Balancing everyday life-Patients' experiences before, during and four months after kidney transplantation

Supportive care in transplantation: A patient-centered care model to better support kidney transplant candidates and recipients

Kidney transplantation (KT), although the best treatment option for eligible patients, entails maintaining and adhering to a life-long treatment regimen of medications, lifestyle changes, self-care, and appointments. Many patients experience uncertain outcome trajectories increasing their vulnerability and symptom burden and generating complex care needs. Even when transplants are successful, for some patients the adjustment to life post-transplant can be challenging and psychological difficulties, economic challenges and social isolation have been reported. About 50% of patients lose their transplant within 10 years and must return to dialysis or pursue another transplant or conservative care. This paper documents the complicated journey patients undertake before and after KT and outlines some initiatives aimed at improving patient-centered care in transplantation. A more cohesive approach to care that borrows its philosophical approach from the established field of supportive oncology may improve patient experiences and outcomes. We propose the "supportive care in transplantation" care model to operationalize a patient-centered approach in transplantation. This model can build on other ongoing initiatives of other scholars and researchers and can help advance patient-centered care through the entire care continuum of kidney transplant recipients and candidates. Multi-dimensionality, multi-disciplinarity and evidence-based approaches are proposed as other key tenets of this care model. We conclude by proposing the potential advantages of this approach to patients and healthcare systems.

Certified Registered Nurse Anesthetists' Experiences of Nursing in Anesthesia Care: An Interview Study

PURPOSE

The purpose of this study was to understand certified registered nurse anesthetists' (CRNAs) experiences of nursing in anesthesia care.

DESIGN

An explorative qualitative study was conducted with inspiration from Ricoeur's hermeneutic phenomenological theory of interpretation.

METHODS

Three focus group interviews were carried out with participants representing 5 anesthesiology departments from 3 hospitals in Denmark (a total of 14 participants). The participants were all CRNAs. The transcribed interviews were examined as one coherent text using a Ricoeur-inspired approach, in which the analysis was conducted on three levels: naive reading, structural analysis, and critical interpretation.

FINDINGS

The structural analysis identified three themes relevant to the CRNAs' experiences of nursing: (1) the relationship with the patient, in which caring and professionalism are equally important; (2) differences between professions when sitting in the operating room; and (3) conflicts between production and caring. The study showed that CRNAs are aware of their professional identities as nurses and view anesthesia nursing as an integration of technical tasks and caring, in which the relationship with the patient and serving as the patient's representative are central. A major aspect of nursing is performed while the patient is anesthetized, and the CRNA attends to the patient's basic needs. The study also found that CRNAs find it difficult to define nursing in anesthesia care because of the overlapping tasks and skills between CRNAs and anesthesiologists.

CONCLUSIONS

CRNAs are very aware of their professional identities as nurses. The professionalism involved in their relationships with patients is evident in the CRNAs' representation of the patients themselves.

Co-Designing Remote Patient Monitoring Technologies for Inpatients: Systematic Review

BACKGROUND

The co-design of health technology enables patient-centeredness and can help reduce barriers to technology use.

OBJECTIVE

The study objectives were to identify what remote patient monitoring (RPM) technology has been co-designed for inpatients and how effective it is, to identify and describe the co-design approaches used to develop RPM technologies and in which contexts they emerge, and to identify and describe barriers and facilitators of the co-design process.

METHODS

We conducted a systematic review of co-designed RPM technologies for inpatients or for the immediate postdischarge period and assessed (1) their effectiveness in improving health outcomes, (2) the co-design approaches used, and (3) barriers and facilitators to the co-design process. Eligible records included those involving stakeholders co-designing RPM technology for use in the inpatient setting or during the immediate postdischarge period. Searches were limited to the English language within the last 10 years. We searched MEDLINE, Embase, CINAHL, PsycInfo, and Science Citation Index (Web of Science) in April 2023. We used the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies and qualitative research. Findings are presented narratively.

RESULTS

We screened 3334 reports, and 17 projects met the eligibility criteria. Interventions were designed for pre- and postsurgical monitoring (n=6), intensive care monitoring (n=2), posttransplant monitoring (n=3), rehabilitation (n=4), acute inpatients (n=1), and postpartum care (n=1). No projects evaluated the efficacy of their co-designed RPM technology. Three pilot studies reported clinical outcomes; their risk of bias was low to moderate. Pilot evaluations (11/17) also focused on nonclinical outcomes such as usability, usefulness, feasibility, and satisfaction. Common co-design approaches included needs assessment or ideation (16/17), prototyping (15/17), and pilot testing (11/17). The most commonly reported challenge to the co-design process was the generalizability of findings, closely followed by time and resource constraints and participant bias. Stakeholders' perceived value was the most frequently reported enabler of co-design. Other enablers included continued stakeholder engagement and methodological factors (ie, the use of flexible mixed method approaches and prototyping).

