Fatigue as experienced by patients with rheumatoid arthritis (RA): A qualitative study

OBJECTIVE

Interest in fatigue research has grown since the finding that fatigue is, besides pain, the symptom most frequently reported by patients with rheumatoid arthritis (RA). The aim of this study was to explore the experience of fatigue from the patients' perspective.

METHODS

Twenty-nine patients with RA filled-out written questionnaires on fatigue severity, disability, quality of life and sleep disturbance, and disease activity was calculated using the Disease Activity Score (DAS28). All patients were individually interviewed and asked about fatigue. Qualitative analyses were completed using software program "The Observer". Basic codes, a code plan and coding rules were developed by two researchers through a consensus-based review process. Frequencies of the central codes were calculated by the program SPSS.

RESULTS

RA fatigue is verbalised as a physical everyday experience with a variety in duration and intensity. Its sudden onset and exhausting nature is experienced as frustrating and causing anger. Patients mentioned having RA as the main cause of their fatigue. The consequences of fatigue are overwhelming and influence patients' everyday tasks, attitudes and leisure time. Patients described how they have to find their own management strategies by trial and error and described pacing and rest, relaxation and planning activities as the most appropriate interventions. Downward comparison and acceptance as part of the disease are also reported as successful coping strategies for fatigue. Most patients did not discuss fatigue with clinicians explicitly, accepting that they were told that fatigue is part of the disease and believing that they have to manage it alone.

CONCLUSION

The results show that RA fatigue is experienced as being different from "normal" fatigue. Patients do not expect much support from health care professionals, assuming that they have to manage fatigue alone as it is part of the disease. These results will help professionals caring for RA patients to communicate about fatigue, to explore the nature of fatigue individually and to develop tailored interventions.

A randomized study of a multidisciplinary program to intervene on geriatric syndromes in vulnerable older people who live at home (Dutch EASYcare Study)

BACKGROUND

The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial. We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians. This study compared the effects of this new model to usual care.

METHODS

Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility. One hundred fifty-one participants (mean age 82.2 years, 74.8% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes. Eighty-five participants received the new intervention, and 66 usual care. In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians. Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental well-being (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model.

RESULTS

After 3 months, treatment arms showed significant differences in favor of the new intervention. Functional abilities improved 2.2 points (95% confidence interval [CI], 0.3-4.2) and well-being 5.8 points (95% CI, 0.1-11.4). After 6 months, the favorable effect increased for well-being (9.1; 95% CI, 2.4-15.9), but the effect on functional abilities was no longer significant (1.6; 95% CI, -0.7 to 3.9).

CONCLUSIONS

This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people. Problem-based interventions can increase the effectiveness of primary care for this population.

Pain prevalence and pain relief in trauma patients in the Accident & Emergency department

BACKGROUND

Acute pain in the A&E department (ED) has been described as a problem, however insight into the problem for trauma patients is lacking.

OBJECTIVE

This study describes the prevalence of pain, the pain intensity and the effect of conventional pain treatment in trauma patients in the ED.

METHODS

In a prospective cohort study of 450 trauma patients, pain was measured on admission and at discharge, using standardized and validated pain instruments.

RESULTS

The prevalence of pain was high, both on admission (91%) and at discharge (86%). Two thirds of the trauma patients reported moderate or severe pain at discharge. Few patients received pharmacological or non-pharmacological pain relieving treatment during their stay in the ED. Pain decreased in 37% of the patients, did not change at all in 46%, or had increased in 17% of the patients at discharge from the ED. The most effective pain treatment given was a combination of injury treatment and supplementary pharmacological interventions, however this treatment was given to a small group of patients.

CONCLUSIONS

Acute pain in trauma patients is a significant problem in the ED's. Pain itself does not seem to be treated systematically and sufficiently, anywhere in the cycle of injury treatment in the ED.

[Nursing diagnoses, interventions and outcomes--application and impact on nursing practice: a systematic literature review]

