Living with chronicity and complexity: Lessons for redesigning case management from patients' life stories - A qualitative study

Consequences of the Covid-19 pandemic on complex multimorbid elderly: Follow-up of a community-based cohort. SAMAC3 Study

BACKGROUND

The restrictions imposed during the management of the pandemic led to lack of care of other health problems.

PURPOSE

To assess changes in the health status of complex multimorbidity elderly, functional and cognitive capacities, perception of the social surroundings, care provided by the nurses, including nursing diagnosis and interventions, use of health services, adverse events, and use of devices and technical help during the first 6 months of the Covid-19 pandemic.

DESIGN

A 1-year longitudinal cohort study was conducted.

METHODS

Ninety-seven complex multimorbid elderly attended in primary care were evaluated every 3 months in a health area of the Spanish National Health System (SNHS). The research was called "SAMAC3 study".

RESULTS

Significant negative changes were observed in the functional and cognitive capacity of the elderly, and in several nursing diagnoses. A decrease was observed in the frequency of visit to the nurses, hospital admittance, length of hospital stays, and falls.

CONCLUSIONS

The functional and cognitive capacities of the cohort became worse. However, a significant decrease in the frequency of use of health services was observed. The nurses detected significant changes in activity-exercise, cognitive-perception, and roles-relationships, but their interventions were mostly centered on resolving clinical matters that required immediate attention.

CLINICAL RELEVANCE

The present study allowed us to observe that a situation of social and health stress has worsened the health indicators of multimorbid elderly, and the clinical care of community nurses was insufficient to providing care for the deterioration of the physical and cognitive domains.

Coping with Multiple Chronic Conditions in the Family Context: A Meta-Synthesis

This study was to collect, synthesize, and interpret the current qualitative evidence from studies that investigated family coping among people with multiple chronic conditions (MCCs). A meta-synthesis approach was used to report this study. A systematic search was performed in five electronic databases, including CINAHL, EMBASE, PsycINFO, Web of Science, and PubMed from January 2000 to December 2020. The PRISMA flow chart and Joanna Briggs Institute Qualitative Assessment and Review Instrument checklist are integrated into the meta-synthesis. A total of ten eligible studies including data from 381 participants were identified. Three meta-themes were identified in the synthesis: (1) family role maintenance in MCCs management, (2) coping as a family, and (3) be frustrated with family interactions. This meta-synthesis indicated the importance of maintaining social roles and family support within family interactions for coping with MCCs. It also demonstrated the frustrations in the family coping process experienced by people with MCCs. Health care professionals should understand the interactions between people with MCCs and their family members that may impact people's coping. Such an understanding may contribute to the development of supportive programs such as family-based interventions for people with MCCs.

Gambling activity in the old-age general population

Old age constitutes a vulnerable stage for developing gambling-related problems. The aims of the study were to identify patterns of gambling habits in elderly participants from the general population, and to assess socio-demographic and clinical variables related to the severity of the gambling behaviours. The sample included N = 361 participants aged in the 50–90 years range. A broad assessment included socio-demographic variables, gambling profile and psychopathological state. The percentage of participants who reported an absence of gambling activities was 35.5 per cent, while 46.0 per cent reported only non-strategic gambling, 2.2 per cent only strategic gambling and 16.3 per cent both non-strategic plus strategic gambling. Gambling form with highest prevalence was lotteries (60.4%), followed by pools (13.9%) and bingo (11.9%). The prevalence of gambling disorder was 1.4 per cent, and 8.0 per cent of participants were at a problematic gambling level. Onset of gambling activities was younger for men, and male participants also reached a higher mean for the bets per gambling-episode and the number of total gambling activities. Risk factors for gambling severity in the sample were not being born in Spain and a higher number of cumulative lifetime life events, and gambling severity was associated with a higher prevalence of tobacco and alcohol abuse and with worse psychopathological state. Results are particularly useful for the development of reliable screening tools and for the design of effective prevention programmes.

Understanding the impact and causes of 'failure to attend' on continuity of care for patients with chronic conditions

Aim

To understand the impact and causes of ‘Failure to Attend’ (FTA) labelling, of patients with chronic conditions.

