Between hope and hopelessness: COPD patients' and their family members' experiences of interacting with healthcare providers – a qualitative longitudinal study

Background

Patient–family–healthcare provider interaction seems important for patients with chronic obstructive pulmonary disease (COPD ) and their family members' self‐management practices. Because the need for support might be enhanced after a hospitalisation, it might be beneficial to explore this interaction further in follow‐up health care.

Aim

To explore the meaning of patients' and their family members' experiences of interacting with healthcare providers to their daily self‐management over time.

Methods

Participant observations and in‐depth interviews were conducted repeatedly with 10 patients and seven family members during follow‐up visits at hospital and at the participants' homes between 2014 and 2016. A phenomenological–hermeneutical approach was used to interpret the data.

Results

‘Between hope and hopelessness’ involved frustrations, concerns and doubts, all of which could relate to the interaction with healthcare providers. ‘Seeking support from healthcare services’, ‘navigating between healthcare providers’ and ‘collaborating with healthcare providers at home’ could entail opportunities to strengthen self‐management and hope; however, it could also entail reduced faith in getting the right help and hopelessness.

Conclusion

During a period of transition after hospitalisation, available and well‐coordinated healthcare services, and alliances with healthcare professionals are crucial to COPD patients and their family members in terms of their self‐management, hope and well‐being.

     

Registered Nurses’ experiences of patient participation in hospital care: supporting and hindering factors patient participation in care

Background

Promoting patient participation in care is an international priority identified by the World Health Organization and various national bodies around the world and an important aspect of person‐centred care.

Aim

The aim of this study was to describe Registered Nurses’ experiences with patient participation in nursing care including their barriers and facilitators for participation.

Method

The study setting was a University Hospital in Sweden. Interviews were conducted with twenty Registered Nurses working at medical wards in 2013. Thematic data analysis was used to analyse the transcribed interview data.

Results

Twenty nurses from four wards in two hospitals were included. Five themes emerged from the analysis including listening to the patient, engaging the patient, relinquishing some responsibility, sharing power and partnering with patients. The core theme ‘partnering with patients’ was enacted when nurses listened to and engaged patients and when they relinquished responsibility and shared power with patients. In addition, hindering and facilitating factors to participation were identified, such as patients wanted to take on a passive role, lack of teamwork which participants understood would enhance interprofessional understanding and improve patient safety. Patient participation was hindered by medical jargon during the ward round, there was a risk of staff talking over patients’ heads but sometimes inevitable having conversations at the patient's bedside. However, nurses preferred important decisions to be made away from bedside.

Conclusions

It all came down to partnering with the patient and participants described how they made an effort to respect the patients’ view and accept patient as a part of the care team. Identified hindering factors for participation were lack of teamwork, patients’ taking on passive roles and communication during ward rounds having conversations at the patient's bedside. Nurses wished for a change but lacked strategies on how. Nurses preferred important decisions to be made away from bedside.

     

Ward nurses' experiences of the discharge process between intensive care unit and general ward

Background

Intensive care unit (ICU) discharges are challenging practices that carry risks for patients. Despite the existing body of knowledge, there are still difficulties in clinical practice concerning unplanned ICU discharges, specifically where there is no step‐down unit.

Aims and objectives

The aim of this study was to explore general ward nurses' experiences of caring for patients being discharged from an ICU.

Design and methods

Data were collected from focus groups and in‐depth interviews with a total of 16 nurses from three different hospitals in Sweden. An inductive qualitative design was chosen.

Findings

The analysis revealed three themes that reflect the challenges in nursing former ICU patients: a vulnerable patient, nurses' powerlessness and organizational structure. The nurses described the challenge of nursing a fragile patient based on several aspects. They expressed feeling unrealistic demands when caring for a fragile former ICU patient. The demands were related to their own profession and knowledge regarding how to care for this group of patients. The organizational structure had an impact on how the nurses' caring practice could be realized. This evoked ethical concerns that the nurses had to cope with as the organization's care guidelines did not always favour the patients.

Conclusions

The structure of the organization and its leadership appear to have a significant impact on the nurses' ability to offer patients the care they need.

Relevance to clinical practice

This study sheds light on the need for extended outreach services and intermediate care in order to meet the needs of patients after the intensive care period.