The aim of this paper is to report a systematic literature review on the outcomes of nursing diagnostics. Specifically, it examines effects on documentation of assessment quality; frequency, accuracy and completeness of nursing diagnoses; and on coherence between nursing diagnoses, interventions and outcomes. Escalating health care costs demand the measurement of nursing's contribution to care. Use of standardized terminologies facilitates this measurement. Although several studies evaluated nursing diagnosis documentation and their relationship with interventions and outcomes, a systematic review was lacking. A MEDLINE, CINAHL, and Cochrane Database search (1982-2004) was conducted and enhanced by the addition of primary source and conference proceedings articles. Inclusion criteria were established and applied. Thirty-six articles were selected and subjected to thematic content analysis, then each study was assessed, and a level of evidence and grades of recommendations assigned. Nursing diagnosis use improved the quality of documented patient assessments (n = 14 studies), the identification of commonly occurring diagnoses within similar settings (n = 10), and coherence among nursing diagnoses, interventions, and outcomes (n = 8). Four studies employed a continuing education intervention and found significant improvements in the documentation of diagnoses, interventions and outcomes. However limitations in diagnostic accuracy, reporting of signs/symptoms, and etiology were also reported (14 studies). Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained. The study reveals deficits in reporting of signs/symptoms and etiology. Consequently, staff educational measures to enhance diagnostic accuracy are recommended. The relationships among diagnoses, interventions and outcomes require further evaluation. Studies are needed to determine the relationship between the quality of documentation and practice.

Multidimensional Geriatric Assessment: Back to the Future Cost-Effectiveness of a Multidisciplinary Intervention Model for Community-Dwelling Frail Older People

Background.  There is growing interest in geriatric care for community-dwelling older people. There are, however, relatively few reports on the economics of this type of care. This article reports about the cost-effectiveness of the Dutch Geriatric Intervention Program (DGIP) compared to usual care in frail older people at 6-month follow-up from a health care system's point of view.

Methods.  We conducted this economic evaluation in an observer-blind randomized controlled trial (Dutch EASYcare Study: ClinicalTrials.gov Identifier NCT00105378). Difference in treatment effect was calculated as the difference in proportions of successfully treated patients (prevented functional decline accompanied by improved well-being). Incremental treatment costs were calculated as the difference in mean total care costs. The incremental cost-effectiveness ratio (ICER) was expressed as total cost per successful treatment. Bootstrap methods were used to determine confidence intervals (CI) for these measures.

Results.  The average cost of the intervention under study (DGIP) was 998 euros (95% CI, 888–1108). The increment in total cost resulting from DGIP was a little over 761 euros (−3336 to 4687). Hospitalization and institutionalization costs were less; home care, adult day care, and meals-on-wheels costs were higher. There was a significant difference in proportions of successful treatments of 22.3% (4.3–41.4). The number needed to treat was approximately 4.7 (2.3–18.0). The ICER is 3418 euros per successful treatment (−21,458 to 45,362). The new treatment is cost-effective at a willingness-to-pay of 34,000 euros.

Conclusion. The results of this economic evaluation suggest that DGIP is an effective addition to primary care for frail older people at a reasonable cost.

The content and effects of palliative care courses for nurses: A literature review

OBJECTIVES

The present literature review describes the literature (1990-2005) that concerns the effects of courses in palliative care at the pre- and postgraduate levels.

DATA SOURCES

A search was made for literature from the period between 1990 and 2005 using CINAHL, Pubmed and Psychlit, supplemented with a search for relevant systematic reviews from the Cochrane Library.

DESIGN

The research questions were directed on the areas of expertise and skills, the didactical methods, the effects of the courses and the standards to measure these effects.

RESULTS

The studies were all focused on general palliative care. Out of 27 studies 21 reported positive effects for communication, attitude, empathy and pain. Six of these 21 positive trails were studies with good quality designs, whereas 15 had moderate designs. The six studies with a lack of effects was one study with good quality and five studies with moderate quality designs. The effects on patients were described in only a few cases. There was still frequent use of self-constructed rating scales, where data about validity and reliability were lacking or where these aspects were not studied.

CONCLUSIONS

The most successful were integrated courses focused on several themes with a variety of didactical methods.

Nursing processes used in the treatment of patients with bipolar disorder

Psychiatric nurses are increasingly being involved in the provision of care for outpatients with bipolar disorder. The establishment of a body of knowledge for the nursing of these patients is vital for the development of integrated evidence-based treatment. The literature for the period January 1980 to January 2006 is reviewed. A sensitive literature search included not only the nursing care based on research results but also nursing care based on experiences acquired by practising nurses. The results show that formal research on the nursing of patients with a bipolar disorder is remarkably limited. Three quantitative studies were identified in five articles and six qualitative studies addressing a broad range of topics. The remainder of articles meeting the inclusion criteria contained mostly descriptive reports. An overview is presented of the nursing processes used during the euthymic stage of a bipolar disorder and during an acute episode of (hypo)mania. No specific nursing processes for acute episodes of bipolar depression are described in the literature. The results show hardly any evidence for the described nursing processes.

Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients

OBJECTIVE

To describe the short-term and long-term effects of a hospital-wide pressure ulcer prevention and treatment guideline on both the incidence and the time to the onset of pressure ulcers in critically ill patients.

DESIGN

Prospective cohort study.

SETTING

Adult intensive care department of a university medical center.

PATIENTS

Critically ill patients (n = 399).

INTERVENTIONS

A guideline for pressure ulcer care was implemented on all intensive care units. The attention of nurses for timely transfer to a specific pressure-reducing device was an important part of this guideline.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, demographics, pressure ulcer risk profile at admission, daily pressure ulcer grading, and type of mattress were determined to describe the short-term and long-term effects 3 and 12 months after the implementation. The incidence density of pressure ulcers grade II-IV decreased from 54 per 1000 patient days at baseline to 32 per 1000 days (p = .001) 12 months after the implementation. The median pressure ulcer-free time increased from 12 days to 19 days (hazard rate ratio, 0.58; p = .02). After adjustment for differences in risk factors in a Cox proportional hazard model, the number of preventive transfers to special mattresses was the strongest indicator for the decreased risk of pressure ulcers (hazard rate ratio, 0.22; p < .001). The number needed to treat to prevent one pressure ulcer during the first 9 days was six.

CONCLUSIONS

The implementation of a guideline for pressure ulcer care resulted in a significant and sustained decrease in the development of grade II-IV pressure ulcers in critically ill patients. Timely transfer to a specific mattress (i.e., transfer before the occurrence of a pressure ulcer) was the main indicator for a decrease in pressure ulcer development.

Adherence to clean intermittent self-catheterization procedures: determinants explored

AIMS & OBJECTIVES

The aim of the current study was to explore factors that hinder or promote adherence to clean intermittent self-catheterization (CISC) procedures in adults.

BACKGROUND

Clean intermittent self-catherization is associated with favourable patient outcomes, but adherence to the procedure is not addressed in the international literature.

METHODS

Relevant factors were explored in two studies. The first study (n = 10) addressed mastery and short-term adherence, whereas the second study (n = 20) addressed long-term adherence in these patients. Determinants of patient adherence were derived from pre-structured interviews with patients, using a content-analysis procedure.

RESULTS

A list of 16 determinants of mastery and short-term adherence and a list of 12 determinants of long-term adherence was found. Most of these determinants were found in both older (>or=65 years of age) and younger patients. However, five determinants of mastery and short-term adherence and six determinants of long-term adherence were specific to patients under the age of 65.

CONCLUSION

Our findings give a first insight into CISC adherence. General determinants of adherence relate to knowledge, complexity of the procedure, misconceptions, fears, shame, motivation and quality and continuity of professional care. Furthermore integrating CISC in everyday life can be difficult. In younger patients, availability of materials, physical impairments and resistance to a sickness role can further compromise adherence.

RELEVANCE TO CLINICAL PRACTICE

Issues of knowledge, fears, motivation and potential psychological impact of performing CISC should be addressed prior to deciding on CISC and instructing patients. Follow-up care should be improved to include re-evaluations of skills, discussing adherence, integrating CISC in daily activities and general coping issues.

Early postoperative 30° lateral positioning after coronary artery surgery: influence on cardiac output

AIMS AND OBJECTIVES

We investigated whether: (i) Early postoperative lateral position after coronary artery bypass surgery may have a negative influence on the cardiac output and (ii) Whether turning procedures cause practical problems.

BACKGROUND

Directly following surgery, coronary artery bypass patients are not receiving routine turning every two hours to prevent pressure ulcers, because a negative influence on hemodynamic parameters is assumed.

DESIGN

Clinical trial.

METHODS

Fifty-five coronary artery bypass patients were randomly assigned to four intervention regimens and underwent a two-hour period of 30 degrees lateral position. Fourteen patients in supine position served as a reference group. We hypothesized that 30 degrees lateral position does not cause a relevant change in the cardiac output.

RESULTS

Turning the patients did not have any significant influence on the cardiac index, not even in the patients in a poor hemodynamic condition. The cardiac index in 30 degrees lateral position and supine position two to eight hours postoperatively after coronary artery bypass surgery is statistically bioequivalent. No clinically relevant deviations from preset 'safe' values for mean arterial pressure, right atrial pressure, pulmonary artery wedge pressure and pulmonary arterial pressure were observed, which would require ending the lateral position. There were no practical problems hindering the turning regimen, not even in the patients with an intra-aortic balloon pump.

