Clinical intervention research in nursing

Nursing Interventions in Neurocritical Care

Highly educated and skilled nursing care is critical to improving patient outcomes in general and in specialties like neurocritical care. Nursing interventions reflect nursing knowledge, critical thinking, and decision-making and is generally rooted in the nursing process. Nursing interventions are also a key focus of research to better understand how nursing care influences patient outcomes. This review describes the literature regarding nursing interventions in key neurocritical diagnoses and contextualizes it within the broader discussion about the nursing process and nursing interventions research. Publications about nursing interventions in neurocritical care emphasize key themes, including managing neurophysiologic parameters, providing psychosocial support, managing the environmental milieu, and interventions to prevent complications. Further study of how to best support nurses in collecting and interpreting data to form nursing interventions is needed, as is understanding the benefits and limitations of the nursing process in low- and middle-income countries.

An integrative review of the use of the concept of reassurance in clinical practice

Aim

To synthesize evidence on the concept of reassurance in nursing practice.

Design

Integrative review.

Review Method

PubMed, OVID MEDLINE, CINAHL and PsycINFO were searched from their inception to the 30 May 2020. The search results were screened. We assessed the quality of primary studies using the Mixed Method Appraisal Tool. Included studies were analysed using narrative synthesis. The review protocol was pre‐registered (PROSPERO‐CRD42020186962).

Results

Thirty‐two papers out of the 2,771 search results met our inclusion criteria. The synthesis of evidence generated three intricate themes, namely “antecedents of reassurance,” “defining attributes of reassurance” and “outcomes of reassurance.” Emotional distress was the main antecedent of reassurance. The three sub‐themes identified under defining attributes of reassurance include self‐awareness, emotional connectedness and verbal and non‐verbal techniques. Ultimately, reposing the confidence of patients and their families in healthcare professionals and the care delivery process to enable them to overcome their challenges constitutes the outcomes of reassurance.

Using a logic model to develop an intervention for improving miscarriage care in the emergency department

Miscarriage is the most common pregnancy-related complication and is frequently treated at the emergency department (ED). Parents have expressed dissatisfaction with the care they received at the ED and few interventions have been developed for improving miscarriage care. When planning an intervention, it is crucial to develop a program theory specifying what must be done for an intervention to achieve its objectives. The purpose of this paper is to describe the logic model process for developing an intervention intended to improve parents' miscarriage experience at the ED. The six steps of W. K. Kellogg Foundation (2004) theory logic model were used to 1) describe the problem; 2) conduct a needs assessment; and to identify 3) expected results, 4) influential factors, 5) intervention strategies, and 6) assumptions related to change strategies. A community-based participatory approach was used. It included two planning groups: parents who had visited the ED for a miscarriage (N = 9) and health professionals (N = 8). The theory logic model provided a rigorous framework for intervention development based on theories, scientific evidence, and the experiences of parents and health professionals. Detailed description of the intervention should facilitate its implementation, evaluation, and replication for other health problems.

Enhancing independent eating among older adults with dementia: a scoping review of the state of the conceptual and research literature

BACKGROUND

Addressing eating difficulties among older individuals with dementia living in nursing homes requires evidence-based interventions. However, to date, there is limited evidence of effective interventions designed to maintain and/or increase independent eating. In a field in which evidence is still lacking, a critical analysis of the state of research describing its main features can help identify methodological gaps that future studies should address. Hence, the aim of this study was to map the state of the research designed to maintain and/or promote independent eating in older individuals with dementia living in nursing homes.

METHODS

A scoping review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Reviews and conceptual analyses performed with different methodological approaches, published in indexed journals, and written in English were included. Keywords Were searched for in the MEDLINE, the Cumulative Index of Nursing and Allied Health, and in the Scopus databases to identify papers published up to 31 May 2018.

RESULTS

17 reviews were included, assessing interventions' effectiveness (n = 15) and providing conceptual frameworks for eating/mealtime difficulties (n = 2). Conceptual frameworks supporting interventions' effectiveness have rarely been described in available studies. Moreover, interventions tested have been categorized according to non-homogeneous frameworks. Their effectiveness has been measured against (1) eating performance, (2) clinical outcomes, and (3) adverse event occurrence.

