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Midlöv EM, Lindberg T, Skär L. Relative's suggestions for improvements in support from health professionals before and after a patient's death in general palliative care at home: A qualitative register study. Scand J Caring Sci 2024; 38:358-367. [PMID: 38258965 DOI: 10.1111/scs.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/26/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
INTRODUCTION The efforts of relatives in providing palliative care (PC) at home are important. Relatives take great responsibility, face many challenges and are at increased risk of poor physical and mental health. Support for these relatives is important, but they often do not receive the support they need. When PC is provided at home, the support for relatives before and after a patient's death must be improved. This study aimed to describe relatives' suggestions to improve the support from health professionals (HPs) before and after a patient's death in general PC at home. METHODS This study had a qualitative descriptive design based on the data from open-ended questions in a survey collected from the Swedish Register of Palliative Care. The respondents were adult relatives involved in general PC at home across Sweden. The textual data were analysed using thematic analysis. RESULTS The analysis identified four themes: (1) seeking increased access to HPs, (2) needing enhanced information, (3) desiring improved communication and (4) requesting individual support. CONCLUSIONS It is important to understand and address how the support to relatives may be improved to reduce the unmet needs of relatives. The findings of this study offer some concrete suggestions for improvement on ways to support relatives. Further research should focus on tailored support interventions so that HPs can provide optimal support for relatives before and after a patient's death when PC is provided at home.
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Affiliation(s)
- Elina Mikaelsson Midlöv
- Department of Health, Faculty of Engineering, Blekinge Institute of Technology, Karlskrona, Sweden
- Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
| | - Terese Lindberg
- Department of Health, Faculty of Engineering, Blekinge Institute of Technology, Karlskrona, Sweden
| | - Lisa Skär
- Faculty of Health Science, Kristianstad University, Kristianstad, Sweden
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O'Sullivan A, Alvariza A, Öhlén J, Larsdotter C. Support received by family members before, at and after an ill person's death. BMC Palliat Care 2021; 20:92. [PMID: 34167530 PMCID: PMC8228910 DOI: 10.1186/s12904-021-00800-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022] Open
Abstract
Background It is widely recognised, that family members are central to care of people with advanced illness, and that support should be provided to all family members in need thereof. The aim of this study was to investigate family members’ experiences of support received during the last three months of life, at the time of death and after the death of a person with advanced illness. Methods A retrospective cross-sectional survey design was employed, using the VOICES(SF) questionnaire and multiple methods for data analyses. The sample consisted of 485 bereaved family members (aged: 20–90 years old, 70% women) of people who died in hospital between August 2016-April 2017. Results Of the family members, 58,8% reported they had received enough help and support during the illness, whereas 30,2% had not. Family members’ comments about support during the illness were mainly related to care the ill person had or had not received, rather than about support they themselves received. Of all family members, 52,8% reported having had enough support at the time of the ill person’s death. Related to support at death, 14,6% reported that the imminence of death was not clear, which was described as having affected their opportunity to be with the dying person at the time of death. Of all, 25,2% had a follow-up conversation after the death, 48% did not and did not want to, and 21% had no follow-up conversation, but would have liked one. A follow-up conversation was described as helpful for the bereavement process, and disappointment was expressed when not receiving support after the death. Conclusions Family members’ experiences of support were partly related to whether the ill person’s care needs were fulfilled. Healthcare staff expressing empathy and respect in the care of dying people and their family members were important for family members’ experiences of support. Family members’ difficulty recognising that death was imminent and the importance of healthcare staff providing them with clear information were expressed in connection with support at death. Follow-up conversations were valued by family members, especially if with a healthcare professional who was present at the time of death.
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Affiliation(s)
- Anna O'Sullivan
- Palliative Research Centre, Department of Healthcare Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Anette Alvariza
- Palliative Research Centre, Department of Healthcare Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden.,Capio Palliative Care, Dalen Hospital, Stockholm, Sweden
| | - Joakim Öhlén
- Centre for Person-Centered Care, University of Gothenburg, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy At the University of Gothenburg, Gothenburg, Sweden.,Palliative Centre, Sahlgrenska University Hospital Västra Götaland Region, Gothenburg, Sweden
| | - Cecilia Larsdotter
- Palliative Research Centre, Department of Healthcare Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden. .,Department of Nursing Science, Sophiahemmet University, P.O. Box 5605, 114 86, Stockholm, Sweden.