CONCLUSIONS

Early postoperative turning of coronary artery bypass surgery patients in lateral position is an easy and feasible procedure that does not influence the cardiac index not even in patients receiving antihypertensive or inotropic/vasopressor therapy. Further research is needed to find out whether our findings are also valid in other patient groups and other position conditions.

RELEVANCE TO CLINICAL PRACTICE

If there are no strict contra-indications, lateral position has to be considered to prevent complications of continuous supine position within two hours after coronary artery bypass surgery patients have been admitted to the intensive care unit.

Improved Quality of Nursing Documentation: Results of a Nursing Diagnoses, Interventions, and Outcomes Implementation Study

PURPOSE

To evaluate the impact of the quality of nursing diagnoses, interventions, and outcomes in an acute care hospital following the implementation of an educational program.

METHOD

In a pretest-posttest experimental design study, nurses from 12 wards of a Swiss hospital received an educational intervention--an introductory class and consecutive classes, using a case discussion method--to implement nursing diagnoses, interventions, and outcomes. Two sets of 36 randomly selected nursing records were evaluated before and after implementation. The quality of documented nursing diagnoses, interventions, and nursing-sensitive patient outcomes was assessed by 29 Likert-type items with a 0-4 scale instrument, called Quality of Nursing Diagnoses, Interventions, and Outcomes (Q-DIO) and tested using t-tests.

FINDINGS

Significant enhancements in the quality of documented nursing diagnoses, interventions, and outcomes were found following the implementation of a planned educational program.

CONCLUSIONS

The implementation of NANDA, NIC, and NOC (NNN) nursing diagnoses, interventions, and outcomes led to higher quality of nursing diagnosis documentation, etiology-specific nursing interventions, and nursing-sensitive patient outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Educational measures support nurses to improve documentation of diagnoses, interventions, and outcomes. The Q-DIO is a useful audit tool.

The impact of home parenteral nutrition on daily life-a review

BACKGROUND

Total parenteral nutrition (TPN) is a lifesaving therapy in patients with severe intestinal failure that can be administered at home. However, patients have to face complex technological nutritional support issues at home, which will influence their personal life.

OBJECTIVES

This review aims to describe the implications of home parenteral nutrition (HPN) on the quality of life, as experienced by patients, as well as to describe the caregiver's reactions regarding these notions.

SEARCH STRATEGY

A systematic review of the literature published between 1965 and 2005 was conducted. Cinahl, Medline, and Psychlit databases were searched. Systematic data extraction and narrative data synthesis were performed.

SELECTION CRITERIA

Papers were included if they described original research published in a peer reviewed journal, with a focus on adult patients on HPN and/or their family caregivers. DATA COLLECTION (AND ANALYSIS): A standardised record was used for data extraction.

MAIN RESULTS

A total of 26 studies were included. The quality of life reported by patients was moderate to good, but psychological problems, e.g. depression and anxiety, were common. Social life was disturbed due to the venous access device, the time schedule for HPN administration, the inability to have normal oral intake, gastrointestinal mobility problems, and physical complaints. Frequently mentioned somatic problems included fatigue, diarrhoea, pain, polyuria during infusion and sleep disruption. Despite social restrictions, depression and fatigue, caregivers reported their overall QoL as similar to the norms for healthy populations.

CONCLUSION

Patients on HPN meet a broad range of problems. Apart from the well-known metabolic and infectious complications, many of these are psychological or social in nature.

Nursing diagnoses, interventions and outcomes ? application and impact on nursing practice: systematic review

AIM

This paper reports a systematic review on the outcomes of nursing diagnostics. Specifically, it examines effects on documentation of assessment quality; frequency, accuracy and completeness of nursing diagnoses; and on coherence between nursing diagnoses, interventions and outcomes.

BACKGROUND

Escalating healthcare costs demand the measurement of nursing's contribution to care. Use of standardized terminologies facilitates this measurement. Although several studies have evaluated nursing diagnosis documentation and their relationship with interventions and outcomes, a systematic review has not been carried out.

METHOD

A Medline, CINAHL, and Cochrane Database search (1982-2004) was conducted and enhanced by the addition of primary source and conference proceeding articles. Inclusion criteria were established and applied. Thirty-six articles were selected and subjected to thematic content analysis; each study was then assessed, and a level of evidence and grades of recommendations assigned.

