Patients' outcomes related to person-centred nursing care in radiation oncology: A case study

Abstract Purpose The aim of this case study is to describe patients' responses to nursing care following the implementation of a person-centred model in a radiation oncology department. Method An instrumental case study design utilised surveys to collect data on a range of key patient outcomes: patient satisfaction (PSS), informational issues (RSEP), quality of life (FACT_G), comfort (RTCQ), and emotional status (HADS). This occurred at the beginning of, and twelve months following, the implementation of the new model of care. Results This study demonstrated that, although adverse effects of radiotherapy continue to affect patient well-being in the latter part of their course of radiation therapy, patients continue to be satisfied with nursing care. There were significant differences between groups in perceptions of the care environment and the use of the nurse as an acknowledged source of information are noteworthy, since these variables were key targets of the new model of care. The finding that nurses were seen by the post-implementation cohort as more likely to be a source of information is an important indicator that the nurses' presence was noted by patients, and they generally reported high levels of functioning despite undergoing a curative course of radiotherapy. Conclusion The person-centred nursing approach in the radiotherapy setting has contributed to some improvements in the provision of patient care. Aspects of this study may assist in planning further nursing interventions for patients undergoing radiotherapy for cancer, and continue to enhance the contribution of the radiation oncology nurse to improved patient outcomes.

Have you got what it takes? Nursing in a Psychiatric Intensive Care Unit

Purpose A Psychiatric Intensive Care Unit (PICU) and or High Dependency Unit (HDU) is a locked, intensive treatment facility available to people experiencing acute psychiatric distress. For many people who access public mental health services in Australia, the PICU/HDU is the primary point of admission, and should represent and facilitate timely assessment and an optimum treatment plan under a recovery framework. Nurses are the largest health discipline working in this specialty area of care. The paper aims to discuss these issues. Design/methodology/approach A qualitative study aimed to investigate the skills, experience, and practice, of nurses working in the PICU/HDU in relation to a recovery model of care. Identifying how nurses provide care in the PICU/HDU will inform a clinical practice guideline to further support this specialty area of care. Four focus groups were facilitated with 52 registered nurses attending. Findings The nurse participants identified specific skills under four distinct themes; Storytelling, Treatment and recovery, Taking responsibility, and Safeguarding. The skills highlight the expertise and clinical standard required to support a recovery model of care in the PICU. Research limitations/implications – The research findings highlight urgency for a National PICU/HDU clinical practice guideline. Practical implications A PICU/HDU practice guideline will promote the standard of nursing care required in the PICU/HDU. The PICU/HDU needs to be recognised as a patient centred, therapeutic opportunity as opposed to a restrictive and custodial clinical area. Social implications Providing transparency of practice in the PICU/HDU and educating nurses to this specialty area of care will improve client outcome and recovery. Originality/value Very few studies have explored the skills, experience, and practice, of nurses working in the PICU/HDU in relation to a recovery model of care. A dearth of research exists on what is required to work in this specialty area of care.

Nurses' accountability for stroke quality of care: part one: Review of the literature on nursing-sensitive patient outcomes

Over the past decade, an exciting area of research has emerged that demonstrates strong links between specific nursing care activities and patient outcomes. This body of research has resulted in the identification of a set of "nursing-sensitive outcomes"(NSOs). These NSOs may be interpreted with more meaning when they are linked to evidence-based best practice guidelines, which provide a structured means of ensuring care is consistent among all health care team members, across geographic locations, and across care settings. Uptake of evidence-based best practices at the point of care has been shown to have a measurable positive impact on processes of care and patient outcomes. The purpose of this paper is to present a systematic, narrative review of the literature regarding the clinical effectiveness of nursing management strategies on stroke patient outcomes sensitive to nursing interventions. Subsequent investigation will explore current applications of nursing-sensitive outcomes to patients with stroke, and identify and validate measurable NSOs within stroke care delivery.

The organisational context of nursing care in stroke units: A case study approach

Background Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. Design A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. Findings Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing leadership and future research into teamwork in stroke settings are made.

