Life with a hemodialysis machine

The aim of the present study was to describe the experience of patients undergoing haemodialysis starting from their own perception. A qualitative perspective using Merleau Ponty's Existential Phenomenology was considered to be the most appropriate methodology for this study. Fifteen patients were interviewed in a haemodialysis unit at a Brazilian teaching hospital. Interviews were based on the question 'What does the experience of living with a haemodialysis machine mean?' Convergences in speeches were grouped into three categories: the machine, improvement in quality of life, reflection on patients' experience. These findings show the existential reality patients experience. A haemodialysis machine dictates their lives: they have to accept strict rules controlled by a team of healthcare providers. They realize it has to be so and there is no way out. It is the only way to get some relief from the symptoms of the disease. The feeling is mostly acceptance of the condition. Healthcare providers' dedication is recognized. Some participants complain bout painful procedures, others deny them, others fantasize the reality. An essential piece of information is the lack of future perspectives; few patients mentioned the possibility of a transplant or the possibility of carrying out their own care. The study may contribute in outlining new perspectives for nurses to understand the needs of patients undergoing haemodialysis. An approach accepting patients' views will probably bring awareness to patients as to the possibilities of helping with their own treatment.     

Patients' perspectives of fluid management: A multicentre comparative study of home and incentre haemodialysis

Background

There is increasing worldwide interest in person-centred care in haemodialysis and home haemodialysis (HHD). Intradialytic fluid management is a vital component of haemodialysis, and often a shared decision, yet patients' perspectives and experience of related decisions are largely unexplored.

Objectives

To explore the perspectives of patients receiving home or incentre haemodialysis (IHD), in relation to intradialytic fluid management.

Design

A multicentre cross-sectional survey.

Participants

Eight hundred and thirty-nine patients receiving IHD and 99 patients receiving HHD, across six English renal units.

Measurements

Self-reported measures of understanding, experiences and control of fluid management, and willingness to achieve target weight. An objective test of patients' ability to relate common signs and symptoms to fluid overload or excessive ultrafiltration.

Results

Patients receiving HHD had greater knowledge than those receiving IHD (66.1% vs. 42.3%, p < 0.001) about causes of common signs and symptoms which remained when controlling for age, education and years since beginning haemodialysis. Patients receiving HHD felt more in control of and had greater self-reported adherence to fluid management (p < 0.01), yet knowledge gaps existed in both cohorts.

Conclusions

Greater patient knowledge and its practice in HHD may contribute to improved fluid balance and outcomes. Whilst patient selection may contribute towards these differences, the training patients receive when opting for HHD and subsequent experience are likely to be key contributing factors. Integrating aspects of education on fluid management from HHD training programmes should be considered in IHD, and further targeted, robust education remains an unmet need.     

How can adherence to asthma medication be enhanced? Triangulation of key asthma stakeholders' perspectives

Background and objectives: Adherence to daily asthma controller medication has been shown to be the most effective component of asthma self-management; however, patient's adherence to asthma medication remains poor. This study aimed to understand how patients' long-term asthma controller medication adherence may be improved and facilitated by comparing key asthma stakeholders' perspectives. Method: Six focus group interviews including 38 asthma stakeholders (n = 13 patients, n = 13 pulmonologist physicians, and n = 12 allied healthcare professionals) were conducted. Interviews were qualitatively analysed. Results: Although similar themes were brought up across different asthma stakeholders, the way in which they were framed differed across stakeholders. The most salient discussion revolved around the content and the moment in which asthma education should be approached to facilitate patients' adherence to asthma medication. Conclusion: Asthma medication adherence is a complex process and successful interventions aimed at its improvement would benefit from: (a) making an effort to understand patients' experiences and negotiate the treatment regimen, rather than imposing recommendations; (b) considering treatment as a shared responsibility involving the patient, the healthcare professional(s), and the patients' social networks; and, (c) taking into account different stakeholders' concerns, needs, perspectives, and knowledge.     

