International Journal of Nursing Studies

Editorial Board

2012-05-01

What's missing for evidence-based fever management? Is fever beneficial or harmful to humans?

Yu-Tzu Dai, Shu-Hua Lu — 2011-12-05

Fever is a common symptom in patients with infection, injury or various inflammatory-related diseases. Since between 29% and 36% of hospitalized patients are estimated to have fever (), fever management is an important nursing practice that requires serious study not only because it influences patients’ health outcomes but also because providing antipyretic therapy consumes considerable resources and nursing manpower. Physiologically, fever is a complex, coordinated and self-contained response that is induced by a group of pyrogens (). Fever rarely exceeds 41°C in humans and may be mediated through a natural antipyretic pathway by endogenous antipyretic molecules (). Retrospective clinical studies on patients with the life-threatening illness bacteremia report that patients who were febrile had a higher survival rate than those who were afebrile (). However, other studies on different patient populations, with different underlying diseases using various research methods have produced inconsistent results regarding the effects of fever on the host (). Due to ethical considerations, few randomized clinical trials have been conducted on patients, especially those with critical illnesses, to examine outcomes in fever patients with or without antipyretic therapy. There appear to be pros and cons to lowering the body temperature in patients with fever. Studies have reported that nurses hold different perceptions about fever, and practice various fever management protocols (). The UK National Institute for Health and Clinical Excellence (NICE) has published a guideline for the management of feverish illness in children younger than five years (), but few other guidelines are available. There is continuing debate about the accuracy of different devices to measure body temperature () and consistent evidence from human studies to support clinical guidelines for fever management is lacking.

Staff outcomes from the Caring for Aged Dementia Care REsident Study (CADRES): A cluster randomised trial

2011-11-11

Abstract: Background: Dementia care mapping and person centred care are well-accepted as processes for improving care and well-being for persons with dementia living in the residential setting. However, the impact of dementia care mapping and person centred care on staff has not been well researched.Objectives: The impact of person centred care and dementia care mapping compared to each other and to usual dementia care on staff outcomes was examined in terms of staff burnout, general well-being, attitudes and reactions towards resident behavioural disturbances, perceived managerial support, and quality of care interactions.Design: A cluster-randomised, controlled trial.Settings: The study was conducted between 2005 and 2007 in 15 residential aged care sites in the Sydney metropolitan area, Australia, with comparable management structures, staffing mix and ratios, and standards of care.Participants: 194 consenting managers, nurses, therapists and nurse assistants working in the participating sites.Methods: Intervention care sites received training and support in either person centred care (n=5) or dementia care mapping (n=5); control sites continued with usual dementia care (n=5). Staff outcomes of those three groups were assessed before, directly after the four month intervention (post) and after a further four months (follow-up). The primary outcome measures were the Maslach Burnout Inventory-Human Services Survey and the 12-item General Health Questionnaire. Analysis involved repeated measures analyses of variance for each of the outcome measures and adjustment for potential confounders to limit bias.Results: The Maslach Burnout Inventory-Human Services Survey results showed that change over time in emotional exhaustion scores differed between the three groups. Post-hoc analyses for each group separately revealed that the only significant time effect was in the dementia care mapping group (p=0.006), with emotional exhaustion scores declining over time. At baseline, more perceived support from management was associated with less emotional exhaustion (rs=0.26, p=0.004, n=122) and less depersonalisation (rs=0.21, p=0.023, n=122), but not for any of the other outcome measures.Conclusions: This study has shown that person centred approaches of care, in particular with dementia care mapping, may contribute to reducing staff job related burnout. The findings also highlight a potentially important role of managerial support and a whole of system approach.