     

Activities of daily living and rehabilitation needs for older adults with a stroke: A comparison of home care and nursing home care

Aim

To compare the changes in benefit levels of activities of daily living (ADLs), rehabilitation, and long‐term care services (LTCS) in older adults with a stroke in different modalities of LTCS, which include home care and nursing home care.

Methods

This study analyzed national data regarding LTCS from 2008 to 2009 in South Korea. The data about 7668 older adults with a stroke were extracted from a pool of 182,535 total beneficiaries. In order to control for the baseline differences between older adults who received home care and those who received nursing home care, propensity score matching (PSM) was carried out and there were 1099 matched pairs of participants ( n = 2198). After the PSM, the changes in ADLs and rehabilitation between the two groups were analyzed by using a paired t‐test and the changes in LTCS benefit levels were compared by using the χ²‐test.

Results

The ADLs and rehabilitation needs of the older adults who received home care improved, while the older adults who received nursing home care experienced deterioration. After 1 year, the LTCS benefit levels were significantly different between the home care and the nursing home care groups

Conclusion

All of the ADLs, rehabilitation needs, and LTCS benefit levels for 1 year had improved in the home care patients, while they worsened in those who received nursing home care. This finding provides evidence to direct the policy of LTCS and offers information to guide older adults with a stroke and their family when deciding between the modalities of LTCS.

     

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review

Background

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes.

Aims

The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes.

Methods

Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in‐hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re‐intubation incidence, ventilation‐associated pneumonia rate and lung‐protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity.

Results

Twelve studies met the inclusion criteria for full review: 11 pre‐ and post‐intervention observational and 1 quasi‐experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator‐associated pneumonia rates, failed weaning trials and improvements in lung‐protective ventilation compliance. Non‐statistically significant results were reported for in‐hospital and intensive care unit mortality, re‐intubation and intensive care unit length of stay.

Conclusion

Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required.

Relevance to clinical practice

Well‐designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

     

Do universal school‐based mental health promotion programmes improve the mental health and emotional wellbeing of young people? A literature review

Aims and objectives

To examine evidence—using a range of outcomes—for the effectiveness of school‐based mental health and emotional well‐being programmes.

Background

It is estimated that 20% of young people experience mental health difficulties every year. Schools have been identified as an appropriate setting for providing mental health and emotional well‐being promotion prompting the need to determine whether current school‐based programmes are effective in improving the mental health and emotional well‐being of young people.

Methods

A systematic search was conducted using the health and education databases, which identified 29 studies that measured the effectiveness of school‐based universal interventions. Prisma guidelines were used during the literature review process.

Results

Thematic analysis generated three key themes: (i) help seeking and coping; (ii) social and emotional well‐being; and (iii) psycho‐educational effectiveness.

Conclusion

It is concluded that whilst these studies show promising results, there is a need for further robust evaluative studies to guide future practice.

Relevance to clinical practice

All available opportunities should be taken to provide mental health promotion interventions to young people in the school environment, with a requirement for educational professionals to be provided the necessary skills and knowledge to ensure that the school setting continues to be a beneficial environment for conducting mental health promotion.

     

Understanding Pediatric Caretakers’ Views on Obtaining Medical Care for Low‐acuity Illness

Background

A significant proportion of low‐acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low‐acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers’ perspectives. The objective of this study was to explore caretaker decision‐making processes, values, and priorities when deciding to seek care.

Methods

We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing.

Results

Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision‐making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low‐acuity care was well received by caretakers.

Conclusions

Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low‐acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.

     

Trapped like a butterfly in a spider's web: Experiences of female spousal caregivers in the care of husbands with severe mental illness

Aims and objectives

To explore the experiences of female spousal caregivers in the care of husbands with severe mental illness.

Background

Family involvement in the care of patients with chronic illness is essential to provide a backbone of support for them. However, little is known about how female spousal caregivers are confronted with challenges while taking care of their husbands with severe mental illness.

Design

An exploratory qualitative study.

Methods

Fourteen female spousal caregivers of people with severe mental illness (defined here as schizophrenia, schizoaffective disorders and bipolar affective disorders) were recruited using purposive sampling and were interviewed using a semistructured in‐depth interview method. Data were analysed by conventional content analysis until data saturation was achieved.