CONCLUSIONS

Co-design methods can help enhance interventions' relevance, usability, and adoption. While included studies measured usability, satisfaction, and acceptability-critical factors for successful implementation and uptake-we could not determine the clinical effectiveness of co-designed RPM technologies. A stronger commitment to clinical evaluation is needed. Studies' use of diverse co-design approaches can foster stakeholder inclusivity, but greater standardization in co-design terminology is needed to improve the quality and consistency of co-design research.

Epistemological aspects of participatory design studies conducted in the field of health science

AIM(S)

To discuss the methodological aspects of participatory design, arguing for a three-phase approach and the suitability of situating participatory design within a phenomenological-hermeneutical tradition in health science.

DESIGN AND METHODS

Methodological discussion based on participatory design theory, epistemology and research studies.

RESULTS

The epistemological and methodological discussions show how the core values and key elements of participatory design align with the phenomenological-hermeneutical approach. In addition, examples of participatory design studies are provided to illustrate how it can be conducted in health science.

CONCLUSION

Participatory design is a flexible framework based on genuine participation, defined by three core values: having a say, mutual learning and democratization. The iterative processes allow for adjustments in alignment with the core values and the scientific stance that defines the choice of methods, tools and techniques. A phenomenological-hermeneutic approach in participatory design studies is relevant and aligned with the core values of participatory design. Thus, this paper argues for a close integration between the participatory design methodology and the phenomenological-hermeneutic scientific approach within health science.

IMPLICATIONS FOR THE PROFESSION

Participatory design is a powerful methodology with core values that can co-design sustainable health technologies with potential to impact patient care and the clinical practice of nurses. When combined with qualitative research methods, patients' lived experiences serve as the foundation for improving clinical nursing practice. Discussing the epistemological aspects of participatory design provides nurse researchers with a coherent methodological understanding, essential for the continual development of nursing research.

IMPACT

This paper discusses the research methodology of participatory design within health sciences. It aims to address the lack of understanding of the methodology, particularly within a specific scientific stance. The main finding is the elaboration on participatory design and the relevance of a phenomenological-hermeneutical approach. The paper has the potential to impact researchers, master's and PhD students, as well as others engaged in participatory design or other methodologies related to user involvement within health science.

REPORTING METHOD

No available EQUATOR guidelines were applicable to this methodological paper, as no new data were created or analysed.

PATIENT OR PUBLIC CONTRIBUTION

There was no direct patient or public contribution, as this is a methodological paper.

Do pre-transplant cultural factors predict health-related quality of life after kidney transplantation?

BACKGROUND

Post-transplant health-related quality of life (HRQOL) is associated with health outcomes for kidney transplant (KT) recipients. However, pretransplant predictors of improvements in post-transplant HRQOL remain incompletely understood. Namely, important pretransplant cultural factors, such as experience of discrimination, perceived racism in healthcare, or mistrust of the healthcare system, have not been examined as potential HRQOL predictors. Also, few have examined predictors of decline in HRQOL post-transplant.

METHODS

Using data from a prospective cohort study, we examined HRQOL change pre- to post-transplant, and novel cultural predictors of the change. We measured physical, mental, and kidney-specific HRQOL as outcomes, and used cultural factors as predictors, controlling for demographic, clinical, psychosocial, and transplant knowledge covariates.

RESULTS

Among 166 KT recipients (57% male; mean age 50.6 years; 61.4% > high school graduates; 80% non-Hispanic White), we found mental and physical, but not kidney-specific, HRQOL significantly improved post-transplant. No culturally related factors outside of medical mistrust significantly predicted change in any HRQOL outcome. Instead, demographic, knowledge, and clinical factors significantly predicted decline in each HRQOL domain: physical HRQOL-older age, more post-KT complications, higher pre-KT physical HRQOL; mental HRQOL-having less information pre-KT, greater pre-KT mental HRQOL; and, kidney-specific HRQOL-poorer kidney functioning post-KT, lower expectations for physical condition to improve, and higher pre-KT kidney-specific HRQOL.

CONCLUSIONS

Instead of cultural factors, predictors of HRQOL decline included demographic, knowledge, and clinical factors. These findings are useful for identifying patient groups that may be at greater risk of poorer post-transplant outcomes, in order to target individualized support to patients.