Challenges in transition from intervention to end of life care in intensive care: A qualitative study

Maureen A. Coombs, Julia Addington-Hall, Tracy Long-Sutehall — 2011-11-14

Abstract: Background: Providing quality end of life care is a challenging area in intensive care practice. The most demanding aspect for doctors and nurses in this setting is not the management of care at end of life per se, but facilitating the transition from active intervention to palliation and finally, end of life care. Whilst there is understanding about some aspects of this transition, recognition of the complex and inter-related processes that work to shift the patient's trajectory from cure to end of life care is required. This is important in order to work towards solutions for issues that continue to pose problems for health care professionals.Objectives: To identify the challenges for health care professionals when moving from a recovery trajectory to an end of life trajectory in intensive care.Design: Qualitative methods of enquiry.Methods and setting: Single semi-structured interviews with 13 medical staff and 13 nurses associated with 17 decedents who underwent treatment withdrawal in intensive care were carried out. Participants were drawn from two Intensive Care Units in a large university-affiliated hospital in England.Findings: Patients who died in intensive care appeared to follow a three-stage end of life trajectory: admission with hope of recovery; transition from intervention to end of life care; a controlled death. The transition from intervention to end of life care was reported as being the most problematic and ambiguous stage in the end of life trajectory, with potential for conflict between medical teams, as well as between doctors and nurses.Conclusions: End of life care policy emphasises the importance of end of life care for all patients regardless of setting. These findings demonstrate that in intensive care, there is need to focus on transition from curative intervention to end of life care, rather than end of life care itself so that effective and timely decision making underpins the care of the 20% of intensive care patients who die in this setting each year.

The impact of an intervention to improve patient participation in a surgical care unit: A quasi-experimental study

Eva Jangland, Maria Carlsson, Ewa Lundgren, Lena Gunningberg — 2011-11-21

Abstract: Background: Organizational changes in surgical care are requiring patients to become more responsible for their own care, both before and after surgery, and also during recovery. Involving patients in their care is vital to improving quality of care and patient safety.Objective: The aim of this study was to investigate the impact of the ‘Tell-us’ card on patients’ perceptions of quality of care, with a specific focus on patient participation. Another aim was to evaluate the use of the Tell-us card from the patients’ perspective.Design: A quasi-experimental design with an intervention group and control groups was used. The patient's self-written Tell-us card was introduced as the intervention.Setting: The study was conducted in two surgical care units at a Swedish university hospital.Participants: A consecutive sample of patients admitted from the waiting list and from the emergency department was included (n=310). The inclusion criteria were surgical patients with a hospital stay of at least one day. Patients who were younger than 18 years, not able to speak or write in Swedish, or unable or unwilling to give informed consent to participate were excluded.Methods: Quality of care was assessed using the questionnaire ‘Quality from the Patient's Perspective’. The patients included in the intervention group were asked to write what was most important for them during the day or just before discharge on patient-written Tell-us cards.Results: The use of the Tell-us card resulted in significant improvements (5 out of 17 items) in patients’ abilities to participate in decisions about their nursing and medical care. The patients found the Tell-us card more useful in their interaction with registered nurses and assistant nurses than with physicians.Conclusions: The use of the Tell-us card improved patients’ participation in some areas of nursing and medical care in the surgical care units. The Tell-us card is an uncomplicated and inexpensive tool that could be an important step towards improved patient participation in the surgical care unit. More research is needed to evaluate the use of the Tell-us card in different hospital units and over a longer period of time.

Understanding the experience of reconstructive treatments from the perspective of people who suffer from facial lipoatrophy: A qualitative study