FINDINGS

Nursing diagnosis use improved the quality of documented patient assessments (n = 14 studies), identification of commonly occurring diagnoses within similar settings (n = 10), and coherence among nursing diagnoses, interventions, and outcomes (n = 8). Four studies employed a continuing education intervention and found statistically significant improvements in the documentation of diagnoses, interventions and outcomes. However, limitations in diagnostic accuracy, reporting of signs/symptoms, and aetiology were also reported (14 studies). One meta-analysis of eight trials including 1497 patients showed no evidence that standardized electronic documentation of nursing diagnosis and related interventions led to better nursing outcomes.

CONCLUSION

Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained. The study reveals deficits in reporting of signs/symptoms and aetiology. Consequently, staff educational measures to enhance diagnostic accuracy are recommended. The relationships among diagnoses, interventions and outcomes require further evaluation. Studies are needed to determine the relationship between the quality of documentation and practice.

Ulcer-related problems and health care needs in patients with venous leg ulceration: a descriptive, cross-sectional study

BACKGROUND

Patients with leg ulceration often have long lasting and recurrent wounds. The treatment exists mainly of wound-care and compression therapy. International literature shows several indications of problems in relation to leg ulceration, but no studies were performed to give a comprehensive overview of all problems identified and care received related to these problems.

OBJECTIVES

The aim of the study was to describe leg ulcer-related problems in patients with leg ulcers based on venous insufficiency or a mixed aetiology. Furthermore, an inventory of current care and care deficits in the care for leg ulcer patients was made.

METHODS

The study had a descriptive, cross-sectional design. A sample of 141 patients was taken from the population of outpatient clinics of seven hospitals in the Netherlands. Data were collected through patient interviews, questionnaires and wound-observations. Medical information was provided by the dermatologist or derived from the patients' medical file.

RESULTS

The study identified a number of serious problems. Main problems were pain (85%), outdoor mobility (47%) and problems in finding appropriate footwear (60%). Statistical analysis showed no differences between patients with ulcers based on a venous aetiology and ulcers based on mixed aetiology. Fifty to seventy percent of the patients did not receive any care in relation to these problems. Only a rather small proportion of the patients, however, regarded the help as insufficient.

CONCLUSION

Care at outpatient clinics is mainly focused on wound care and compression therapy. Pain treatment and care related to problems encountered by patients appears to be insufficient. This is not only affecting the patient's quality of life, but is likely to affect also the healing process and prevention of leg ulcers. Nurses and dermatologist should take their responsibilities in this matter.

Supporting adherence and healthy lifestyles in leg ulcer patients: systematic development of the Lively Legs program for dermatology outpatient clinics

OBJECTIVES

The objective of our project was to develop a lifestyle program for leg ulcer patients at outpatient clinics for dermatology.

METHODS

We used the intervention-mapping (IM) framework for systematically developing theory and evidence based health promotion programs. We started with a needs-assessment. A multidisciplinary project group of health care workers and patients was involved in all five IM steps; formulating proximal program objectives, selecting methods and strategies, producing program components, planning for adoption and implementation and planning for evaluation. Several systematic literature reviews and original studies were performed to support this process.

RESULTS

Social Cognitive Theory was selected as the main theory behind the program 'Lively Legs' and was combined with elements of Goal-Setting Theory, the precaution adoption model and motivational interviewing. The program is conducted through health counseling by dermatology nurses and was successfully pre-tested. Also, an implementation and evaluation plan were made.

CONCLUSION

Intervention mapping helped us to succeed in developing a lifestyle program with clear goals and methods, operational strategies and materials and clear procedures.

PRACTICE IMPLICATIONS

Coaching leg ulcer patients towards adherence with compression therapy and healthy lifestyles should be taken on without delay. Systematic development of lifestyle programs for other patient groups should be encouraged.

Meeting the criteria of a nursing diagnosis classification: Evaluation of ICNP, ICF, NANDA and ZEFP

BACKGROUND

Few studies described nursing diagnosis classification criteria and how classifications meet these criteria.

OBJECTIVES

The purpose was to identify criteria for nursing diagnosis classifications and to assess how these criteria are met by different classifications.

DESIGN/METHODS

First, a literature review was conducted (N=50) to identify criteria for nursing diagnoses classifications and to evaluate how these criteria are met by the International Classification of Nursing Practice (ICNP), the International Classification of Functioning, Disability and Health (ICF), the International Nursing Diagnoses Classification (NANDA), and the Nursing Diagnostic System of the Centre for Nursing Development and Research (ZEFP). Using literature review based general and specific criteria, the principal investigator evaluated each classification, applying a matrix. Second, a convenience sample of 20 nursing experts from different Swiss care institutions answered standardized interview forms, querying current national and international classification state and use.