Reliability of point-of-care testing of INR in acute stroke

Background In the emergency department, portable point-of-care testing (POCT) coagulation devices may facilitate stroke patient care by providing rapid International Normalized Ratio (INR) measurement. The objective of this study was to evaluate the reliability, validity, and impact on clinical decision-making of a POCT device for INR testing in the setting of acute ischemic stroke (AIS). Methods A total of 150 patients (50 healthy volunteers, 51 anticoagulated patients, 49 AIS patients) were assessed in a tertiary care facility. The INR's were measured using the Roche Coaguchek S and the standard laboratory technique. Results The interclass correlation coefficient and 95% confidence interval between overall POCT device and standard laboratory value INRs was high (0.932 (0.69 - 0.78). In the AIS group alone, the correlation coefficient and 95% CI was also high 0.937 (0.59 - 0.74) and diagnostic accuracy of the POCT device was 94%. Conclusions When used by a trained health professional in the emergency department to assess INR in acute ischemic stroke patients, the CoaguChek S is reliable and provides rapid results. However, as concordance with laboratory INR values decreases with higher INR values, it is recommended that with CoaguChek S INRs in the > 1.5 range, a standard laboratory measurement be used to confirm the results.

Nursing care of children in general practice settings: roles and responsibilities

Aims. To examine roles and responsibilities of Practice Nurses in the area of child health and development and in advising parents about child health issues. Background. As the focus of Australia’s health care system shifts further towards the primary health care sector, governmental initiatives require that Practice Nurses are knowledgeable, confident and competent in providing care in the area of child health and development. Little is known about roles and responsibilities of Practice Nurses in this area. Design. Cross-sectional survey design. Methods. Practice Nurses completed a national online survey examining the roles and responsibilities in child health and development, professional development needs and role satisfaction. Data were collected from June 2010–April 2011. Results. Respondents (N = 159) reported having a significant role in well and sick child care and were interested in extending their role. Frequent activities included immunization, phone triage/advice, child health/development advice, wound care and Healthy Kids Checks. However, few had paediatric/child nursing backgrounds or postgraduate qualifications in paediatric nursing and they reported limited preparation for the role. Practice Nurses reported difficulties with keeping up-to-date with child health information and advising parents confidently. Satisfaction was relatively low regarding opportunities and encouragement to undertake professional development and expand scope of practice. Conclusion. Practice Nurses are largely unprepared to meet the demands of their child health role and need support to develop and maintain the skills and knowledge base necessary for high-quality, evidence-based practice. Both financial and time support is needed to enable Practice Nurses to access child health professional development.

Patterns of care: Primary research in mental health nursing

The foundation of mental health nursing has historically been grounded in an interpersonal, person-centred process of health care, yet recent evidence suggests that the interactional work of mental health nursing is being eroded. Literature emphasises the importance of person-centred care on consumer outcomes, a model reliant upon the intimate engagement of nurses and consumers. Yet, the arrival of medical interventions in psychiatry has diverted nursing work from the therapeutic nursing role to task-based roles delegated by medicine, distancing nurses from consumers. This study used work sampling methodology to observe the proportion of time nurses working in an inpatient mental health setting engage in specific activities. The observations of this study determined that nurses' time is accounted for 31.65% in direct care, 51.63% in indirect care and 16.71% in service related activities.

Models of care in geriatric oncology nursing

Objectives To review models of care for older adults with cancer, with a focus on the role of the oncology nurse in geriatric oncology care. International exemplars of geriatric oncology nursing care are discussed. Data source Published peer reviewed literature, web-based resources, professional society materials, and the authors' experience. Conclusion Nursing care for older patients with cancer is complex and requires integrating knowledge from multiple disciplines that blends the sciences of geriatrics, oncology, and nursing. and which recognizes the dimensions of quality of life. Implications for Nursing Practice: Oncology nurses can benefit from learning key skills of comprehensive geriatric screening and assessment to improve the care they provide for older adults with cancer.