Marilou Gagnon — 2011-11-30

Abstract: Background: Facial lipoatrophy has been described as the most distressing and stigmatizing expression of the lipodystrophy syndrome, a syndrome that is caused by antiretroviral combination therapy. In recent years, reconstructive treatments (such as poly-l-lactic acid and polyalkylimide) have been increasingly considered for this condition. These treatments allow for facial contours and facial fullness to be restored while being minimally invasive.Objective: The main objective of this qualitative research was to explore and describe the experience of people who suffer from facial lipoatrophy, specifically in regard to reconstructive treatments.Method: A qualitative design, which incorporates explorative and descriptive attributes, was thought to be an appropriate choice for this research project. The data was collected using semi-structured interviews and was then analyzed following the principles of thematic analysis.Participants: Over a period of three months, 11 men and 1 woman enrolled in the study which was conducted in Montreal (Quebec), Canada.Findings: Overall, participants explained that facial lipoatrophy had forced them into a situation of intense vulnerability by making them recognizable as persons living with HIV/AIDS and discreditable in the eyes of others. In this sense, they were willing to go to great lengths to restore their facial features and regain a sense of normalcy. Findings revealed that people who suffer from facial lipoatrophy engage in a process of reconstruction to reduce the visibility and disruptiveness of their condition but face many uncertainties along the way.Conclusions: While the findings of this research corroborated what has been previously stated by other researchers about the impact of reconstructive treatments, they also shed light on the consequences of not making these treatments accessible as well as the undocumented realities of those who cannot afford the recommended course of dermal fillers.

Interpersonal Community Psychiatric Treatment for non-psychotic chronic patients and nurses in outpatient mental health care: A controlled pilot study on feasibility and effects

2011-11-30

Abstract: Background: In psychiatric care professionals perceive some patients as ‘difficult’, especially patients with long-term non-psychotic disorders. For these patients few evidence-based treatments exist. An intervention program, Interpersonal Community Psychiatric Treatment (ICPT), was developed by the authors. It was evaluated with the aim to increase effective behaviours by both patients and community psychiatric nurses (CPNs).Objective: To assess the feasibility and effectiveness of an intervention program for use by CPNs in the care of ‘difficult’ patients with non-psychotic chronic disorders, in a controlled pilot study.Design: A mixed-methods quasi-experimental study using process and outcome measures across several dimensions. Measurements took place at 0, 3, and 6 months.Settings: Three community mental health centres in the centre of The Netherlands.Participants: 14 CPNs and 36 long-term non-psychotic patients who were perceived as ‘difficult’ were selected. Patients were offered either ICPT (20) or care as usual (16). All patients and CPNs could be followed up at all measurements.Methods: Quantitative data included type and severity of psychiatric disorder, psychosocial functioning, needs for care, quality of life and social participation. Also, service use, satisfaction with care, and quality of the therapeutic alliance were measured. Qualitative interviews were conducted with all CPNs and patients in the experimental group.Results: ICPT was found feasible by both CPNs and patients. Both the experimental and control condition showed improvement on a number of outcomes. ICPT, however, resulted in significantly better results in some areas. Patients’ social network size increased and their care utilization decreased. Also, the quality of the working alliance increased and perceived patient difficulty decreased, both as scored by professionals.Conclusions: ICPT is one of very few intervention programs aimed at ‘difficult’ non-psychotic chronic patients. In this pilot study was found that it can be successfully carried out by CPNs, is generally experienced as acceptable and useful by patients and CPNs alike, and results in some significantly better effects on both process and outcome measures. In the main study, some alterations will be made to the instruction manual and training program. Also, the diagnostic interview may be briefer, and the characteristics and treatment integrity of CPNs will be included in measurements. Further controlled and randomized research is needed to test the effectiveness of the program in a larger group of patients.

Help-seeking and coping with the psychosocial burden of chronic hepatitis C: A qualitative study of patient, hepatologist, and counsellor perspectives

Benjamin J. Stewart, Antonina A. Mikocka-Walus, Hugh Harley, Jane M. Andrews — 2011-12-09