Improving Medication Management Competency of Clinical Trainees in Geriatrics

The authors hypothesized that an interprofessional workshop would improve geriatrics trainees' medication management. The workshop was based on a needs assessment and comprised an interactive session with pharmacists on managing medications in elderly adults. Participants were trainees in their geriatrics rotation at a tertiary care medical center. Trainees completed a medication appropriateness survey for three patients, one of which was their own. After the workshop, trainees reviewed medications of the three patients. Trainees completed online surveys after their rotation and 3 months later. Of 95 trainees rotating through geriatrics, 76 (80%) attended the workshop and completed the worksheet. Trainees' scores on reviewing medication lists improved significantly, from 6.7 ± 2.3 to 7.7 ± 2.0 out of 11 for standardized patient 1 (P < .001) and from 5.7 ± 1.8 to 6.4 ± 1.5 out of 11 for standardized patient 2 (P = .009). Trainees' scores on their own patients' lists also improved significantly, from 5.6 ± 1.5 to 6.6 ± 1.5 out of 10 (P < .001). After the workshop, 95% (71/75) planned to change the medication regimen of the patient they presented, and 93% (68/73) planned to change other patients' medications based on information learned during the workshop. Three months later, 35% (12/34) had made changes to the regimen of the patient they discussed during the workshop, and 71% (15/21) had made changes to other patients' regimens. Seventy‐eight percent (18/23) rated the workshop as the top nonclinical experience of their geriatrics rotation. In conclusion, this interprofessional medication management workshop improved trainees' ability to perform medication reviews accurately and led to change in self‐reported prescribing behavior.     

A CASE STUDY ‐ INITIATION OF HAEMODIALYSIS

End‐stage renal disease (ESRD) is a chronic failure of normal kidney function, which is precipitated by a number of factors, such as diabetes, pyelonephritis, hypertension, and polycystic kidney disease (1). The loss of kidney function is gradual, and many patients do not have any symptoms until the end‐stage of the disease. Killingworth and Van Den Akker (2) point out that people undergoing haemodialysis have to comply with a wide range of medications and restrictions, which affect both their physiological and psychological status. This paper presents a case study of a woman with ESRD, requiring initiation of haemodialysis. An assessment of the patient's health needs is addressed, followed by the implementation and evaluation of the nursing process. Finally, the analysis of the overall plan used in the case study is presented.     

Illuminating multiple perspectives: meanings of nasogastric feeding in anorexia nervosa

This qualitative study examined the range of meanings that female adolescent patients with anorexia nervosa attach to nasogastric feeding (NGF). In‐depth interviews were conducted with 23 patients. Qualitative analysis revealed that patients attached four broad meanings to NGF: an unpleasant physical experience; a necessary or helpful intervention; a physical and/or psychological signifier of anorexia; and a focus in a broader struggle for control. Importantly, individual patients sometimes attached multiple and seemingly contradictory meanings to NGF, and the meanings patients attached to NGF shaped their responses to treatment. The findings illustrate the difficulties of a ‘one‐size‐fits‐all’ approach to NGF and the importance of accommodating patients' perspectives into clinical practice. The implications for the institution of NGF are discussed and a framework for developing clinical protocols that accommodate patients' constructions of NGF is proposed. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association.     

Drawing asthma: An exploration of patients' perceptions and experiences

Objective: As an art form, drawings can facilitate the tangible expression of patients' inner images and feelings in a range of health conditions. However, there are currently no published studies investigating adults' perspectives of asthma using drawings. This study aimed to explore how adults' drawings illustrate their perceptions and experiences of asthma. Methods: Adults with asthma participated in a one-on-one drawing activity. Analysis was grounded in the participants' accounts of their drawing, which were examined alongside the relevant image. A coding approach was used to cluster thematic material and map the data according to the Common-Sense Model of Self-Regulation (CSM). Results: Eighteen participants took part. Three themes emerged: (1) asthma is constrictive and restrictive, (2) feeling alone, feeling different, and (3) the life journey of asthma. The drawings aligned with several domains of the CSM, in particular consequences. The images drawn by the participants and their subsequent discussions highlighted the prominence of the emotional burden of asthma. Conclusions: The drawings provided powerful and evocative communication of the experience of asthma. Future research using drawings can further both healthcare professionals' and patients' understanding of the physical, social and emotional demands of living with asthma, and support the development of asthma self-management practices.     

Beliefs about inhaled corticosteroids: Comparison of community pharmacists,pharmacy technicians and patients with asthma

Objectives: To compare pharmacists' and pharmacy technicians' perceptions of patients' beliefs regarding inhaled corticosteroids (ICS) with those of patients and to compare the ICS beliefs of pharmacists and technicians with those of patients with asthma. Methods: 1269 community pharmacies were approached to fill out an online questionnaire; 1952 patients were sent a questionnaire by post. Beliefs (i.e., necessity and concerns) regarding ICS were measured using (an adapted version of) the Beliefs about Medicines Questionnaire (BMQ-specific). Pharmacists and technicians were instructed to fill out the BMQ for themselves, and to fill it out in the way they thought most of their patients would complete it. Results: 136 pharmacists, 90 pharmacy technicians and 161 patients with asthma completed the questionnaire. Pharmacists and technicians thought patients had more concerns about ICS than patients themselves reported (p < 0.0001). They also thought that patients had stronger beliefs in their personal need for ICS than patients reported (p < 0.01). Pharmacists reported lower levels of concerns than patients (p < 0.05) and both providers attributed a higher level of necessity to ICS than patients did (p < 0.0001). Conclusion: Pharmacists and technicians overestimate the personal need for treatment as well as the concerns patients with asthma have regarding ICS. They also have, to some extent, stronger positive beliefs about ICS than patients. If pharmacists and technicians expect that patients share their positive views about ICS, they might be less likely to elicit and address patients' doubts and concerns about ICS, which might be relevant for effective ICS treatment and subsequent patient outcomes.     