Perspectives on prescribing in nursing homes in Helsinki

Prescribing for older patients is challenging. The prevalence of diseases increases with advancing age and causes extensive drug use. Impairments in cognitive, sensory, social and physical functioning, multimorbidity and comorbidities, as well as age-related changes in pharmacokinetics and pharmacodynamics all add to the complexity of prescribing. This study is a cross-sectional assessment of all long-term residents aged ≥ 65 years in all nursing homes in Helsinki, Finland. The residents’ health status was assessed and data on their demographic factors, health and medications were collected from their medical records in February 2003. This study assesses some essential issues in prescribing for older people: psychotropic drugs (Paper I), laxatives (Paper II), vitamin D and calcium supplements (Paper III), potentially inappropriate drugs for older adults (PIDs) and drug-drug interactions (DDIs)(Paper IV), as well as prescribing in public and private nursing homes. A resident was classified as a medication user if his or her medication record indicated a regular sequence for its dosage. Others were classified as non-users. Mini Nutritional Assessment (MNA) was used to assess residents’ nutritional status, Beers 2003 criteria to assess the use of PIDs, and the Swedish, Finnish, INteraction X-referencing database (SFINX) to evaluate their exposure to DDIs. Of all nursing home residents in Helsinki, 82% (n=1987) participated in studies I, II, and IV and 87% (n=2114) participated in the study III. The residents’ mean age was 84 years, 81% were female, and 70% were diagnosed with dementia. The mean number of drugs was 7.9 per resident; 40% of the residents used ≥ 9 drugs per day, and were thus exposed to polypharmacy. Eighty percent of the residents received psychotropics; 43% received antipsychotics, and 45% used antidepressants. Anxiolytics were prescribed to 26%, and hypnotics to 28% of the residents. Of those residents diagnosed with dementia, 11% received antidementia drugs. Fifty five percent of the residents used laxatives regularly. In multivariate analysis, those factors associated with regular laxative use were advanced age, immobility, poor nutritional status, chewing problems, Parkinson’s disease, and a high number of drugs. Eating snacks between meals was associated with lower risk for laxative use. Of all participants, 33% received vitamin D supplementation, 28% received calcium supplementation, and 20% received both vitamin D and calcium. The dosage of vitamin D was rather low: 21% received vitamin D 400 IU (10 µg) or more, and only 4% received 800 IU (20 µg) or more. In multivariate analysis, residents who received vitamin D supplementation enjoyed better nutritional status, ate snacks between meals, suffered no constipation, and received regular weight monitoring. Those residents receiving PIDs (34% of all residents) more often used psychotropic medication and were more often exposed to polypharmacy than residents receiving no PIDs. Residents receiving PIDs were less often diagnosed with dementia than were residents receiving no PIDs. The three most prevalent PIDs were short-acting benzodiazepine in greater dosages than recommended, hydroxyzine, and nitrofurantoin. These three drugs accounted for nearly 77% of all PID use. Of all residents, less than 5% were susceptible to a clinically significant DDI. The most common DDIs were related to the use of potassium-sparing diuretics, carbamazepine, and codeine. Residents exposed to potential DDIs were younger, had more often suffered a previous stroke, more often used psychotropics, and were more often exposed to PIDs and polypharmacy than were residents not exposed to DDIs. Residents in private nursing homes were less often exposed to polypharmacy than were residents in public nursing homes. Long-term residents in nursing homes in Helsinki use, on average, nearly eight drugs daily. The use of psychotropic drugs in our study was notably more common than in international studies. The prevalence of laxatives equaled other prior international studies. Regardless of the known benefit and recommendation of vitamin D supplementation for elderly residing mostly indoors, the proportion of nursing home residents receiving vitamin D and calcium was surprisingly low. The use of PIDs was common among nursing home residents. PIDs increased the likelihood of DDIs. However, DDIs did not seem a major concern among the nursing home population. Monitoring PIDs and potential drug interactions could improve the quality of prescribing.

Design a simulated multimedia enriched immersive learning environment (SMILE) for nursing care of dementia patient

This thesis is to establish a framework to guide the development of a simulated, multimedia-enriched, immersive, learning environment (SMILE) framework. This framework models essential media components used to describe a scenario applied in healthcare (in a dementia context), demonstrates interactions between the components, and enables scalability of simulation implementation. The thesis outcomes also include a simulation system developed in accordance with the guidance framework and a preliminary evaluation through a user study involving ten nursing students and practicioners. The results show that the proposed framework is feasible and effective for designing a simulation system in dementia healthcare training.