Abstract: Background: Chronic hepatitis C affects millions of people worldwide, may have significant physical consequences, and patients are also at increased risk of psychiatric morbidity. However, it is currently unknown how patients cope with, and seek help for the psychosocial issues which contribute to this psychiatric morbidity.Objectives: This study aimed to qualitatively explore the biopsychosocial burden of chronic hepatitis C, patients’ subsequent coping and help-seeking, and the patient–health professional relationship from the different perspectives of patients, hepatologists, and counsellors.Methods: Thirteen patients, five hepatologists, and two hepatitis C specific counsellors from South Australia participated in semi-structured interviews, which were audio-recorded, transcribed verbatim, and analysed thematically.Results: All groups perceived chronic hepatitis C as a severe disease involving inextricably intertwined biological, psychological, and social impacts. Negative factors included the impact of diagnosis, stigmatisation, and often unwarranted fears regarding transmission and disease progression. The key positive influences reported across the groups involved information provision and access to informal and formal support. However, a number of barriers were noted to accessing this support, particularly stigmatisation. All respondents highlighted the importance of the patient–health professional relationship. This relationship was perceived to be enhanced by empathetic, compassionate professionals who provided comprehensive information in a sensitive and timely manner. Key negative influences on this relationship included discrimination or inappropriate treatment from mainstream health professionals, time constraints of doctors, patient non-attendance, and discordant views regarding treatment decisions.Conclusions: Reducing the psychosocial impact of chronic hepatitis C requires targeted information provision for patients, the general public, and mainstream health services. This may increase patient education, reduce the extent and impact of stigmatisation, remove barriers to help-seeking, and improve the patient–health professional relationship.

Individual and institutional factors affecting cardiac monitoring in coronary care units: A national survey of Chinese nurses

2011-10-31

Abstract: Background: As cardiovascular diseases have become the leading cause of death in many countries including China, nurses are increasingly required to be abreast of technological advances and the skills necessary to manage this increasing health care problem. Chinese nurses are under pressure to provide skilled electrocardiography monitoring, and be sufficiently skilled to detect myocardial ischemia and infarction, in this large patient population. This presents a challenge for the nursing profession in China, particularly for nurses working in coronary care in a country where advancement has been so rapid, yet little research has been conducted or reported in the literature.Objectives: The two main objectives were: to explore the demographic and educational factors that affect the use of ST-segment monitoring and correct electrode placement by CCU/ICU nurses in China; and to explore the factors both individual and institutional that affect monitoring and lead placement.Methods: A self-administered questionnaire was distributed to nurses in 126 randomly selected tertiary hospitals, which were stratified into three homogeneous regions across China. The instrument examined demographics, information about hospitals, electrocardiogram devices, current practice patterns and perceptions toward monitoring and lead placement. Data from 734 nurses and 59 nurse managers from 59 hospitals were analyzed using t-tests, ANOVA, Chi-square test and logistic regression.Results: Electrocardiogram monitoring was used to detect myocardial ischemia by 43.7% of respondents, and 35.1% selected leads according to electrocardiogram or angiography findings. Most (70%) agreed that monitoring for acute coronary syndrome was important, while 39.2% did so, and 15.7% were able to identify correct placement. Logistic regression revealed a significant relationship between the uses of ST-segment monitoring and number of hospital beds, continuing education and a belief in its use and ease of use. Correct electrode placement was significantly correlated with respondents from university hospitals, hospitals with more acute coronary syndrome admissions and more independent thinking nurses.Conclusions: Despite best practice evidence, less than half of the sample used electrocardiogram monitoring to detect myocardial ischemia and the majority could not identify correct electrode placement, while ST-segment monitoring was not used routinely. This paper highlights the need for improvements in education both in universities and hospitals and discussion addresses conventions in units, which inhibit development of nurses’ skills.