CONCLUSION

An increased use of conceptual frameworks in studies, as well as greater clarity in intervention categorization and outcomes, is necessary to enhance the reviews' value in providing useful cumulative knowledge in this field. Interventions delivered should embody different components that integrate individual, social, cultural, and environmental factors, while when evaluating an intervention's effectiveness, eating performance, clinical outcomes and adverse events should be considered. Together with more robust studies, involving clinicians could prove to be useful, as their knowledge of practice developed from direct experience can help develop innovative research questions.

Strengthening the role and functions of nursing staff in inpatient stroke rehabilitation: developing a complex intervention using the Behaviour Change Wheel

Purpose: Over the past two decades, attempts have been made to describe the nurse’s role and functions in the inpatient stroke rehabilitation; however, the nursing contribution is neither clear nor well-defined. Previous studies have highlighted the need for research aimed at developing interventions in the neuro-nursing area. The objective of this paper was to describe the development of a nursing intervention aimed at optimising the inpatient rehabilitation of stroke patients by strengthening the role and functions of nursing staff.

Method: A systematic approach was used, consistent with the framework for developing and evaluating complex interventions by the UK’s Medical Research Council (MRC). Based on qualitative methods and using the Behaviour Change Wheel’s (BCW) stepwise approach, we sought behaviours related to nursing staffs’ roles and functions.

Results: We conducted a behavioural analysis to explain why nursing staff were or were not engaged in these behaviours. The nursing staff’s Capability, Opportunity and Motivation were analysed with regard to working systematically with a rehabilitative approach and working deliberately and systematically with the patient’s goals.

Conclusion: We developed the educational intervention Rehabilitation 24/7. Following the MRC and the BCW frameworks is resource-consuming, but offers a way of developing a practical, well-structured intervention that is theory- and evidence based.

Promoting psychosocial well-being following stroke: study protocol for a randomized, controlled trial

Background

Stroke is a major public health threat globally. Psychosocial well-being may be affected following stroke. Depressive symptoms, anxiety, general psychological distress and social isolation are prevalent. Approximately one third report depressive symptoms and 20% report anxiety during the first months or years after the stroke. Psychosocial difficulties may impact significantly on long-term functioning and quality of life, reduce the effects of rehabilitation services and lead to higher mortality rates. The aim of the study is to evaluate the effect of a previously developed and feasibility tested dialogue-based psychosocial intervention aimed at promoting psychosocial well-being and coping following stroke among stroke survivors with and without aphasia.

Methods

The study will be conducted as a multicenter, randomized, single blind controlled trial with one intervention and one control arm. It will include a total of 330 stroke survivors randomly allocated into either an intervention group (dialogue-based intervention to promote psychosocial well-being) or a control group (usual care). Participants in the intervention group will receive eight individual sessions of supported dialogues in their homes during the first six months following an acute stroke. The primary outcome measure will be psychosocial well-being measured by the General Health Questionnaire (GHQ). Secondary outcome measures will be quality of life (SAQoL), sense of coherence (SOC), and depression (Yale). Process evaluation will be conducted in a longitudinal mixed methods study by individual qualitative interviews with 15–20 participants in the intervention and control groups, focus group interviews with the intervention personnel and data collectors, and a comprehensive analysis of implementation fidelity.

Discussion

The intervention described in this study protocol is based on thorough development and feasibility work, guided by the UK medical research council framework for developing and testing complex interventions. It combines classical effectiveness evaluation with a thorough process evaluation. The results from this study may inform the development of further trials aimed at promoting psychosocial well-being following stroke as well as inform the psychosocial follow up of stroke patients living at home.

Trial registration

NCT02338869; registered 10/04/2014 (On-going trial).

[An evidence-based healthcare system and the role of the healthcare professions]

An evidence-based healthcare system necessitates a new role allocation and new role definitions of the players. By means of professional delegation, physician-nurse substitution and adoption of new professional functions, which so far have not been part of their professional profiles, nurses, midwives and allied health professionals will adopt a broad spectrum of new responsibilities. At present, nurses, midwives and allied health professionals lack basic scientific competencies and opportunities to acquire skills in evidence-based practice. A reliable link between evidence-generating sciences in nursing, midwifery and allied health professions and clinical practice is missing. In the future, an increase of academically qualified health professionals and a new skills mix within each profession might promote active and effective participation in an evidence-based healthcare system. (As supplied by author).

