Psychological Adaptation to Serious Illness: A Qualitative Study of Culturally Diverse Patients With Advanced Chronic Kidney Disease

ContextPsychological distress is associated with adverse health outcomes in serious illness and magnified among patients of low socioeconomic status. Aspects of one's culture, such as religion and spirituality, can influence these patients' coping response to distress. Advanced chronic kidney disease (CKD) is a serious illness that disproportionately affects patients of low socioeconomic status, but a theory-based understanding of this group's lived experience of CKD is lacking.ObjectivesWe explored the cognitions, emotions, and coping behaviors of patients with CKD with emphasis on those of low socioeconomic status. We further inquired into any influences of religion or spirituality.MethodsWe interviewed 50 English-speaking or Spanish-speaking adults with advanced CKD from three medical centers in Nashville, Tennessee. Analyses occurred with isolation of themes; development of a coding system; and creation of a conceptual framework using an inductive-deductive approach.ResultsMedian age was 65 years; median annual income was $17,500 per year; and 48% of participants had not progressed beyond high school. Key beliefs (awareness of mortality and lack of control) influenced patients' emotions (existential distress in the form of death anxiety, prognostic uncertainty, and hopelessness) and coping behaviors (acceptance, avoidance, emotion regulation via spirituality, and seeking social support via a religious community).ConclusionIndividuals with advanced CKD and low socioeconomic status lack control over disease progression, experience death anxiety and existential distress, and emphasize spirituality to cope. Our study identifies novel components for a psychotherapeutic intervention for patients with advanced CKD at high risk for adverse health outcomes.     

Study protocol: The Improving Care of Acute Lung Injury Patients (ICAP) study

Introduction

The short-term mortality benefit of lower tidal volume ventilation (LTVV) for patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) has been demonstrated in a large, multi-center randomized trial. However, the impact of LTVV and other critical care therapies on the longer-term outcomes of ALI/ARDS survivors remains uncertain. The Improving Care of ALI Patients (ICAP) study is a multi-site, prospective cohort study that aims to evaluate the longer-term outcomes of ALI/ARDS survivors with a particular focus on the effect of LTVV and other critical care therapies.

Methods

Consecutive mechanically ventilated ALI/ARDS patients from 11 intensive care units (ICUs) at four hospitals in the city of Baltimore, MD, USA, will be enrolled in a prospective cohort study. Exposures (patient-based, clinical management, and ICU organizational) will be comprehensively collected both at baseline and throughout patients' ICU stay. Outcomes, including mortality, organ impairment, functional status, and quality of life, will be assessed with the use of standardized surveys and testing at 3, 6, 12, and 24 months after ALI/ARDS diagnosis. A multi-faceted retention strategy will be used to minimize participant loss to follow-up.

Results

On the basis of the historical incidence of ALI/ARDS at the study sites, we expect to enroll 520 patients over two years. This projected sample size is more than double that of any published study of long-term outcomes in ALI/ARDS survivors, providing 86% power to detect a relative mortality hazard of 0.70 in patients receiving higher versus lower exposure to LTVV. The projected sample size also provides sufficient power to evaluate the association between a variety of other exposure and outcome variables, including quality of life.

Conclusion

The ICAP study is a novel, prospective cohort study that will build on previous critical care research to improve our understanding of the longer-term impact of ALI/ARDS, LTVV and other aspects of critical care management. Given the paucity of information about the impact of interventions on long-term outcomes for survivors of critical illness, this study can provide important information to inform clinical practice.     

Nursing Leadership,Missing Questions,and the Elephant(s) in the Room: Problematizing the Discourse on Nursing Leadership

To expose inconsistencies and contradictions in the nurse leadership literature (“text”), this article adopts a deconstructive approach and draws upon the work of Derrida in examining the text or discourse. What is almost entirely missing in the literature are articles that ask difficult, searching questions that challenge some of the taken-for-granted truths or maxims about nursing leadership. The current examination of the literature, described in this article, shows: (a) a lack of convergence of the literature and health care/nursing organizations concerning leadership, (b) a conflation of nursing leadership with managerial or administrative positions, and (c) a possible lack of understanding about the complexity of nursing leadership coupled with an unwillingness to raise these issues.     

Music and Other Strategies to Improve the Care of Agitated Patients with Dementia

Many patients with dementia symptoms display forms of agitation such as the repeating of words, restlessness and aggression. These forms of behaviour may inflict strain on the co-patients and the caregivers. In this study, 17 experienced formal caregivers from nursing homes and collective residential units were interviewed about their experiences of agitated patients with dementia and strategies to improve their care. The questions were open except for specific questions about sound, music, and opinions about pharmacological treatment. A calm atmosphere and a slow pace emerged as important strategies to control agitation. Fixed routines could develop this. The mixing of lucid and agitated dementia patients appeared as a major problem, because some lucid patients became angry when patients with dementia displayed agitation. Irritability in one patient could trigger agitation in other patients but was possible to stop at an early stage. Several responders had successfully used music to calm individual agitated patients. Music seemed to be an underestimated nursing intervention to control agitation in daily life, but uncontrolled sound could cause agitation in the patients and stress in the nursing staff.     

The GAP-ED Project: Improving Care for Elderly Patients Presenting to the Emergency Department

BackgroundOlder adults presenting to the emergency department (ED) represent a highly vulnerable patient population with complex conditions and multiple comorbidities. The introduction of a Geriatric and Palliative (GAP)-ED partnership may be an effective strategy to avoid unneeded admissions and improve outcomes for this population.ObjectivesThe primary objective was to decrease 30-day revisit and hospitalization rates in this population through identifying patients that could be safely sent home with connection to community resources. Secondary outcomes included achieving high patient and family satisfaction scores assessed through follow-up interviews.MethodsThe GAP-ED intervention included the placement of a Specialist in the ED to coordinate care for older adults presenting to the ED who were likely to be discharged home. Independent t-tests and chi-squared tests were used to assess for changes in outcomes between the intervention group and a blocked matched historical usual-care group.ResultsThere was no significant difference in 30-day ED revisits between the two groups, but there was a statistically significant reduction in hospital admissions from these 30-day revisits. Patient and family satisfaction with the presence of the GAP-ED Specialist was high.ConclusionThe implementation of a GAP-ED partnership and use of a GAP-ED Specialist is an effective means of reducing hospitalization in older adults revisiting the ED.     

整体护理改善护患关系的体会

整体护理的实施,重塑了护士的职业价值观,增加了护患之间的接触。护士能够在自己的专业范围内积极主动地解决病人的问题,挖掘了护理人员的自身潜力,加深了护患交流,使护患关系明显改善。