Background

Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended.

Method

The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation.

Results

Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient’s capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap.

Conclusion

The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase ‘Failure to Attend’ has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase “appointment did not proceed” to replace FTA.

Implications for Nursing management

This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term ‘appointment did not proceed.’

Nurse navigators and person-centred care; delivered but not valued?

Positioning the individual at the centre of care (person-centred care [PCC]) is essential to improving outcomes for people living with multiple chronic conditions. However, research also suggests that this is structurally challenging because health systems continue to adopt long-standing, episodic care encounters. One strategy to provide a more cohesive, individualised approach to care is the implementation of the nurse navigator role. Current research shows that although PCC is a focus of navigation, such care may be hindered by the rigid, systematised health services providing siloed specialist care. In this paper, we utilised a case study method to investigate the experiences of a nurse navigator and patient. The nurse navigator and the patient participated in individual interviews, the transcripts of which were analysed using critical discourse analysis. Findings from a larger research project suggest that traditional measures (hospital avoidance, emergency department usage) which work as the service objectives of the nurse navigator service have the potential to stifle the delivery of PCC. The analysis from this case study supports the broader findings and further highlights the need for improved alignment between service objectives and the health and well-being of the individuals utilising the services.

Family Caregiver Support of Patient Self-Management During Chronic, Life-Limiting Illness: A Qualitative Metasynthesis

Family caregivers play an integral role in supporting patient self-management, yet how they perform this role is unclear. We conducted a qualitative metasynthesis of family caregivers' processes to support patient self-management of chronic, life-limiting illness and factors affecting their support. Methods included a systematic literature search, quality appraisal of articles, data abstraction, and data synthesis to produce novel themes. Thirty articles met inclusion criteria, representing 935 international family caregivers aged 18 to 89 years caring for patients with various health conditions. Three themes characterized family caregivers' processes to support patient self-management: "Focusing on the Patient's Illness Needs," "Activating Resources to Support Oneself as the Family Caregiver," and "Supporting a Patient Living with a Chronic, Life-Limiting Illness." Factors affecting family caregivers' support included Personal Characteristics, Health Status, Resources, Environmental Characteristics, and the Health Care System. The family caregiver role in supporting patient self-management is multidimensional, encompassing three processes of care and influenced by multiple factors.

Development and External Validity of a Short-Form Version of the INICIARE Scale to Classify Nursing Care Dependency Level in Acute Hospitals

Background: The increasing dependence care in patients hospitalized in acute hospitals around the world entails classification systems heeding the wide range of care dependency levels generated by the many different types of dependent patients. This article is a report of a study assessing the validity and reliability of a short-from version of the instrument (Inventario del NIvel de Cuidados mediante Indicadores de Resultados de Enfermería (INICIARE)) used to classify inpatients according to their care dependency level. Methods: The validation, carried out in a multicenter longitudinal study, included three different samples: the first sample of 1800 patients to evaluate the reliability and validity, a second of 762 patients for confirmatory factor analysis, and a third of 762 to test the short-form version. Patients over 16 years of age, admitted to medical or surgical units at 11 public hospitals, were included. Results: The final sample included 3605 patients. Patients had a mean age of 64.5 years, 60% were admitted to medical units, with severe dependency. The validation process yielded two versions of the instrument: a 40-item version, with eight factors with 83.6% of total variance explained and Cronbach’s alpha values between 0.98 and 0.92, and a short-form with 26 items, with five factors and Cronbach’s alpha values between 0.96 and 0.90. The Confirmatory Factor Analysis yielded a good fit model to the 40-item version (Chi Square on Degrees of Freedom CMIN/DF) = 1.335; Normed Fit Index (NFI); Tucker–Lewis Index (TLI); Comparative Fit Index (CFI) > 0.90; Standardized Residual Root Mean Square (RMSEA) = 0.02; and Standardized Residual Root Mean Square (SRMR) = 0.027) and 26-item version (Chi Square on Degrees of Freedom CMIN/DF = 1.385; NFI = 0.998; CFI = 0.999; RMSEA = 0.02; and SRMR 0.02). Both INICIARE versions obtained a high correlation between them (r = 0.96; p < 0.001). Conclusion: INICIARE has proved to be a valid and reliable instrument for the assessment of the level of care dependency of acutely hospitalized patients.