Routes to total joint replacement surgery: Patients' and clinicians' perceptions of need

Objective

To explore patients' perspectives of need for total joint replacement associated with decision making in orthopaedic consultations for hip or knee osteoarthritis.

Methods

Twenty‐six orthopaedic consultations in 3 UK hospitals were observed and audio recorded, and semistructured interviews were conducted with the involved patients and clinicians. Data were analyzed using thematic analysis.

Results

Two main routes to orthopaedic consultation were identified: patients who waited until their symptoms were no longer bearable (holding off), and patients who sought consultation preemptively (before it gets worse). These routes were mediated by age, comparison with others, demands and desires, deterioration, and convenience. Whether patients had held off or sought help preemptively influenced their perceptions of need. Patients' perceptions of their route to orthopaedic consultation, and consequently their perception of need, were either confirmed or contradicted by clinicians.

Conclusion

When clinicians and patients have differing perceptions of need there may be ongoing patient anxiety, concern, and feelings of disempowerment. It is important for primary and secondary care clinicians to identify and explore a patient's perception of need in order to provide consistency in referral pathways and to support patient involvement in, and understanding of, shared decision making. Exploring the patient's perspective of their route to consultation is proposed as one easily achievable method of identifying patients' views on urgency of their need.     

Asthma Management Failure: A Flaw in Physicians' Behavior or in Patients' Knowledge?

Objectives. Patient–physician communication and patients' knowledge about asthma are relevant factors that influence health outcomes. The aim of this study was to explore general practitioners' (GPs) behaviors, asthma patients' knowledge requirements, and the relationship between physicians' communicative issues, and failures in patients' knowledge. Methods. GPs participating in a continuing medical education program on asthma completed an ad hoc survey on communicative style and recruited at least three adult asthma patients to indicate, among 10 options, three aspects of asthma about which they felt less informed. Results. The survey was completed by 2332 GPs (mean age 54.39 ± 5.93 years) and 7884 patients (mean age 49.59 ± 18.03 years). Several ineffective strategies emerged in the physicians' behaviors: 28.5% of GPs did not encourage patients to express doubts, expectations, or concerns; 39.4% tried to frighten patients concerning disease-related risks; only 25.7% used a written action plan. In addition, 18.6% of GPs were not averse to informing the patient about potential side effects; 16.3% did not try to simplify asthma treatment; approximately 30% considered ease of use when selecting drugs; 18% were not disposed to carry out a partnership with the patient; 36.9% were unlikely to involve the patient in asthma management; and 73% tried to retain control over their patients. Finally, 90.3% of GPs declared they want to be consulted before any treatment change. The three topics on which patients felt less informed were the meaning of asthma control (14% of patients); integration of asthma into daily life (13.3%); and periodic checkups (12.7%). There were significant associations between patients' choices and physicians' answers. Conclusion. These results demonstrate that in general medicine the recommendations of international guidelines on education, communication, and development of a doctor–patient partnership are still ignored and that patients' educational priorities may differ from those identified by medical specialists and by patients belonging to patients' associations.     

Irritable bowel syndrome patients' perspectives on their relationships with healthcare providers