The impact of term-time paid work on academic performance in nursing students: A longitudinal study

2011-11-18

Abstract: Background: Nursing students in higher education are spending more time in paid employment despite evidence that this can impact negatively on academic performance.Objectives: To examine the effect of paid work on academic performance in undergraduate nursing students.Design: Descriptive, correlational survey with longitudinal follow-up.Participants: Nursing students in metropolitan Sydney, Australia.Methods: First year nursing students surveyed at baseline were followed up at the end of the final year of their nursing program to examine factors influencing academic performance.Results: Of the 566 Year 1 nursing students who were surveyed in the second semester of their Bachelor of Nursing program, 182 students (32%) completed the follow-up survey in Year 3. The percentage of students engaging in paid work during term-time had increased (p<0.001), from 70% in Year 1 to 84% in Year 3. There was an inverse relationship between mean hours in paid work during term-time and nursing students’ GPA in their final year. Taking into account demographic factors, the mean hours spent in paid work during term-time had a negative impact on nursing students’ GPA (p<0.001).Conclusion: In view of these findings, we suggest that new models of undergraduate nursing education be explored to include faculty approved nursing-related employment with defined opportunities for learning. This would accommodate the dual roles of undergraduate nursing students as students and employees and therefore not endanger their academic performance.

An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation

2011-12-02

Abstract: Background: In the United Kingdom approaching 20% of people aged 85 years and over live in care homes and most will die there. Improving end-of-life care is a government health priority and homes may work with primary care staff and specialist palliative practitioners to provide comprehensive end-of-life care. Consequently effective collaboration between care home and health service practitioners is vital to ensure high quality end-of-life care.Objectives: To evaluate the impact of a training programme to improve end-of-life care in nursing homes, on collaboration between nursing home staff and other health practitioners.Design: Evaluation using survey methods and qualitative case studies.Participants and setting: All 95 nursing homes in the first national ‘Gold Standards Framework in Care Homes’ programme in England were invited to participate in the evaluation.Methods: A survey of homes’ characteristics, the approaches to end-of-life care, and liaison with other services, was completed pre and post programme implementation. Case studies were conducted in a sub-sample of 10 homes to provide important context and depth to the evaluation.Results: Pre and post surveys were returned by 49 (52%) homes. Improved collaborations as a result of the programme were anticipated by 31% of managers. Challenges to collaboration included working with large numbers of general practitioners, out-of-hours services and access to specialist practitioners. Improved collaborations between home staff and health service practitioners were identified by 33% of managers as one of the main programme outcomes. Staff reported increased knowledge of end-of-life care, and enhanced confidence, which in turn resulted in improved communication and collaboration. Post-programme, staff felt more confident initiating contact and discussing residents’ end-of-life care with general practitioners and those working in specialist palliative care services.Conclusions: The Gold Standards Framework in Care Homes programme can contribute towards end-of-life care by helping to improve the quality and quantity of communication and collaboration between nursing home staff and primary care and specialist practitioners. Further research is needed to determine why this was not consistent across all homes.

Patient, practice and organisational influences on asthma control: Observational data from a national study on primary care in the United Kingdom

Gaylor Hoskins, Brian Williams, Cathy Jackson, Paul Norman, Peter Donnan — 2011-11-14