Promoting psychosocial wellbeing following stroke using narratives and guided self-determination: a feasibility study

BACKGROUND

Extensive studies have documented the complex and comprehensive psychosocial consequences of stroke. Psychosocial difficulties significantly affect long-term functioning and quality of life. Many studies have explored psychosocial interventions to prevent or treat psychosocial problems, but most have found modest effects. This study evaluated, from the perspective of adult stroke survivors, (1) the content, structure and process and (2) experienced usefulness of a dialogue-based psychosocial nursing intervention in primary care aimed at promoting psychosocial health and wellbeing.

METHODS

This was part of a feasibility study guided by the UK MRC complex interventions framework. It consisted of dialogue-based encounters with trained health professionals during approximately the first year poststroke. It was tested in two formats; individual or group encounters. Inclusion criteria were: Acute stroke, above 18 y.o., sufficient physical and cognitive functioning to participate. Data were collected immediately before, during and 14 days after the completion of the intervention. Pre- and post-data included medical and demographic data, quality of life, emotional wellbeing, life satisfaction, anxiety and depression. Qualitative interviews focusing on participant experiences were conducted two weeks following the intervention. Log notes taken by the health professionals conducting the intervention and work sheets filled in by participants also comprised data. Data analysis was case-oriented. The structured instruments were analysed regarding completeness of data and indication of changes in outcome variables. The qualitative interviews, log notes and work sheets were analysed using thematic content analysis.

RESULTS

Twenty-five stroke survivors (17 men, 8 women), median age 64 (range 33-89), participated. Physical limitations varied from mild to severe. Seven participants had moderate to severe expressive aphasia. The participants found the content and process of the intervention relevant. Both the individual and group formats were found useful. Patients with aphasia reported that there were too few encounters (eight encounters were originally planned). The participants underscored the benefits of being supported through a difficult time, having a chance to tell and (re)create their story and being supported in their attempts to cope with the situation.

CONCLUSIONS

This study provides initial support for the usefulness of the psychosocial intervention and highlights areas requiring further consideration and development.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01912014.

Challenges of conducting experimental studies within a clinical nursing context

In recent years, several distinguished scholars have advocated for nursing research that may carry strong evidence for practice. Their advocacy have highlighted that nursing science has reached a point where as nurse researchers we need to develop the questions we ask and design studies that have the power to produce solid, translational, evidence-based knowledge. To do so, we need to carry out experimental tests on complex, everyday nursing interventions and activities. We also need to create public space to present accounts of our endeavours pursuing this type of design in clinical practice. This paper will discuss some of the most important insights gained from conducting a quasi-experimental study in which the aim was to investigate the effect of a theory-based intervention, targeting knowledge and attitudes among registered nurses regarding cancer pain management. The importance of careful practical and methodological planning is emphasised, and the need for participation-friendly interventions is discussed.

Participatory action research in the implementing process of evidence-based intervention to prevent childhood obesity: project design of the "Healthy Future" study

OBJECTIVE

To describe the design of the developmental project Healthy Future that aims to implement a new evidence-based program for the prevention of childhood obesity and collaboration and sharing of work between specialist and community health care professionals in parts of a county in western Norway.

METHODS

Comprehensive participatory planning and evaluation (CPPE) process as an action-oriented research approach was chosen, using mixed data sources, mixed methods, and triangulation.

DISCUSSION

A bottom-up approach might decrease the barriers when new evidence-based childhood prevention interventions are going to be implemented. It is crucial not only to build partnership and shared understanding, motivation, and vision, but also to consider the frames of the organizations, such as competencies, and time to carry out the interventions at the right level of health care service and adapt to the overweight children and their families needs.

CONCLUSION

The developmental process of new health care programs is complex and multileveled and requires a framework to guide the process. By CPPE approach evidence-based health care practice can be delivered based on research, user knowledge, and provider knowledge in the field of childhood overweight and obesity in a certain context.

Between the lines: generating good qualitative data in studies involving persons with aphasia

High-quality data are essential for developing knowledge in qualitative inquiries. Language impairments affect the ability to meet the requirements that constitute good qualitative data. In this article, we focus on generating good qualitative data in persons with aphasia following stroke. We drew on experiences from a longitudinal nursing intervention to discuss how to maximize data generation in accordance with norms for data quality in this population. The longitudinal design, using a combination of research methods, and the iterative process of data generation and analysis over time constituted a continuity that enhanced communication, mutual understanding, and a trustful partnership.

