independent variables made in stage 1.

Conclusions

Future application of EE research methods is warranted. If the present results are replicated, then evidence-based family interventions developed by EE researchers to reduce criticism might also improve TBI outcomes.     

Brain Injury Coping Skills Group: A Preventative Intervention for Patients With Brain Injury and Their Caregivers

Backhaus SL, Ibarra SL, Klyce D, Trexler LE, Malec JF. Brain Injury Coping Skills Group: a preventative intervention for patients with brain injury and their caregivers.

Objective

To determine whether training in coping strategies will improve psychologic functioning and self-efficacy in survivors of brain injury (BI) and caregivers.

Design

Randomized controlled pilot study with measurements at baseline, postintervention, and 3-month follow-up.

Setting

Postacute rehabilitation clinic.

Participants

Survivors of BI (n=20) and caregivers (n=20).

Interventions

The Brain Injury Coping Skills Group is a 12-session, manualized, cognitive-behavioral treatment (CBT) group providing psychoeducation, support, and coping skills training. Effects of this preventative intervention were examined on emotional functioning and perceived self-efficacy (PSE).

Main Outcome Measures

Brief Symptom Inventory-18 (BSI-18) and Brain Injury Coping Skills Questionnaire.

Results

Analyses revealed that the Brain Injury Coping Skills group showed significantly improved PSE compared with the control group immediately posttreatment (F=14.16; P=.001) and maintained this over time. PSE assessed posttreatment predicted global distress at 3-month follow-up across groups (ρ=-.46). No differences between treatment and control groups were apparent on the BSI-18 posttreatment. However, the control group showed increased emotional distress at 3-month follow-up while the Brain Injury Coping Skills group remained stable over time.

Conclusions

Few CBT studies have included survivors of BI and caregivers together in group treatment or included a control group. No prior studies have examined the role of PSE specifically. Prior intervention studies show inconsistent effects on emotional functioning, raising questions regarding the role of intervening variables. This study offers a new conceptualization that PSE may moderate longer-term emotional adjustment after brain injury. Results indicate that PSE is an important and modifiable factor in helping persons better adjust to BI.     

Differential features of burden between spouse and adult-child caregivers of patients with Alzheimer's disease: An exploratory comparative design

Background

Research into burden among spouse and adult-child caregivers of patients with Alzheimer's disease has generated contradictory results as regards the group which suffers the greatest burden and the factors underlying any differences.

Objectives

The aim of the present study was to identify and compare the factors associated with caregiver burden among spouse and adult-child caregivers.

Design

Cross-sectional analytic study.

Settings

All clinical subjects had been referred on an out-patient basis to the Memory and Dementia Assessment Unit of the Santa Caterina Hospital in Girona (Spain).

Participants

Data were collected from 251 patients and their caregivers, 112 with spouse and 139 with adult-child caregivers.

Methods

The association between caregiver burden and the socio-demographic and clinical variables of both patients and caregivers was analysed, the results being compared for spouse vs. adult-child caregivers. Burden was analysed using a multivariate linear regression including all the variables for the two groups of caregivers.

Results

The results show greater burden among adult-child caregivers (p < .05), who experience more feelings of guilt (p < .001). In both groups the behavioural and psychological symptoms of patients were correlated with burden (p < .001). Living with the patient has a notable influence on burden among adult children (p < .001). Husbands, wives, daughters and sons, in this order, showed increasing levels of burden (p < .05) and progressively worse mental health (p < .01). However, the correlations between burden and mental health were strongest in daughters (p < .001).

Conclusion

The differences in burden between spouse and adult-child caregivers were not associated with age, physical health or clinical factors of the patients. Overall burden was greater among adult-child caregivers, especially those who lived with the patient and who had other family duties. Feelings of guilt were associated with not living with the patient, and there was a strong correlation between burden and mental health. These results support the hypothesis that spouses regard caregiving as part of their marital duties, whereas for adult children such tasks imply an important change in their lifestyle.     

Writing ourselves into a web of obedience: A nursing policy analysis

Background

Nursing work is governed by a web of overarching documents from professional bodies, registration bodies, and individual health care organisations. The focus for these documents is to maintain high standards and protect patients and organisations from unnecessary risk. The presentation of the nurse within these documents has important implications for the ability of nurses to function as autonomous professionals.

Objectives

How the role of the nurse is situated in hospital procedural policy, and more specifically how these presentations of the nurse define, limit, and enable nursing practice is the focus of this paper.