Innovation through participatory design: Collaborative qualitative methods in the development of speech-language pathology technology

Speech-language pathologists have embraced many aspects of technology in their practice, from telehealth to tablet device applications (apps) that support intervention practice. In this article, we consider the design, development, and implementation of technology. We discuss how some processes of technology development in Speech-language pathology (SLP) tend to follow research pathways which centre clinicians and researchers as designers of the intervention. This approach side-lines user involvement. We propose that a Participatory Design framework is a suitable way to reconceptualise design and development of these technological innovations in a client-centred way. Further, we explore how Participatory Design approaches utilise methods from and have much in common with qualitative research. We explore this overlap and propose that technology design teams take up the challenge of innovation in technology by engaging in a participatory rather than clinician-driven process for future technology design. Implications for both research and clinical practice are explored.

The 3-T Model of Informed Consent for Nonstandard Risk Donors: A Proposal for Transplant Clinical Practice

Background

The risk of disease transmission from nonstandard risk donors (NSRDs) is low, and outcomes are similar or better relative to transplants performed with standard criteria donors. However, NSRDs have posed new ethical challenges to the informed consent (IC) process. Based on the shared decision-making model, coinciding with the 3 main timings of the IC process ([1] pretransplant assessments and waiting list registration, [2] time on the waiting list, and [3] time of the organ offer), we put forward a model (3-T Model) to summarize the knowledge on IC for NSRDs and to deliver conceptual and practical support to transplant providers on this emergent issue.

Methods

We searched PubMed and analyzed data from our area to provide evidence and ethical arguments to promote standardization of the timing of patient information, degree of patient participation, and disclosure of donor risk factors throughout the 3 stages of the time continuum leading to the potential acceptance of NSRDs.

Results

Each of the 3 timings carries special ethical significance and entails well-defined duties for transplant providers relative to patient involvement and information of the benefits and risks associated with NSRDs. Based on our framework, experience, and interpretation of the literature, we put forward a list of recommendations to combine standardization (ie, timing, content, and degree of patient participation) and individualization of IC.

Conclusions

The 3-T Model may enable the prevention of physicians' arbitrariness and the promotion of patient-centered care. Future studies will assess the effectiveness of the 3-T Model in transplant clinical practice.

Changes in Health Literacy during the first year following a kidney transplantation: Using the Health Literacy Questionnaire

OBJECTIVES

The study aimed to identify changes in health literacy (HL) and associated variables during the first year following a kidney transplantation.

METHODS

A total of 196 transplant recipients were included in a prospective follow-up study. The patients answered the Health Literacy Questionnaire (HLQ) at 5 days, 8 weeks, 6 and 12 months following the kidney transplantation. Mixed linear models were used to analyze changes in HL and backward elimination was used to identify variables associated with HL.

RESULTS

Two main patterns of change were identified: a) HL increased during the first 8 weeks of close follow-up and b) in several domains, the positive increase from 5 days to 8 weeks flattened out from 5 days to 6 and 12 months. Self-efficacy, transplant-related knowledge, and general health were core variables associated with HL.

CONCLUSIONS

Overall, HL increased during the 8 weeks of close follow-up following the kidney transplantation, while 6 months seem to be a more vulnerable phase. Furthermore, low self-efficacy, less knowledge, and low self-perceived health may represent vulnerable characteristics in patients.

PRACTICAL IMPLICATIONS

Future kidney transplant care should take into account patients' access to and appraisal of health information and social support, and draw attention to potentially vulnerable groups.

[Narrative inquiries from kidney transplant patients: From the onset of the disease to the transplant]

INTRODUCTION

In 2018, we counted 14 291 patients on the French kidney transplantation waiting list, and 3546 grafted. The law applies the presumed consent and public surveys shows a desire for information. The objective of this research was to describe transplanted patients' lives history in order to cope with this need for information.

METHODS

Qualitative study, narrative inquiries, of French Auvergne-Rhône-Alpes transplanted patients' life story, between December 2016 and February 2019. Interviews were fully transcribed and analyzed by two researchers. The sampling was defined by gender, age, dialysis time and socio-professional categories. Notification to the French data protection authority was carried out.

RESULTS

With the ninth interview, sufficient data was collected. The start of the disease could be insidious or brutal. All interviewees changed lifestyle habits. Sometimes, the dialysis made the recovery of certain autonomy possible, but had nutritional and organizational constraints. Transplantation, without complications, reduced significantly the burden of the disease and its treatment. The difficult and agonizing expectancy of the transplant was then replaced by the patients' feeling of Damocles sword due to the uncertainty around the graft's life expectancy. The dialysis burdens were replaced by the immunosuppressive side effects. The patients' dependence on the graft resonated with a moral duty towards the donor, their relatives and themselves.

CONCLUSION

Renal insufficiency comprises alternations of autonomy and dependence.

The experiences of living with a transplanted kidney from a deceased donor

BACKGROUND

Kidney transplantation is considered an optimal treatment option for patients with end-stage kidney disease in terms of survival rate, quality of life and cost-effectiveness. However, posttransplant life involves many medical, psychological and social challenges for transplant recipients. Understanding individuals' challenges and needs after transplantation is a prerequisite for developing effective patient education and self-management programmes.