Results

Care of a husband with severe mental illness had a disruptive influence on the emotional relationships of the family and resulted in emotional detachment over time. Despite the caregivers’ struggle to protect their families, the lack of supportive resources caused emotional exhaustion. Caregiving tasks interfering with their many other responsibilities, along with being a reference for family matters, led to loss of self. Consequently, they experienced psychological distress because of the transition to a caregiver role without any supportive resources.

Conclusion

Constant caring, without supportive resources, forced them to do various roles and manage other issues within the family. Being unprepared for a caregiving role led to the psychological distress of female spousal caregivers. Therefore, adequate information, education and supportive resources must be provided for spouses to facilitate their transition to caregiving roles.

Relevance to clinical practice

It is necessary to pay close attention to the spousal caregivers’ own mental health problems while they care for their mentally ill husbands. Mental health professionals should adopt a new approach to the prioritisation and planning of policies that support both family caregivers and patients.

     

Dot enzyme‐linked immunosorbent assay strip as a screening tool for detection of autoantibody to interferon gamma in sera of suspected cases of adult‐onset immunodeficiency

Background

Being able to detect the presence of autoantibodies to interferon (IFN)‐γ in serum is essential for evaluating patients with suspected adult‐onset immunodeficiency (AOID) with unusual intracellular infections. Most reported patients with AOID have been Asian, although the exact prevalence of this illness is unknown. To date, no standard assay exists to detect autoantibodies to IFN‐γ. An easy‐to‐use, low‐cost assay that can be performed in any laboratory would be a valuable tool for clinical management of AOID, as well as better reveal its prevalence.

Methods

Our experimental study exploited a dot enzyme‐linked immunosorbent assay (Dot‐ELISA) strip to detect autoantibodies to IFN‐γ. Sera from 66 HIV‐negative patients having autoantibodies to IFN‐γ as determined by indirect ELISA were tested.

Results

Dot enzyme‐linked immunosorbent assay was sensitive (100%) and specific (94.5%), with a positive predictive value of 97.6% and a negative predictive value of 100%.

Conclusion

This simple method provides prompt qualitative results that can be read visually and used in facilities with limited testing capabilities.

     

The impact of improving access to primary care

Objectives

To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8‐year period (2007 to 2014).

Study design and methods

Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co‐pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference‐in‐differences methods assessed the significance of between‐group changes in utilization and costs.

Results

The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P < 0.001). This was accompanied by a reduction in urgent care visits by the intervention group compared with the control group (?43% vs ?5%, P < 0.001). There were no differences in the other types of visits, and the total visit costs for the intervention group increased 5.7% versus 2.7% for the control group (P = 0.008). A sub‐group analysis of the intervention group (comparing dependents to employees) found that that the dependents achieved a reduction in costs of 2.7% (P < 0.001) across the study period.

Conclusions

The potential for long‐term reduction in utilization and costs with better access to primary care is significant, but not easily nor automatically achieved.

     

Evaluation of a self‐efficacy enhancement program to prevent pressure ulcers in patients with a spinal cord injury

Aim

This study developed a self‐efficacy enhancement program and evaluated its effects on the self‐care behaviors, self‐care knowledge, and self‐efficacy regarding pressure ulcer prevention in patients with a spinal cord injury.

Methods

This was a multicenter randomized controlled trial. Six hospitals were invited to recruit patients with a spinal cord injury who were undergoing rehabilitation after receiving acute treatment. These hospitals were randomly allocated into experimental (three hospitals) or control (three hospitals) groups and 47 patients participated (24 in the experimental group and 23 in the control group). The experimental group was given an 8 week self‐efficacy enhancement program for pressure ulcer prevention. The self‐efficacy enhancement program consisted of small‐group face‐to‐face intervention (education and skills training), education with computer animation, phone counseling, face‐to‐face counseling, and self‐management records. The control group only received a pressure ulcer prevention information booklet. Self‐care knowledge, self‐efficacy, self‐care behaviors, and pressure ulcer incidence were measured at baseline and after the 8 week self‐efficacy enhancement program.

Results

The experimental group showed a significantly greater improvement in self‐care knowledge, self‐efficacy, and self‐care behaviors for pressure ulcer prevention than did the control group. One participant in the control group developed a pressure ulcer, while none of the participants in the experimental group developed a pressure ulcer; this difference was not statistically significant.