Design

A combination of random and purposive sampling of the nursing policies of one tertiary level hospital was utilised to collect policy documents for thematic content analysis.

Setting

The study was completed in a tertiary level health institution, in one Australian jurisdiction with a population of approximately 500,000 people. This health institution employs over 4000 people and admitted 49,000 patients in the 2004-2005 financial year.

Methods

An inductive approach, which utilised theoretical and contextual comprehension of the nursing policies, informed the collation of coded data which determined the themes of the study.

Findings

Analysis consisted of coding of particular words, textual structure and theory content. Practice was presented in the nursing procedural policies in two themes, called ‘lingering tradition’ and ‘bureaucratic template’.

Conclusions

The discourse of hospital procedural policy situates the nurse as obedient to organisational requirements by limiting practice to a performance of actions without explicit recognition of professional autonomy. This sets up a puzzling contradiction between performance expectations from the employing organisation and the nursing profession. Writing hospital policy in the discourse of procedural directives reduces nurses’ ability to act as autonomous, critically thinking professionals, with implications for patient safety, nurse autonomy and the professional status of nursing.     

A shared care model pilot for palliative home care in a rural area: impact on symptoms, distress, and place of death

Context

Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs.

Objectives

To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death.

Methods

An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models.

Results

Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed.

Conclusion

Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration.     

Physiotherapy and Guillain-Barré syndrome: results of a national survey

Objective

To discover the extent to which persons with Guillain-Barré syndrome receive treatment by a physiotherapist (as inpatients and outpatients), and to assess whether the amount of treatment received is related to outcome.

Design

Survey method using self-administered questionnaires distributed through a national database.

Participants

Members of the Guillain-Barré Syndrome Support Group (n = 1535).

Main outcome measures

General patient data, general mobility, F-score, Hospital Anxiety and Depression Scale, Short Form-36 and Fatigue Severity Scale.

Results

In total, 884/1535 (58%) complete responses were received. Nearly 10% of respondents had not received treatment by a physiotherapist in hospital despite their average functional level being the same as respondents who had received treatment in hospital. One-quarter of respondents said that they had not received treatment following hospital discharge despite the identification of relatively high levels of disability. Those who did not receive treatment by a physiotherapist following discharge were less severely disabled. This may indicate that physiotherapists tend to offer treatment to more severely disabled patients. The majority of patients reported disabling fatigue; whilst not statistically related to receipt of treatment by a physiotherapist, this highlights the importance of assessing fatigue in treatment plans to improve physical functioning.

Conclusion

Improvements to policy and practice can be made by widening inpatient accessibility to treatment by a physiotherapist and increasing outpatient provision of treatment for patients with Guillain-Barré syndrome of all degrees of severity.     

Older people's and relatives’ experiences in acute care settings: Systematic review and synthesis of qualitative studies

Objective

To explore older people's and their relatives’ views on and experiences of acute health care.

Design

Systematic procedures were used for study selection and data extraction and analysis. A comparative thematic approach to synthesis was taken with a number of features adopted from the literature on meta-ethnography.

Data sources

Worldwide grey and published literature written in English between January 1999 and June 2008 identified from databases: CINAHL, Medline, British Nursing Index, EMBASE Psychiatry, International Bibliography of the Social Sciences, PsychINFO, and AgeInfo.

Review methods

We conducted a systematic review and synthesis of qualitative studies describing older patients’ and/or their relatives’ experiences of care in acute hospital settings. 42 primary studies and 1 systematic review met the inclusion criteria.

Results

A number of themes emerged. The quality of technical care is often taken for granted by older patients, and good or bad experiences are described more in terms of relational aspects of care. Older patients in hospital may feel worthless, fearful or not in control of what happens, especially if they have impaired cognition, or communication difficulties. Three key features of care consistently mediated these negative feelings and were linked to more positive experiences: “creating communities: connect with me”, “maintaining identity: see who I am” and “sharing decision-making: include me”.

Conclusion

These findings highlight the perspectives of older people and their relatives on the delivery of personalized and dignified care in acute settings. They lend support to previous calls for relationship-centred approaches to care and provide a useful experience-based framework for practice for those involved in care for older people.     

Problem-solving training for family caregivers of persons with traumatic brain injuries: a randomized controlled trial

Rivera PA, Elliott TR, Berry JW, Grant JS. Problem-solving training for family caregivers of persons with traumatic brain injuries: a randomized controlled trial.