Established cardiovascular disease and CVD risk factors in a primary care population of middle-aged Irish men and women

Contemporary Irish data on the prevalence of major cardiovascular disease (CVD) risk factors are sparse. The primary aims of this study were (1) to estimate the prevalence of major cardiovascular disease risk factors, including Type 2 Diabetes Mellitus, in the general population of men and women between the ages of 50 and 69 years; and (2) to estimate the proportion of individuals in this age group at high absolute risk of cardiovascular disease events on the basis of pre-existing cardiovascular disease or as defined by the Framingham equation. Participants were drawn from the practice lists of 17 general practices in Cork and Kerry using stratified random sampling. A total of 1018 people attended for screening (490 men, 48%) from 1473 who were invited, a response rate of 69.1%. Cardiovascular disease risk factors and glucose intolerance are common in the population of men and women aged between 50 and 69 years. Almost half the participants were overweight and a further quarter met current international criteria for obesity, one of the highest recorded prevalence rates for obesity in a European population sample. Forty per cent of the population reported minimal levels of physical activity and 19% were current cigarette smokers. Approximately half the sample had blood pressure readings consistent with international criteria for the diagnosis of hypertension, but only 38% of these individuals were known to be hypertensive. Eighty per cent of the population sample had a cholesterol concentration in excess of 5 mmol/l. Almost 4% of the population had Type 2 Diabetes Mellitus, of whom 30% were previously undiagnosed. A total of 137 participants (13.5%) had a history or ECG findings consistent with established cardiovascular disease. Of the remaining 881 individuals in the primary prevention population, a total of 20 high-risk individuals (19 male) had a risk of a coronary heart disease event 30% over ten years according to the Framingham risk equation, giving an overall population prevalence of 2.0% (95% CI 1.3 - 3.0). At a risk level 20% over ten years, an additional 91 individuals (8.9%) were identified. Thus a total of 24.4% of the population were at risk either through pre-existing CVD (13.5%) or an estimated 10-year risk exceeding 20% according to the Framingham risk equation (10.9%). Thus a substantial proportion of middle-aged men are at high risk of CVD. The findings emphasise the scale of the CVD epidemic in Ireland and the need for ongoing monitoring of risk factors at the population level and the need to develop preventive strategies at both the clinical and societal level.

Establishing a regional, multisite database for quality improvement and service planning in community-based palliative care and hospice.

BACKGROUND: Outpatient palliative care, an evolving delivery model, seeks to improve continuity of care across settings and to increase access to services in hospice and palliative medicine (HPM). It can provide a critical bridge between inpatient palliative care and hospice, filling the gap in community-based supportive care for patients with advanced life-limiting illness. Low capacities for data collection and quantitative research in HPM have impeded assessment of the impact of outpatient palliative care. APPROACH: In North Carolina, a regional database for community-based palliative care has been created through a unique partnership between a HPM organization and academic medical center. This database flexibly uses information technology to collect patient data, entered at the point of care (e.g., home, inpatient hospice, assisted living facility, nursing home). HPM physicians and nurse practitioners collect data; data are transferred to an academic site that assists with analyses and data management. Reports to community-based sites, based on data they provide, create a better understanding of local care quality. CURRENT STATUS: The data system was developed and implemented over a 2-year period, starting with one community-based HPM site and expanding to four. Data collection methods were collaboratively created and refined. The database continues to grow. Analyses presented herein examine data from one site and encompass 2572 visits from 970 new patients, characterizing the population, symptom profiles, and change in symptoms after intervention. CONCLUSION: A collaborative regional approach to HPM data can support evaluation and improvement of palliative care quality at the local, aggregated, and statewide levels.

Hypertension - a contemporary approach to nursing care

The incidence of hypertension is increasing as the number of patients with obesity and diabetes mellitus increases. Hypertension results when the peripheral vascular resistance is increased, the blood viscosity is elevated and/or the flow of blood through the main arteries is impeded. Chronic hypertension results in enlarged heart, myocardial damage and lung and renal abnormalities. While some causative factors such as obesity can be controlled, others for example genetics are more difficult to treat because often there is more than one factor involved. This paper explores how essential and secondary factors contribute to the incidence of hypertension and the physiological changes resulting from raised blood pressure. It proposes that although traditional treatment has some success, nurse-led clinics are having better success not only in controlling raised blood pressure but also in reducing cardiac, pulmonary and renal morbidity. It is more cost-effective, staff is more productive and clients are more compliant with treatment.