Experiences and support needs of informal caregivers of people with multimorbidity: a scoping literature review

Objective: Describe and synthesise existing published research on the experiences and support needs of informal caregivers of people with multimorbidity.Design: Scoping literature review. Primary database and secondary searches for qualitative and/or quantitative English-language research with an explicit focus on informal carers of people with multimorbidity (no date restrictions). Quality appraisal of included papers. Thematic analysis to identify key themes in the findings of included papers.Results: Thirty-four papers (reporting on 27 studies) were eligible for inclusion, the majority of which were rated good quality, and almost half of which were published from 2015 onwards. The review highlights common difficulties for informal carers of people with multiple chronic illnesses, including practical challenges related to managing multiple health care teams, appointments, medications and side effects, and psychosocial challenges including high levels of psychological symptomatology and reduced social connectedness. Current gaps in the literature include very few studies of interventions which may help support this caregiver group.Conclusion: Interest in this research area is burgeoning. Future work might fruitfully examine the potential benefits of audio-recorded health care consultations, and digitally delivered psychosocial interventions such as online peer support forums, for supporting and enhancing the caring activities and wellbeing of this caregiver group.

Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: a scoping review

BACKGROUND

As the population is aging, the number of persons living with multiple chronic conditions (MCC) is expected to increase. This review seeks to answer two research questions from the perspectives of older adults with MCC, their caregivers and their health care providers (HCPs): 1) What are the health and social care needs of community-dwelling older adults with MCC and their caregivers? and 2) How do social and structural determinants of health impact these health and social care needs?

METHODS

We conducted a scoping review guided by a refinement of the Arksey & O'Malley framework. Articles were included if participants were 55 years or older and have at least two chronic conditions. We searched 7 electronic databases. The data were summarized using thematic analysis.

RESULTS

Thirty-six studies were included in this review: 28 studies included participants with MCC; 12 studies included HCPs; 5 studies included caregivers. The quality of the studies ranged from moderate to good. Five main areas of needs were identified: need for information; coordination of services and supports; preventive, maintenance and restorative strategies; training for older adults, caregivers and HCPs to help manage the older adults' complex conditions; and the need for person-centred approaches. Structural and social determinants of health such as socioeconomic status, education and access influenced the needs of older adults with MCC.

CONCLUSION

The review highlights that most of the needs of older adults with MCC focus on lack of access to information and coordination of care. The main structural and social determinants that influenced older adults' needs were their level of education/health literacy and their socioeconomic status.

How older adults with multimorbidity manage their own care within a formal care coordination program?

As the number of older adults with multimorbidity increases, care coordination programs are being designed to streamline the complex care older adults receive from multiple providers by improving health and reducing unnecessary costs. Well-coordinated care requires actions by both patients and providers. Yet little attention is paid to the what older adults do to manage their own care alongside a formal Care Coordination Program (CCP). This paper presents a qualitative descriptive study that explored what actions older adults took on their own to manage their care. Findings from this study identified that there were two actions older adults took to manage their care; they lived within their limits and they lived with grit. This study suggests that by recognizing what older adults do to self-manage their care within the context of a CCP, nurses can build on older adults' actions and provide person-centered strategies for care coordination.

Palliative and end-of-life care for adults with advanced chronic obstructive pulmonary disease: a rapid review focusing on patient and family caregiver perspectives

PURPOSE OF REVIEW

The aim of the review was to explore patient and family caregiver perspectives on key issues for ensuring quality of end-of-life care for people with chronic obstructive pulmonary disease (COPD). The growing evidence on the value of specialist palliative care services demonstrates significant improvements in treatments and provisions; however, much of the literature is generic in nature or centred on people with a cancer diagnosis. In this review, we examine the literature to ascertain the views and needs of patients and carers affected by advanced COPD, a highly debilitating condition that can have a profoundly negative impact on the quality of end-of-life experience.