Objective

To test the hypothesis that a problem-solving training program would lower depression, health complaints, and burden, and increase well-being reported by community-residing family caregivers of persons with traumatic brain injuries (TBIs).

Design

Randomized controlled trial.

Setting

General community.

Participants

Of the 180 people who expressed interest in the study, 113 did not meet eligibility criteria. A consenting sample of family caregivers were randomized into a problem-solving training group (4 men, 29 women; average age, 51.3y) or an education-only control group (34 women; average age, 50.8y). Care recipients included 26 men and 7 women in the intervention group (average age, 36.5y) and 24 men and 10 women in the control group (average age, 37.2y).

Intervention

Problem-solving training based on the D'Zurilla and Nezu social problem-solving model was provided to caregivers in the intervention group in 4 in-home sessions and 8 telephone follow-up calls over the course of their year-long participation. Control group participants received written educational materials and telephone calls at set intervals throughout their 12 months of participation.

Main Outcome Measures

Caregiver depression, health complaints, well-being, and social problem-solving abilities.

Results

Hierarchical linear models revealed caregivers receiving problem-solving training reported significant decreases in depression, health complaints, and in dysfunctional problem-solving styles over time. No effects were observed on caregiver well-being, burden, or constructive problem-solving styles.

Conclusions

Problem-solving training provided in the home appears to be effective in alleviating distress and in decreasing dysfunctional problem-solving styles among family caregivers of persons with TBI. Methodologic limitations and the implications for interventions and future research are discussed.     

Family Functioning Is Associated With Depressive Symptoms in Caregivers of Acute Stroke Survivors

Epstein-Lubow GP, Beevers CG, Bishop DS, Miller IW. Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors.

Objective

To determine whether family functioning is uniquely associated with caregiver depressive symptoms in the immediate aftermath of stroke.

Design

Cross-sectional data from the baseline assessment of an intervention study for stroke survivors and their families.

Setting

Neurology inpatient service of a large urban hospital.

Participants

Stroke survivors (n=192), each with a primary caregiver. The mean age of stroke survivors was 66 years, and most, 57%, were men (n=110). The mean age of caregivers was 57 years, and 73% (n=140) of the caregivers were women. Eighty-five percent of caregivers were white.

Interventions

Not applicable.

Main Outcome Measures

Measures were chosen to assess caregivers' depressive symptoms (Centers for Epidemiologic Studies Depression Scale), family functioning (Family Assessment Device), and additional factors such as health status (Medical Outcomes Study 36-Item Short-Form Health Survey) and stroke survivors' cognitive abilities (modified Mini-Mental State Examination) and functional impairments (FIM and Frenchay Activities Index).

Results

Depressive symptoms were mild to moderate in 14% and severe in 27% of caregivers. Family functioning was assessed as unhealthy in 34% of caregiver-patient dyads. In statistical regression models, caregiver depression was associated with patients' sex, caregivers' general health, and family functioning.

Conclusions

Forty-one percent of caregivers experienced prominent depressive symptoms after their family member's stroke. Higher depression severity in caregivers was associated with caring for a man, and having worse health and poor family functioning. After stroke, the assessment of caregivers' health and family functioning may help determine which caregivers are most at risk for a depressive syndrome.     

‘It got right to the spot’ The patient experience of primary angioplasty: A qualitative study

Background

Primary angioplasty is becoming an established treatment for myocardial infarction. Yet we have a limited understanding of patients' attitudes toward this treatment and their experiences of receiving it in practice.

Aims

Exploration of patients' experiences and perceptions of primary angioplasty as treatment for their heart attack.

Methods

Qualitative study of a purposive sample of patients admitted to a tertiary cardiology unit in east London, UK. Participants were interviewed either in their own homes or in hospital. Recruitment continued until no new substantial themes emerged. Eleven men and four women aged 35 to 74 years who had sustained a myocardial infarction were interviewed 13 to 90 days after primary angioplasty. We used the framework method of analysis to identify and explore emerging themes.

Results

Informants were expecting open-heart surgery as treatment for their heart attack. They were impressed by the service they actually received. They were generally not engaged in decisions about their treatment in the acute setting and this passivity sometimes persisted after discharge. Expectations of follow up in primary care were not often met.