Abstract

Objective. The objective of this qualitative study was to examine patients' perspectives on their relationships with healthcare providers (HCPs) as communicated in their expressive writings about irritable bowel syndrome (IBS). Methods. As part of a large national online study, IBS patients were asked to: (a) write expressively about their IBS illness experience for 30 min/day for four consecutive days and (b) answer the question, “What is the most important thing your HCP can do to maximize his/her relationship with you?” A key word search was used to identify comments that mentioned the words “doctor,” “doc,” “physician,” “MD,” “gastroenterologist,” “nurse,” “nurse practitioner,” or “physician assistant” in the 228 expressive writings completed by the first 57 participants (four writings for each subject). Analyses of the comments about the patient–HCP relationship and responses to the above question were performed by the authors who identified themes and their frequencies over several sessions using a quantitative content analysis method. Results. We report the results of the first 57 subjects who participated in the study. Subjects' mean age was 41.1 (± 12.7) years, gender was 82% female, 98% had seen an MD for IBS, 58% had IBS <10 years, with mild/moderate disease severity (IBS severity scale (IBSSS) 190.6 + 45.55), and IBS-quality of life (QOL; 62.7.3 + 21.58). Of the 57 subjects who wrote expressively about their experiences related to IBS, 40 (70%) wrote about their relationships with their HCPs in at least one of their four writings. Of the 197 relationship comments about HCPs made in a total of 84 writings, 106 (54%) were categorized as “negative,” 22 (11%) as “positive,” and 69 (35%) comments were categorized as “neutral mentions.” The top five themes identified were: “I need more empathy and listening from my HCP about how much IBS affects my life” (27%), “Nothing my HCP does helps my IBS” (25%), “My HCP has been helpful and reassuring” (17%), “My HCP thinks I'm crazy” (8%), and “I don't trust my HCP” (5%). Forty-nine (86%) subjects answered the question regarding maximizing the relationship with their HCP, with 53% reporting that listening, empathy, and providing education were the most important factors for maximizing the relationship. Conclusion. Our results demonstrate that the patient–HCP relationship is central to patients' illness experience. The majority of our study subjects viewed their relationships with HCPs negatively, with major concerns relating to being heard and receiving empathy. The study findings highlight the need for improved patient–HCP communication. Further research utilizing novel modalities, such as expressive writing, in eliciting patient information and perspectives, may provide valuable educational tools.     

A case study--initiation of haemodialysis

End-stage renal disease (ESRD) is a chronic failure of normal kidney function, which is precipitated by a number of factors, such as diabetes, pyelonephritis, hypertension, and polycystic kidney disease (1). The loss of kidney function is gradual, and many patients do not have any symptoms until the end-stage of the disease. Killingworth and Van Den Akker (2) point out that people undergoing haemodialysis have to comply with a wide range of medications and restrictions, which affect both their physiological and psychological status. This paper presents a case study of a woman with ESRD, requiring initiation of haemodialysis. An assessment of the patient's health needs is addressed, followed by the implementation and evaluation of the nursing process. Finally, the analysis of the overall plan used in the case study is presented.     

Sex under the influence of alcohol among Norwegian adolescents

The purpose of this paper is to study alcohol consumption among Norwegian adolescents at their most recent experience of sexual intercourse. The material comprises a stratified sample of 920 adolescents aged 16–20 years in a Norwegian county (52.3% of the girls and 41.4% of the boys had coital experience). Data were collected by means of questionnaires; 21.0% of the adolescents reported sex under influence of alcohol. A logistic regression analysis showed that the best predictors of sex under influence of alcohol were intercourse location, sexual enjoyment and sexual intercourse motivated by “Don't know, it just turned out that way”. Adolescents who had their most recent experience of intercourse away from home, who had problems enjoying sex and/or who said it just turned out that way, were more likely than others to have had sex under influence of alcohol. A multivanate logistic regression analysis showed that among adolescents who reported that the intercourse took place away from their homes, the odds ratio (OR) for sex under influence of alcohol increased by 8. 7. Those who had consumed alcohol before sex, more often than non-drinkers, tended to enter into sexual intercourse motivated by factors external to their own person. This tendency was more pronounced among boys than girls.     

Acute Effect of Inhaled Budesonide on Bronchial Inflammation in Asthmatic Rats

The aim of this study was to determine the level of asthma control and the concordance between physicians' and patients' opinions and the real patients' situation. A total of 777 subjects (55% female) with asthma were recruited. The study comprised a 4-week follow-up period, during which subjects completed a diary recording peak expiratory flow (PEF), symptoms, and use of rescue medication. At the end, both physicians and patients rated asthma control status. The level of control was evaluated using a composite measure. Agreement among subjective assessments of asthma control by patients and physicians and objective evaluation with the composite measure was assessed through kappa scores. A total of 518 (67%) patients had “not well-controlled asthma,” being the remaining “totally controlled” (8%) or “well-controlled” (25%). “Not well-controlled asthma” was more frequent in smokers (82%) than in ex-smokers (70%) or in non-smokers (62%; p = 0.0002). Kappa scores between patients' and physicians' opinions and the real patients' status were 0.02 (95% CI, 0.01–0.05) and 0.07 (95% CI, 0.03–0.09), respectively. In conclusion, current level of asthma control is suboptimal for a majority (67%) of patients in Spain. Besides, asthma control is worse in smokers. Neither patients' nor physicians' opinions agree with patients' real situation. Both patients and physicians accept as normal a suboptimal status of their disease.     