Conclusions

The self‐efficacy enhancement program enabled patients with a spinal cord injury to engage in continued self‐care behaviors and helped them to improve their knowledge and self‐efficacy concerning pressure ulcer prevention.

     

Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial

Background

Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system.

Objectives

The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days.

Methods

This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital‐level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45‐day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures.

Results

Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45‐day health care diary review. There was no difference in patient‐reported health care utilization between the study arms. Hospital‐level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI] = 40.8–149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI = 15.5–23.3). When evaluating the entire encounter and follow‐up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI = 29.3–221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI = 3.74–47.9) in the intervention arm.

Conclusions

Shared decision making in low‐risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.

     

Implementation and Preliminary Clinical Outcomes of a Pharmacist‐managed Venous Thromboembolism Clinic for Patients Treated With Rivaroxaban Post Emergency Department Discharge

Objective

The objective was to describe the implementation, work flow, and differences in outcomes between a pharmacist‐managed clinic for the outpatient treatment of venous thromboembolism (VTE) using a non‐vitamin K oral anticoagulant versus care by a primary care provider (PCP).

Methods

Patients in the studied health system that are diagnosed with low‐risk VTE in the emergency department are often discharged without hospital admission. These patients are treated with a non‐vitamin K oral anticoagulant and follow‐up either in a pharmacist‐managed VTE clinic or with their PCP. Pharmacists in the VTE clinic work independently under a collaborative practice agreement (CPA). An evaluation of 34 patients, 17 in each treatment arm, was conducted to compare the differences in treatment‐related outcomes of rivaroxaban when managed by a pharmacist versus a PCP.

Results

The primary endpoint was a 6‐month composite of anticoagulation treatment‐related complications that included a diagnosis of major bleeding, recurrent thromboembolism, or fatality due to either major bleeding or recurrent thromboembolism. Secondary endpoints included number of hospitalizations, adverse events, and medication adherence. There was no difference in the primary endpoint between groups with one occurrence of the composite endpoint in each treatment arm (p = 1.000), both of which were recurrent thromboembolic events. Medication adherence assessment was formally performed in eight patients in the pharmacist group versus no patients in the control group. No differences were seen among other secondary endpoints.

Conclusions

The pharmacist‐managed clinic is a novel expansion of clinical pharmacy services that treats patients with low‐risk VTEs with rivaroxaban in the outpatient setting. The evaluation of outcomes provides support that pharmacist‐managed care utilizing standardized protocols under a CPA may be as safe as care by a PCP.

     

Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: Associations and impact on aggressive behaviour

Aim and objectives

To examine associations between risk of aggression and nursing interventions designed to prevent aggression.

Background

There is scarce empirical research exploring the nature and effectiveness of interventions designed to prevent inpatient aggression. Some strategies may be effective when patients are escalating, whereas others may be effective when aggression is imminent. Research examining level of risk for aggression and selection and effectiveness of interventions and impact on aggression is necessary.

Design

Archival case file.

Methods

Data from clinical files of 30 male and 30 female patients across three forensic acute units for the first 60 days of hospitalisation were collected. Risk for imminent aggression as measured by the Dynamic Appraisal of Situational Aggression, documented nursing interventions following each assessment, and acts of aggression within the 24‐hours following assessment were collected. Generalised estimating equations were used to investigate whether intervention strategies were associated with reduction in aggression.

Results

When a Dynamic Appraisal of Situational Aggression assessment was completed, nurses intervened more frequently compared to days when no Dynamic Appraisal of Situational Aggression assessment was completed. Higher Dynamic Appraisal of Situational Aggression assessments were associated with a greater number of interventions. The percentage of interventions selected for males differed from females; males received more pro re nata medication and observation, and females received more limit setting, one‐to‐one nursing and reassurance. Pro re nata medication was the most commonly documented intervention (35.9%) in this study. Pro re nata medication, limit setting and reassurance were associated with an increased likelihood of aggression in some risk bands.

Conclusions

Structured risk assessment prompts intervention, and higher risk ratings result in more interventions. Patient gender influences the type of interventions. Some interventions are associated with increased aggression, although this depends upon gender and risk level.

Relevance to clinical practice

When structured risk assessments are used, there is greater likelihood of intervention. Intervention should occur early using least restrictive interventions.