RESULTS

The first general criterion is that a diagnosis classification should describe the knowledge base and subject matter for which the nursing profession is responsible. ICNP) and NANDA meet this goal. The second general criterion is that each class fits within a central concept. The ICF and NANDA are the only two classifications built on conceptually driven classes. The third general classification criterion is that each diagnosis possesses a description, diagnostic criteria, and related etiologies. Although ICF and ICNP describe diagnostic terms, only NANDA fulfils this criterion. The analysis indicated that NANDA fulfilled most of the specific classification criteria in the matrix. The nursing experts considered NANDA to be the best-researched and most widely implemented classification in Switzerland and internationally.

CONCLUSIONS

The international literature and the opinion of Swiss expert nurses indicate that-from the perspective of classifying comprehensive nursing diagnoses-NANDA should be recommended for nursing practice and electronic nursing documentation. Study limitations and future research needs are discussed.

Promotion of evidence-based practice by professional nursing associations: literature review

AIM

This paper reports a literature review examining the activities of professional nursing associations in the promotion of evidence-based practice.

BACKGROUND

Professional nursing associations can play a role in the implementation and achievement of evidence-based practice as such associations aim to develop and further educate nurses professionally, build professional networks representing the interests of nurses and the nursing profession, influence the government and policymakers, and support and protect the basic values of nurses. The exact role of professional nursing associations in the promotion of evidence-based practice is as yet unclear, along with just how the role of such associations can be expanded and which strategies can be used to promote evidence-based practice among members.

METHOD

A literature and Internet search was undertaken using the PUBMED, CINAHL, SCIRUS, INVERT, and the Cochrane databases using the terms evidence-based practice(s)* or EBP*, which were then combined with Nursing Society*, Nursing Organization*, Nursing Organisation*, Nursing Association* or Nursing Council*. Other sources included a Google search of the Internet, and the sites of various members of the International Council of Nurses. Publications in English, French or German from 1993 to 2004 were used, and the Internet search was conducted on 17 July 2003.

RESULTS

Sixty nursing associations described the dissemination of evidence-based practice using one or more types of activities (179 activities in total). All of these activities were of a voluntary nature, with a predominant focus (132/179 activities) on intrinsic motivation of nurses. More specifically, most of the activities were aimed at nurses' competences and attitudes in relation to evidence-based practice.

CONCLUSION

Professional nurses' associations are active in promoting evidence-based practice among their nurse members, but only those focusing on changing competences and attitude by addressing intrinsic motivation are well used. Other types of activities deserve to be explored, including behaviour-oriented approaches, approaches using structural, social or financial influence measures and perhaps methods based on 'involuntary involvement'.

The design of the Dutch EASYcare study: a randomised controlled trial on the effectiveness of a problem-based community intervention model for frail elderly people [NCT00105378]

BACKGROUND

Because of their complex clinical presentations and needs frail elderly people require another approach than people who age without many complications. Several inpatient geriatric health services have proven effectiveness in frail persons. However, the wish to live independently and policies that promote independent living as an answer to population aging call for community intervention models for frail elderly people. Maybe models such as preventive home visits, comprehensive geriatric assessment, and intermediate care qualify, but their efficacy is controversial, especially in frail elderly persons living in the community. With the Dutch EASYcare Study Geriatric Intervention Programme (DGIP) we developed a model to study effectiveness of problem based community intervention models in frail elderly people.

METHODS/DESIGN

DGIP is a community intervention model for frail elderly persons where the GP refers elderly patients with a problem in cognition, mood, behaviour, mobility, and nutrition. A geriatric specialist nurse applies a guideline-based intervention with a limited number of follow up visits. The intervention starts with the application of the EASYcare instrument for geriatric screening. The EASYcare instrument assesses (instrumental) activities of daily life, cognition, mood, and includes a goal setting item. During the intervention the nurse regularly consults the referring GP and a geriatrician. Effects on functional performance (Groningen Activity Restriction Scale), health related quality of life (MOS-20), and carer burden (Zarit Burden Interview) are studied in an observer blinded randomised controlled trial. 151 participants were randomised over two treatment arms--DGIP and regular care--using pseudo cluster randomisation. We are currently performing the follow up visits. These visits are planned three and six months after inclusion. Process measures and cost measures will be recorded. Intention to treat analyses will focus on post intervention differences between treatment groups.

DISCUSSION

The design of a trial evaluating the effects of a community intervention model for frail elderly people was presented. The problem-based participant selection procedure satisfied; few patients that the GP referred did not meet our eligibility criteria. The use of standard terminology makes detailed insight into the contents of our intervention possible using terminology others can understand well.