Using meta-analyses for comparative effectiveness research

Comparative effectiveness research seeks to identify the most effective interventions for particular patient populations. Meta-analysis is an especially valuable form of comparative effectiveness research because it emphasizes the magnitude of intervention effects rather than relying on tests of statistical significance among primary studies. Overall effects can be calculated for diverse clinical and patient-centered variables to determine the outcome patterns. Moderator analyses compare intervention characteristics among primary studies by determining whether effect sizes vary among studies with different intervention characteristics. Intervention effectiveness can be linked to patient characteristics to provide evidence for patient-centered care. Moderator analyses often answer questions never posed by primary studies because neither multiple intervention characteristics nor populations are compared in single primary studies. Thus, meta-analyses provide unique contributions to knowledge. Although meta-analysis is a powerful comparative effectiveness strategy, methodological challenges and limitations in primary research must be acknowledged to interpret findings.

Development of the SALdável programme to reduce salt intake among hypertensive Brazilian women: an intervention mapping approach

BACKGROUND

Despite strong evidence for a relationship between high salt intake and hypertension, plus the widespread recommendations for dietary salt restriction among hypertensive subjects, there are no nursing studies describing effective theory-based interventions.

AIM

To describe a systematic process for development of a theory-based nursing intervention that is aimed at reducing salt intake among hypertensive women, by applying the 'intervention mapping' protocol.

METHODS

We developed our intervention following the six steps of the 'intervention mapping' protocol: assessing needs, creating a matrix of change objectives, selecting theoretical methods and practical applications, defining the intervention programme, organizing the adoption and implementation plan, and defining the evaluation plan.

RESULTS

Addition of salt during cooking is identified as the main source for salt consumption, plus women are identified as the people responsible for cooking meals at home. In our study, the motivational predictors of this behaviour were self-efficacy and habit. Guided practice, verbal persuasion, coping barriers, consciousness-raising and counter-conditioning were the theoretical methods we selected for enhancing self-efficacy and promoting habit change, respectively. Brainstorming, role-playing, cookbook use, measuring spoon use, label reading, hands-on skill-building activities and reinforcement phone calls were the chosen practical applications. We designed our intervention programme, and then organized the adoption and implementation plans. Finally, we generated a plan to evaluate our intervention.

CONCLUSIONS

'Intervention mapping' was a feasible methodological framework to guide the development of a theory-based nursing intervention for dietary salt reduction among hypertensive women.

Nurse-patient collaboration: a grounded theory study of patients with chronic obstructive pulmonary disease on non-invasive ventilation

OBJECTIVES

This paper provides a theoretical account of nurses' collaboration with patients with chronic obstructive pulmonary disease during non-invasive ventilation treatment in hospital.

BACKGROUND

Despite strong evidence for the effect of non-invasive ventilation treatment, success remains a huge challenge. Nurse-patient collaboration may be vital for treatment tolerance and success. A better understanding of how nurses and patients collaborate during non-invasive ventilation may therefore contribute to improvement in treatment success.

DESIGN

A constant comparative classical grounded theory.

METHOD

The data comprised sessions of qualitative participant observation during the treatment of 21 patients with non-invasive ventilation that included informal conversations with the nurses and semi-structured interviews with 11 patients after treatment completion. Data were collected at three intensive care units and one general respiratory ward in Denmark.

RESULTS

Succeeding emerged as the nurses' main concern in the nurse-patient collaboration during non-invasive ventilation treatment. Four collaborative typologies emerged as processing their main concern: (1) twofold oriented collaboration; (2) well-being oriented collaboration; (3) outcome oriented collaboration; and (4) absent collaboration.

CONCLUSIONS

This study offers a theoretical account of nurses' main concern and how they activate different ways of collaboration to achieve successful treatment. We offer a theoretical basis for developing complex interventions.

Promoting psychosocial well-being following a stroke: developing a theoretically and empirically sound complex intervention

BACKGROUND

The psychosocial consequences of stroke are complex and comprehensive and include substantial and longlasting impacts on mood, identity, social relationships, return to work and quality of life. Many studies have explored possible interventions to prevent or treat psychosocial problems, but the results have generally been disappointing. Very few studies have provided adequate theoretical accounts of the mechanisms assumed to contribute to positive outcomes.

OBJECTIVES

To describe the development of a psychosocial nursing intervention aimed at promoting psychosocial health and well-being and to stimulate dialogue about how to develop and report theoretically and empirically sound complex interventions in nursing.