Effect of a self-efficacy promotion training programme on the body weight changes in patients undergoing haemodialysis

Introduction: Haemodialysis is the most common form of medical management of patients affected by end‐stage renal disease (ESRD). For haemodialysis to be successful, strict fluid and weight control is recommended. Education, in terms of self‐care activities, is an important intervention for improving patients’ outcomes. A self‐efficacy promotion training programme can be an effective strategy to bring about behavioural change. The aim of this study was to investigate the effect of a self‐efficacy promotion training programme on the body weight changes in patients undergoing haemodialysis. Methods: In this single‐blind quasi‐experimental study, we recruited a convenience sample of 63 patients undergoing haemodialy‐sis from two teaching hospitals and allocated them randomly to the experimental or control group. Patients in the experimental group received a six‐session self‐efficacy promotion training programme while the control group received the routine care of the institute. Mean body weight gain and self‐efficacy were measured before, immediately and two months after the study. Findings: The groups did not differ significantly regarding the study variable before the study. However, immediately and two months after the study, the mean body weight gain and self‐efficacy in the experimental group were significantly lower and higher, respectively, than the control group (p < 0.05). Conclusion: Implementing a self‐efficacy promotion training programme is effective in decreasing weight gain and increasing self‐efficacy in patients undergoing haemodialysis. Nurses in haemodialysis units can use self‐efficacy promotion training pro‐grammes as an effective intervention for improving patients’ outcomes.     

Lipoprotein abnormalities in hypertriglyceridaemic patients on long-term haemodialysis

Abstract. Objectives. To analyse by ultracentrifugation in a zonal rotor the plasma lipoproteins in hypertriglyceridaemic patients on long-term haemodialysis. Design. Case-control study. Setting. Tertiary referred care centre. Subjects. Ten consecutive hypertriglyceridaemic patients on haemodialysis and 12 consecutive healthy controls. Main outcome measures. Plasma lipid and lipoprotein cholesterol concentrations, lipoprotein physical properties and compositions, apolipoprotein concentrations. Results. Hypertriglyceridaemia in patients undergoing haemodialysis is characterized by an increased amount of small and slow floating very-low density lipoproteins (VLDL), higher concentrations of intermediate density lipoproteins (IDL) and small and dense low-density lipoprotein (LDL) particles; reduced levels of high-density lipoproteins (HDL), in particular of HDL2. The lipoprotein composition of such patients indicates reduced cholesterol ester and increased triglyceride content. Compared to controls, they have lower levels of plasma apolipoprotein A-I and A-II and higher B, C-II, C-III and E values. Conclusions. The lipoprotein abnormalities observed in hypertriglyceridaemic patients undergoing haemodialysis have recently been associated with an increased incidence of vascular complications and may in part explain the high incidence of vascular disease reported in these subjects.     

Patients' intuitive judgments about surveillance endoscopy in Barrett's esophagus: a review and application to models of decision‐making

Adherence to practice guidelines for endoscopic surveillance of Barrett's esophagus is equivocal with evidence of underutilization and overutilization. While physicians report strong agreement with and adherence to recommended surveillance endoscopy (esophagogastroduodenoscopy [EGD]) guidelines, less is known about modifiable barriers and facilitators shaping patients' adherence behaviors. The aim of this study is to conduct a structured literature review of studies exploring patients' perspectives regarding surveillance EGD and to place these results within a conceptual framework. A structured literature review of PubMed, Cochrane, and Google Scholar databases with qualitative thematic analysis was performed. Six studies met eligibility criteria. Analysis of results identified five distinct themes. First, patients' objective cancer risk estimates are consistent with subjective risk perceptions, but neither is associated with EGD surveillance. Second, patients have strong beliefs in the benefits of cancer screening and surveillance and trust in their doctors. Third, anxiety and depression symptoms are related to risk perceptions and outcome expectancies of surveillance. Fourth, endoscopic surveillance itself has affective and physical consequences. Finally, health services and system variables are related to risk perception and EGD surveillance. These themes coherently fit within an integrated model of intuitive decision‐making and health behaviors. Studies meeting eligibility criteria were heterogeneous in terms of their study objectives and findings. Quantitative meta‐analyses of study findings could not be performed. To improve adherence, endoscopic surveillance programs should consider how patients intuitively frame risks and benefits and patients' emotional reactions to the endoscopy procedure, and focus on how physicians communicate recommendations.