RECENT FINDINGS

A total of 19 papers were included in the review. The main themes in the literature were Holistic Care, Illness Trajectory and Technology.

SUMMARY

Areas of unmet need emphasized across physical, psychosocial and spiritual domains were identified, particularly in relation to appropriate and timely conversations. Positive developments in the care and treatment of advanced COPD include the use of the STIOLTO Respimat inhaler, a brief educative and psychosocial intervention based on cognitive-behavioural therapy, and high-intensity exercise training. There is some evidence regarding the use of technology in end-stage COPD.

Taking a look to promoting health and complications' prevention: differences by context

Objectives:

to acknowledge and compare the health promotion and complications' prevention practices performed by nurses working in hospital and primary health care contexts.

Methods:

descriptive, exploratory and crosscutting study, performed with 474 nurses selected by convenience sampling. It was used a form that encompassed two categories of descriptive statements about quality in the professional exercise of nurses. This study had ethical committee approval.

Results:

the nurses' population was mainly women (87,3%) with an average age of 35,5 years. There was more practices of the hospital's nurses related to the identification of potential problems of the patient (p=0.001) and supervision of the activities that put in place the nursing interventions and the activities that they delegate (p=0.003).

Conclusion:

the nurses perform health promotion and complications' prevention activities, however not in a systematic fashion and professional practices differ by context. This study is relevant as it may promote the critical consciousness of the nurses about the need of stressing quality practices.

Adaptation and Validation of a Chinese Version of Patient Health Engagement Scale for Patients with Chronic Disease

The Patient Health Engagement Scale (PHE-s) was designed to assess the emotional and psychological attitudes of patients' engagement along their healthcare management journey. The aim of this study was to validate a culturally adapted Chinese version of the PHE-s (CPHE-s). Three hundred and seventy-seven participants were recruited from eight community health centers in a sample of patients with chronic disease in Hunan Province, China. The original Italian PHE-s was translated into Mandarin Chinese using a standardized forward–backward translation. The Rasch model was utilized and presented uni-dimensionality and good items fitness of the PHE-s. The internal consistency was 0.89 and the weighted Kappa coefficients of the items (test–retest reliability) ranged from 0.52 to 0.79. Both principal component analysis and confirmatory factor analysis supported a single-factor structure of the PHE-s. In testing the external validity, the PHE-s showed a significant moderate correlation with patient activation but not with medicine adherence behavior, which requires further exploration. The result suggested that the PHE-s is a reliable and valid instrument to assess the level of patient engagement in his or her own health management among chronic patients in China. Further analysis of reliability and validity should be assessed among other patient cohorts in China, and future directions for testing changes after patient engagement interventions should be developed by exploring some clinical relevance.

Socioanthropological contributions to physical therapy in chronic back pain

Abstract Introduction: The high prevalence of chronic back pain is related to biopsychosocial factors. In this respect, pain is understood as a multifactorial phenomenon made unique by the previous ideas of each individual. Thus, the present study aimed Objective: To understand the experience of chronic back pain and the effectiveness of physiotherapeutic approaches to support new care strategies. Methods: In terms of qualitative research, a comprehensive approach was adopted using the theoretical and conceptual framework developed in the fields of anthropology and health. The sample consisted of 13 women residing in the municipality of Várzea Grande, Mato Grosso state (MT), Brazil, over 40 years old, homemakers, diagnosed with chronic back pain, treated at the Univag clinical school and who had completed physiotherapy more than six months previously. Results: Data analysis indicated that more traditional forms of outpatient physiotherapy prompted a significant improvement in chronic back pain. However, because the condition is chronic, all patients relapsed and their pain and dysfunctional conditions returned. Conclusion: Multiple factors influence the experience of chronic back pain and the constant self-management required forms a circular relationship between objective and subjective elements. On the other hand, by disregarding these elements, physiotherapeutic approaches provide predominantly technical and scientific care far removed from the experience of the affected subject. In this respect, the chronic condition requires long-term care, whereby the focus should shift from the pursuit of a cure to the care model.