Conclusions

Patients are satisfied with the primary angioplasty as treatment for acute myocardial infarction but have poor understanding of the management of this condition.     

Accuracy of Manual Needle Placement for Gastrocnemius Muscle in Children With Cerebral Palsy Checked Against Ultrasonography

Yang EJ, Rha D, Yoo JK, Park ES. Accuracy of manual needle placement for gastrocnemius muscle in children with cerebral palsy checked against ultrasonography.

Objective

To investigate the accuracy of manual needle placement into gastrocnemius muscle (GCM) for botulinum toxin type A (BTX-A) injection in children with spastic cerebral palsy (CP).

Design

Prospective clinical study.

Setting

University-affiliated hospital.

Participants

A total of 272 injections in GCMs of 39 children with spastic CP who were scheduled to receive BTX-A injections in GCMs.

Intervention

Not applicable.

Main Outcome Measures

The accuracy of manual needle placement was checked against ultrasonography.

Results

The needle was accurately inserted into GCM muscles in 78.7% of cases. Accuracy was 92.6% into gastrocnemius medialis (GM) and 64.7% into gastrocnemuis lateralis (GL). Muscle thickness at the needle insertion site was significantly thinner in GL than GM. Accuracy of GL in the younger age group (<4y, 57.6%) was lower than in the older age group (≥4y, 78.1%). For GM, accuracy in both younger and older age groups was good (>90%).

Conclusions

Injection of the toxin into GCMs through the use of anatomic landmark was acceptable in GM, but not acceptable in GL, especially in young children.     

A partnership approach to service needs assessment with family caregivers of an aging relative living at home: A qualitative analysis of the experiences of caregivers and practitioners

Background

As the global population ages, support for family caregivers who provide the bulk of care to community-dwelling older people is becoming ever more important. However, in many countries, homecare-service practitioners currently do not follow a systematic approach to assessing and responding to caregiver needs.

Objectives

The aim of this study was to explore the experiences of caregivers and practitioners who took part in a field test of the Family Caregivers Support Agreement (FCSA) tool, a modified version of the Carers Outcome Agreement Tool (COAT) initially developed as the result of an Anglo-Swedish study. Both the COAT and the FCSA are designed to facilitate partnerships between caregivers and practitioners so that needs assessment and subsequent support services are negotiated and agreed so as to meet caregiver expectations.

Design and participants

A qualitative design was adopted and data were collected through focus groups with six practitioners (nurses and social workers) working in two Local Community Service Centres in the province of Quebec (Canada). These practitioners had previously completed the FCSA tool with 17 primary caregivers of frail elderly relatives who were clients of homecare services. Individual interviews were conducted with the caregivers to explore their experiences. Data were analyzed to identify significant themes, from the perspectives of caregivers and practitioners, which provided insights into their experiences and the strategies used by practitioners to facilitate partnership working.

Findings

To facilitate meaningful exchanges, practitioners adopted strategies such as sensitive listening and the use of enabling questions to identify and contextualize caregiver needs and to highlight the ability of caregivers to find their own creative solutions to the challenges they face. The caregivers described experiencing a climate of trust that allowed them to express their concerns, to reflect upon their situation and to participate in the development of an action plan for their support.

Conclusions

The study reaffirms findings from Sweden and UK that the use of a tool such as the FCSA enhances partnership working and creates a caregiver-practitioner relationship based on a genuine alliance. As a result, both parties gain new insights into the caring situation. The approach underpinning the FCSA tool has potential for a more widespread application in different contexts.     

The association between nursing diagnoses, resource utilisation and patient and caregiver outcomes in a nurse-led home care service: longitudinal study

Background

The information generated by nurses through standardised nursing languages is insufficiently evaluated and exploited, mainly in home care services, as is its potential impact on outcomes.

Objectives

To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with use of resources, mortality, institutionalisation and satisfaction.

Design

Observational, longitudinal follow-up study.

Settings

Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almería and Granada, in Spain.

Participants

Patients and caregivers who initiated the Home Care Programme.

Methods

The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of resources, mortality, institutionalisation and satisfaction.

Results

Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8 diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits (p = 0.033). Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers were, in 78% of cases, due to the recipient’s baseline functional status. No relation was detected for institutionalisation or for patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for mortality (RR: 2.08 CI 95%: 1.26-3.42) (p = 0.012).

Conclusions

These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources use. Their synergy with other case-mix systems in home care should be investigated.