Impact of long-term HPN on daily life in adults

BACKGROUND AND AIMS

Home parenteral nutrition (HPN) is a therapy that changes life radically and often means lifelong dependence on parenteral feeding. The aim of this study was to gain insight into problems experienced by adult patients who were dependent on long-term HPN.

METHODS

A survey was performed on all patients at the ambulatory care clinics of two university centres. We used two techniques: written questionnaires and interviews. The questionnaires addressed fatigue (CIS), quality of sleep, anxiety, depression (BDI), social impairment (subscale SIP68), and sexual functioning. Data were analysed descriptively. Structured interviews inquired about the negative influence of HPN dependence on daily life. These data were quantified by content analysis.

RESULTS

The response rate was 76% (n = 48). Questionnaire results: all the respondents had multiple physical symptoms, which they attributed to the underlying disease. Furthermore, severe fatigue (63%), sleeping disorders, (severe) depression (65%), social impairment (55%), and sexual disorders (33%) were present. Quality of life (QoL) correlated with fatigue, sleeping disorders, anxiety, depression, and social impairment (P<0.02). Interview results: psychosocial problems were the main complaints in daily life due to HPN dependence, e.g. negative changes in moods and feelings (including anxiety), lack of freedom, limitations in social life and being dependent.

CONCLUSIONS

Although many somatic symptoms were present, HPN-dependent patients reported primarily psychosocial problems in daily life. To improve QoL, HPN teams should assess somatic as well as psychosocial aspects standard. Given the large proportion of patients with depressive disorders, therapies such as anti-depressant medication, psychosocial support and cognitive training, should be offered.

Pressure ulcers: diagnostics and interventions aimed at wound-related complaints: a review of the literature

AIMS AND OBJECTIVES

To describe the current scientific evidence in the field of diagnostics and treatment of pain, malodour and exudate from pressure ulcers and to give recommendations for practice, based on these findings.

BACKGROUND

Patients with pressure ulcers are confronted with symptoms of chronic wounds and impaired wound healing. Assessment and treatment of these symptoms have received very little attention.

DESIGN

Systematic literature review.

METHODS

Medline, CINAHL, and Cochrane, were searched for studies on pain, malodour and exudate in patients with pressure ulcers.

RESULTS

The McGill Pain Questionnaire, the Visual Analogue Scale and the Faces Rating Scale are useful instruments to assess pressure ulcer related pain. Strong evidence was found to support a positive effect of (dia)morphine. Some evidence was found to support a positive effect of benzydamine gel and Eutectic Mixture of Local Anaesthetic-cream. Wound malodour is subjectively assessed. In a laboratory study, it is proved that activated charcoal is capable of absorbing gas molecules causing malodour. At present, no studies are available on the odour-absorbing capacity of activated charcoal dressings in pressure ulcer patients. Exudate is a symptom of impaired wound healing. The Pressure Sore Status Tool is a valid and reliable instrument for assessing the wound healing process. There is a possible indication that hydrocolloid positively influences healing time because the absorption of exudates is more effective.

CONCLUSION

Little sound research has been performed on wound-related complaints in patients with pressure ulcers. Nevertheless several recommendations could be made on the present state of the art.

RELEVANCE TO CLINICAL PRACTICE

Regarding pressure ulcer related pain, this review supports the intervention of local pain relieve in patients with pressure ulcers. Regarding pressure ulcer related odour and exudates, this study identifies the gaps in evidence and research.

Leg ulcers: a review of their impact on daily life

BACKGROUND

Current nursing care for leg ulcer patients often focuses on wound care and providing compression therapy. Nurses perceive leg ulcer patients as 'under-served' with regard to problems patients experience in daily life. An overview of patient problems is a first and essential step in the development of comprehensive nursing care.

AIMS AND OBJECTIVES

To gather information about the impact of leg ulcers on patient's daily life as described in quantitative and qualitative studies.

DESIGN

Systematic literature review.

METHODS

Medline and Cinahl databases were searched for venous leg ulcer studies, up to 2002; this was followed by the 'snowball method'. Studies were selected in accordance with preset criteria.

RESULTS

A total of 37 studies was included. All studies report that leg ulcers pose a threat to physical functioning. Furthermore, a negative impact on psychological functioning is reported and, to a lesser degree, on social functioning. Major limitations are pain and immobility, followed by sleep disturbance, lack of energy, limitations in work and leisure activities, worries and frustrations and a lack of self-esteem. Patients have a significantly poorer quality of life compared with healthy people. Finally, patients report problems with regard to follow-up treatment.