DESIGN

A systematic, stepwise approach was used, consistent with the framework recommended for developing and evaluating complex interventions by the UK Medical Research Council.

DATA SOURCES

Systematic reviews of empirical studies regarding the psychosocial consequences and needs of patients following stroke; qualitative, experiential studies of stroke and stroke recovery; theories of psychosocial well-being, coping, life skills, narrative approaches to rehabilitation and guided self-determination.

REVIEW METHODS

Each systematic review was examined to determine the major psychosocial challenges and needs experienced by stroke survivors, focusing on how these challenges and needs developed over the illness trajectory, how previous interventions had sought to address them and the effective mechanisms assumed to affect the level of success of interventions. Qualitative studies were examined to reveal the subjective experiences of stroke and stroke recovery, paying particular attention to the development of needs across time and context. A qualitative synthesis of the major characteristics of the trajectory of stroke rehabilitation and recovery during the first year was developed. Theories were examined to illuminate possible effective mechanisms and actions aimed at promoting psychosocial well-being during the stroke recovery process.

RESULTS

A dialogue-based intervention comprising eight encounters between stroke survivors and trained health care workers was designed, based on narrative theories, empowerment philosophy and guided self determination. Worksheets and a guiding topical outline were developed to support the dialogue.

CONCLUSIONS

The UK Medical Research Council framework facilitated the systematic development of an empirically and theoretically informed complex nursing intervention aimed at promoting post-stroke psychosocial well-being.

Evidence-based refinement of health and social services: exploring the possibilities of intravention research

To promote evidence-based refinement of quality health and social services delivery and care, decision makers, researchers, and practitioners often undertake intervention research. Intervention research tests and describes new strategies for achieving desired outcomes. But theoretical, methodological, and practical issues continue to plague even alternative participatory approaches to intervention research, raising questions about its potential for promoting quality health and social services and care. In response to this persistent challenge, the authors of this article propose a radical solution, namely intravention research, laying out its unique features as well as its theoretical and practical implications. Their conceptualization sets the stage for dialogue on options for advancing research methodologies and methods that might better promote evidence-informed health and social services.

Protecting the power of interventions through proper reporting

Authors, reviewers, and journal editors are responsible for ensuring that standards of research reporting include detailed descriptions of interventions. The impact of nursing intervention research is much reduced when interventions are poorly described. Nursing research reports often fail to detail descriptions of interventions sufficiently to move future research forward, apply new knowledge in practice, and refine theories. To address this deficit, the authors constructed detailed guidelines for reporting interventions. Based on a review of health care literature, these guidelines include a discussion of theoretical, participant, interventionist, content, and delivery intervention elements with rationale for their inclusion. Suggestions for presenting this information in limited journal space are also presented.

Telephone follow-up to improve glycaemic control in patients with Type 2 diabetes: systematic review and meta-analysis of controlled trials

OBJECTIVE

To examine the impact of telephone follow-up interventions on glycaemic control in patients with Type 2 diabetes.

METHODS

This was a systematic review and meta-analysis of randomized controlled trials using The Cochrane Library, including the Cochrane central register of controlled trials; MEDLINE, EMBASE, PsycINFO and CINHAL, together with citation searching. The included studies were randomized controlled trials examining the effect of a telephone follow-up intervention on glycaemic control in patients with Type 2 diabetes. All the included trials were subject to critical appraisal. Data were extracted on study design, characteristics of patients, exact nature of the telephone intervention and details of comparison. Pooled standardized effects were calculated for the primary outcome. Glycaemic control was measured by HbA(1c) .

RESULTS

HbA(1c) levels reported in the reviewed studies were pooled using random effects models. The standardized effect of telephone follow-up was equivocal, with endpoint data showing weighted mean differences of -0.44 (95% CI -0.93 to 0.06) (Z = -1.72, P=0.08) in favour of the telephone follow-up intervention. Subgroup analysis of more intensive interventions (interactive follow-up with health professional plus automated follow-up or non-interactive follow-up) showed (n=1057) a significant benefit in favour of the treatment group, with a standardized mean difference of -0.84 (95% CI -1.67 to 0.0) (Z=1.97, P=0.05), indicating that more intensive (targeted) modes of follow-up may have better effects on glycaemic control.

CONCLUSIONS

The analysis suggested that telephone follow-up interventions following a more intensive targeted approach could have a positive impact on glycaemic control for Type 2 diabetes.