Abstract: Background: Achieving asthma control is central to optimising patient quality of life and clinical outcome. Contemporary models of chronic disease management across a variety of countries point to the importance of micro, meso and macro level influences on patient care and outcome. However, asthma outcomes research has almost invariably concentrated on identifying and addressing patient predictors. Little is known about higher level organisational influences.Objective: This paper explores the contribution of organisational factors on poor asthma control, allowing for patient factors, at three organisational levels: the individual patient, local service deliverers, and strategic regional providers.Design, setting and participants: Prospective cross-sectional observational cohort study of 64,929 people with asthma from 1205 primary care practices spread throughout the United Kingdom (UK). Patient clinical data were recorded during a routine asthma review.Method: Data were analysed using simple descriptive, multiple regression and complex multi-level modelling techniques, accounting for practice clustering of patients.Results: Poor asthma control was associated with areas of higher deprivation [regression coefficient 0.026 (95% confidence intervals 0.006; 0.046)] and urban practice [−0.155 (−0.275; −0.035)] but not all local and regional variation was explained by the data. In contrast, patient level predictors of poor control were: short acting bronchodilator overuse [2.129 (2.091; 2.164)], days-off due to asthma [1.203 (1.148; 1.258)], PEFR<80 [0.76 (0.666; 0.854)], non-use of a self-management plan (SMP) [0.554 (0.515; 0.593)], poor inhaler technique [0.53 (0.475; 0.585)], poor medication compliance [0.385 (−0.007; 0.777)], and gender [0.314 (0.281; 0.347)]. Pattern of medication use, smoking history, age, body mass index (BMI), and health service resource use were also significant factors for predicting control.Conclusions: Targeting of health service resource requires knowledge of the factors associated with poor control of asthma symptoms. In the UK the contribution of local and regional structures appears minimal in explaining variation in asthma outcomes. However, unexplained variation in the data suggests other unrecorded factors may play a part. While patient personal characteristics (including self-management plan use, inhaler technique, medication compliance) appear to be the predominant influence the complex nature of the disease means that some, perhaps more subtle, influences are affecting the variability at all levels and this variance needs to be explored. Further research in other international contexts is required to identify the likely applicability of these findings to other health care systems.

Effectiveness of heart failure management programmes with nurse-led discharge planning in reducing re-admissions: A systematic review and meta-analysis

Ekaterini Lambrinou, Fotini Kalogirou, Demetris Lamnisos, Panayota Sourtzi — 2011-12-26

Abstract: Background: Heart failure (HF) is a clinical condition with major socioeconomic burden. Scientists are trying to find effective solutions to eliminate the effects of the disease and the current innovations in research address the introduction of HF management programmes (HF-MPs).Objectives: A meta-analysis was undertaken to estimate the effect of HF-MP with a nurse-driven pre-discharge phase on the outcomes of HF and all-cause re-admission.Data sources: A systematic search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Library (reviews and clinical trials) was performed to locate randomised controlled trials (RCTs), published in English language, which implemented any HF-MP with discharge planning carried out by a nurse. Identified articles were further screened for additional studies.Study selection: Two reviewers independently screened relevant abstracts or titles using a standardised predefined check list. Pilot studies, studies additionally assessing other conditions and studies that evolved technology utilities or included medication management beyond optimisation of therapy, were excluded.Data extraction: Selected articles were thoroughly screened and data of interest (characteristics and outcomes) were obtained. Quality assessment was done by two reviewers separately.Data synthesis: Nineteen RCTs were selected for the meta-analysis. The overall pooled effect (relative risk, RR) of the intervention group compared with the control group was estimated by using a random effects analysis (95% confidence interval (CI)) for the outcomes of HF-related re-admission and all-cause re-admission. The overall RR of HF re-admissions was 0.68, 95% CI (0.53, 0.86), p<0.05 and of all-cause re-admission was 0.85, 95% CI (0.76, 0.94), p<0.05 favouring the intervention. Metaregression analysis was performed while trying to explain the observed heterogeneity but none of the factors (environment, duration of follow-up, origin and complexity) were significantly related with the RR.No significant publication bias was observed regarding both HF and all-cause re-admission.Conclusions: The results of the current meta-analysis highlight the potential of HF-MPs with nurse-driven pre-discharge interventions to reduce hospital re-admissions. Essential characteristics or components of a successful HF-MP are still to be determined; thus more studies are required to solve this issue.

Reflections on the ethics of Internet newsgroup research

Stephen K. Bradley, Bernie Carter — 2011-11-18

What is already known about the topic? Internet based health research has become of interest to nurse researchers, educators and supervisors.

Postoperative pain assessment should not be solely based on numeric ratings! Commentary on van Dijk et al. (2011)

2012-01-04

Author's response Colleague van Dijk wrote an interesting article about the perception of pain scores, based on the relationship between two questionnaires and the results on these questionnaires of patients and caregivers (). It is a nice article with a good description of the questionnaires and their background, the methodology and the results.