CONCLUSIONS

Having a leg ulcer has a major impact on a patient's life. There are indications of under-treatment of pain.

RELEVANCE TO CLINICAL PRACTICE

Keeping in mind that leg ulceration is notorious for its chronic character, the negative impact on patient's life implies that many patients suffer over longer periods of time. This emphasizes the need to focus on quality of life aspects in patient care. There is much to gain, especially concerning pain and mobility. The development of comprehensive care programmes is essential.

Venous leg ulcer patients: a review of the literature on lifestyle and pain-related interventions

BACKGROUND

Having a leg ulcer has a major impact on daily life. Lifestyle is mentioned in most leg ulcer guidelines but mostly without much emphasis on the subject.

AIMS AND OBJECTIVES

Evidence for the effect of nutrition, leg elevation and exercise on the healing of leg ulcers was reconsidered. Furthermore, the evidence for effective pain-related interventions was investigated.

DESIGN

Systematic literature review.

METHODS

Medline, Cinahl, Psychinfo and Cochrane were searched for studies on pain related interventions, and the effectiveness of leg elevation, leg exercise and nutritional interventions in patients with venous leg ulceration.

RESULTS

Some evidence was found to support a positive effect of leg exercises on the endurance and power of the calf muscle and on the haemodynamic status of the limb. There is also evidence for a positive effect of leg elevation during bed rest without compression. No hard evidence was found concerning the effect of enriched or altered nutrition on wound healing. However, there is some evidence of nutritional deficits in this patient group. The use of eutectic mixture of local anaesthetic cream is effective for reducing pain in wound debridement, but pain relief in daily life is insufficiently treated.

CONCLUSION

There is no real evidence of effectiveness of the investigated lifestyle interventions but there are indications that lifestyle interventions might contribute to healing or prevention of venous leg ulceration.

RELEVANCE TO CLINICAL PRACTICE

Although there is no hard evidence, it can be expected that interventions such as nutritional monitoring, guided exercise and leg elevation will have a substantial impact on wound healing in patients with venous leg ulceration. The use of eutectic mixture of local anaesthetic cream can be advised for pain relief with wound debridement. The current lack of effective pain treatment with venous leg ulceration emphasizes the need for effective pain treatment.

Turning toward the psychosocial domain of oncology nursing: a main problem analysis in the Netherlands

The purpose of this descriptive exploratory study by the Dutch Oncology Nursing Society was to describe the problem areas in the care of patients who are receiving chemotherapy as perceived by patients and professional caregivers as well as to explore differences between the perceptions of patients and professional caregivers. Three independent samples of 120 patients who are being treated with chemotherapy, 42 chemotherapy prescribing medical specialists, and 68 oncology nurses who are involved in the daily bedside care of the patients undergoing chemotherapy participated in the study. Patients and professional caregivers completed a 69- and a 58-item self-administered questionnaire, respectively. Results show that patients were satisfied with the medical and nursing care they received. Furthermore, results suggest that professional caregivers perceive the experience of patients with chemotherapy differently than patients, eg, patients perceive chemotherapy as reassuring that something is being done; whereas caregivers think that patients experience chemotherapy as something to fear or be anxious or uncertain about. It further seems that professional caregivers are more prone to act upon the medical-technical aspects of the treatment than to act on psychosocial sequelae of the treatment.

Using ICIDH-2 in the classification of nursing diagnoses: results from two pilot studies

BACKGROUND

Using ICIDH-2 in the classification of nursing diagnoses: results from two pilot studies Background. As an International Classification of Functioning and Disability, the ICIDH-2 is potentially relevant to the work of all health care professionals. Nurses, however, had little involvement in the development of this classification and have no tradition of using it.

AIM

Two pilot studies were designed to explore the fit between ICIDH-2 and the nursing domain.

METHODS

In the first study, experts (n=2) and nurses (n=9) were asked to identify and classify patient problems that they observed on a video taped case. In the second study, problem statements from nursing diagnoses (n=199) that had been retrieved from patient files were classified using ICIDH-2. Each problem statement was classified by a panel of three individuals.

RESULTS AND CONCLUSION

Results from the two studies suggest that the ICIDH-2 is certainly relevant to the nursing discipline and allows a large majority of nursing diagnoses to be classified. It is recommended that nurses take an active role in the ongoing development of the ICIDH in order to further improve its usefulness to the nursing profession.

LIMITATIONS

The studies were small-scale pilots performed in a single medical centre. Preliminary insight resulted from these pilots, but more research is needed.