OBJECTIVE

To explore how individuals experience life with a transplanted kidney from a deceased donor.

METHODS

The purposive sample included eight kidney transplant recipients. In-depth semi-structured interviews were conducted and analysed using interpretative phenomenological analysis.

FINDING

Three main themes emerged from the data and each one presents a certain aspect of the posttransplant experience: an inner struggle to find a new normality (personal level), me and the others (relational level) and only between me, my donor and god (spiritual level).

CONCLUSION

The experience of receiving a kidney from a deceased donor represents a complex psychological challenge for recipients. The study is unique as it shows the spiritual dimension of the transplantation experience and how the recipients' views on transplantation and organ donation are shaped by their religious and cultural background, indicating the importance of a holistic nursing approach.

"I Wish Someone Had Told Me That Could Happen": A Thematic Analysis of Patients' Unexpected Experiences With End-Stage Kidney Disease Treatment

BACKGROUND

Preparedness regarding prognosis and treatment options enables patients to cope with uncertainties, make value-based treatment decisions, and set treatment goals. Yet, little is known about the expectedness of end-stage kidney disease (ESKD) patients' treatment experiences beyond their desire for better treatment education.

OBJECTIVE

To describe unexpected adverse treatment experiences among ESKD patients.

METHOD

The authors conducted 7 focus groups with 55 dialysis patients and living-donor kidney transplantation recipients receiving medical care in Baltimore, Maryland. Data were analyzed thematically. Themes present in different treatment groups were highlighted to provide insight into common experiences.

RESULTS

The authors identified 5 themes: (1) psychological reactions, (2) constrained freedom of choice, (3) treatment delivery and logistics, (4) morbidity, and (5) finances.

CONCLUSION

Patients were unprepared for nonclinical, logistical, and clinical aspects of ESKD treatment. The need for providers' use of tailored preparatory techniques and the development of pretreatment interventions to help patients know what to expect from and feel psychologically prepared for treatment, particularly with respect to nonclinical implications, is critical. These efforts have great potential to improve patients' treatment experiences.

Evaluation of a telehealth solution developed to improve follow-up after kidney Transplantation

AIM

To explore patients' and healthcare professionals' experiences of using a telehealth solution developed to improve follow-up after kidney transplantation.

BACKGROUND

Transplantation is the treatment of choice whenever feasible for patients with end-stage kidney disease. However, it implies lifelong adherence of self-monitoring, medicine and other restrictions to ensure successful outcomes. Based on user involvement, a telehealth solution was developed to support patients and healthcare professionals post-transplantation.

DESIGN

An explorative qualitative study with a phenomenological-hermeneutic approach.

METHODS

The developed app and workflow for follow-up were tested by patients and healthcare professionals and evaluated with interviews. In total, 16 patients and 20 healthcare professionals participated. Individual interviews were conducted with the patients, four nurses participated in two sets of interviews, and 16 doctors participated in a focus group. Data were analysed with inspiration from Ricoeur's theory of interpretation, on three levels: Naïve reading, structural analysis and critical interpretation and discussion. The COREQ checklist was applied in reporting the study.

RESULTS

Three themes emerged: Challenging conditions for training sessions, telehealth improves patient reflection and collaboration, and telehealth gives patients a voice in consultations. In a challenging time, post-transplantation patients found the app easy to use; it facilitated support and reflection on how to manage. It also supported both patients and healthcare professionals at follow-up consultations in terms of enhanced preparation, improved dialogue and enabling consultations by phone.

CONCLUSION

The study showed that patients and healthcare professionals found the app and workflow valuable and easy to use. The Patient Data feature in the app has potential as a communication tool. However, adjustments and further investigations are needed to develop the solution.

RELEVANCE TO CLINICAL PRACTICE

The potential of telehealth brings new opportunities to provide treatment and care to newly transplanted patients. Telehealth can support both patients and health professionals by improving dialogue and collaboration.

User involvement in the development of a telehealth solution to improve the kidney transplantation process: A participatory design study

Kidney transplantation is the treatment of choice for patients with end-stage renal disease, and leads to everyday self-management of this chronic condition. This article aims to provide documentation for a participatory design study of a telehealth solution to improve the kidney transplantation process, and to identify the impact from the different participants in the participatory design study. Through a participatory design approach, a smartphone application (app) was developed for the entire kidney transplantation process together with a workflow for post-transplantation follow-up. A core element in participatory design is user involvement. By way of workshops and laboratory tests, the telehealth solution was developed in close cooperation with patients, their families, healthcare professionals, kidney association representatives, and Information Technology designers. The participatory design approach means that the telehealth solution was designed to be functional in a clinical setting, address patients' needs, and support their self-management.