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3
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Chen SH, Lai XB, Chen LQ, Xia HO, Chen CY. A qualitative study of caring in hospice wards in Shanghai. Nurs Health Sci 2021. [DOI: 10.1111/nhs.12797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Shu Hui Chen
- School of Nursing, Fudan University Shanghai China
| | - Xiao Bin Lai
- School of Nursing, Fudan University Shanghai China
| | - Li Qun Chen
- School of Nursing, Fudan University Shanghai China
| | - Hai Ou Xia
- School of Nursing, Fudan University Shanghai China
| | - Chun Yan Chen
- Department of Nursing Fudan University Shanghai Cancer Center Shanghai China
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Sarfo-Walters C, Boateng EA. Perceptions of patients with end-stage kidney disease (ESKD) and their informal caregivers on palliative care as a treatment option: a qualitative study. BMC Palliat Care 2020; 19:133. [PMID: 32819349 PMCID: PMC7441556 DOI: 10.1186/s12904-020-00640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/16/2020] [Indexed: 12/03/2022] Open
Abstract
Background Palliative care is increasingly becoming an accepted treatment choice for many individuals diagnosed with end-stage kidney disease (ESKD). Yet, its utilisation is non-existent in many lower- and middle-income countries (LMICs). This study explored the perceptions of individuals with ESKD and their informal caregivers on palliative care as a treatment option for the disease in Ghana. Methods This was a phenomenological study, with an in-depth analysis of data collected from nine individuals with ESKD and six informal caregivers through individual, face-to-face semi-structured interviews. The study was conducted in two renal centres within the Kumasi metropolis, Ghana among individuals with ESKD seeking care from both renal centres and their informal caregivers. Results Three main themes were derived from this study – motivation for initiating haemodialysis, facing realities of haemodialysis, and considering palliative care. Participants felt that haemodialysis (HD) was not meeting their health expectations and demonstrated a general willingness to utilise palliative care if it would reduce suffering. Conclusions This study has shown that individuals with ESKD or their informal caregivers would consider palliative care services, if available. It paves the way for discussions about palliative care for ESKD to begin across renal centres within Ghana and other similar settings. Exploring perspectives of clinicians in such settings could inform strategies on how to implement palliative care for ESKD management in such settings.
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Affiliation(s)
| | - Edward Appiah Boateng
- Department of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
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Testoni I, Wieser MA, Kapelis D, Pompele S, Bonaventura M, Crupi R. Lack of Truth-Telling in Palliative Care and Its Effects among Nurses and Nursing Students. Behav Sci (Basel) 2020; 10:E88. [PMID: 32403378 PMCID: PMC7287675 DOI: 10.3390/bs10050088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/16/2022] Open
Abstract
Unclear communication of inauspicious prognoses may disorientate both patients and their relatives, drastically jeopardizing the planning of palliative care. This paper considers the issue of truth-telling in the communicative problems of nurses and students of nursing with terminally ill patients. The fundamental objective is the analysis of the difficulties related to the lack of truth-telling and how it might impact their professional and personal lives. A qualitative study was realized, involving 47 participants, both nurses (25) and nursing students (22), working in palliative care units or in associations of volunteers for the assistance of oncological patients. The exploration was focused on the way they relate to patients who are not aware of their real health conditions and their consequences. Particular attention was paid to their opinions concerning what could be done in order to manage such problematic situations in the near future.
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Affiliation(s)
- Ines Testoni
- Department of Philosophy, Sociology, Pedagogy and Applied psychology (FISPPA), University of Padova, 35131 Padova, Italy; (I.T.); (S.P.)
- Arts Therapies Research Center, University of Haifa, Haifa 3498838, Israel
| | | | - Dafni Kapelis
- Palliative Care Department, ULSS n. 8 Asolo, 31011 Treviso, Italy;
| | - Sara Pompele
- Department of Philosophy, Sociology, Pedagogy and Applied psychology (FISPPA), University of Padova, 35131 Padova, Italy; (I.T.); (S.P.)
| | | | - Robert Crupi
- NewYork-Presbyterian Queens, New York, NY 11355, USA;
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Chan WCH, Wong KLY, Leung MMM, Lin MKY. Perceived challenges in pediatric palliative care among doctors and nurses in Hong Kong. DEATH STUDIES 2018; 43:372-380. [PMID: 30015574 DOI: 10.1080/07481187.2018.1478912] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/05/2018] [Accepted: 04/08/2018] [Indexed: 06/08/2023]
Abstract
This study aims to examine perceived challenges, including knowledge, skills, self, and work environment, of professionals in providing pediatric palliative care (PPC) in Hong Kong and the differences in perceived challenges between groups. A total of 680 pediatric doctors and nurses participated in the survey. They tended to perceive the provision of PPC as difficult and considered "advanced skills" (those dealing with death-related issues) challenging. Findings indicate that nurses, professionals who are less experienced, do not have children, and have not received palliative care training perceived a higher level of challenges in providing PPC. Implications for training and support are discussed.
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Affiliation(s)
- Wallace Chi Ho Chan
- a Department of Social Work , The Chinese University of Hong Kong , Hong Kong
| | - Karen Lok Yi Wong
- a Department of Social Work , The Chinese University of Hong Kong , Hong Kong
| | - M M M Leung
- b Department of Pediatric and Adolescent Medicine , United Christian Hospital , Hong Kong
| | - M K Y Lin
- c Children's Cancer Foundation , Hong Kong
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Hernández-Marrero P, Fradique E, Pereira SM. Palliative care nursing involvement in end-of-life decision-making: Qualitative secondary analysis. Nurs Ethics 2018; 26:1680-1695. [PMID: 29807491 DOI: 10.1177/0969733018774610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nurses are the largest professional group in healthcare and those who make more decisions. In 2014, the Committee on Bioethics of the Council of Europe launched the "Guide on the decision-making process regarding medical treatment in end-of-life situations" (hereinafter, Guide), aiming at improving decision-making processes and empowering professionals in making end-of-life decisions. The Guide does not mention nurses explicitly. OBJECTIVES To analyze the ethical principles most valued by nurses working in palliative care when making end-of-life decisions and investigate if they are consistent with the framework and recommendations of the Guide; to identify what disputed/controversial issues are more frequent in these nurses' current end-of-life care practices. DESIGN Qualitative secondary analysis. PARTICIPANTS/CONTEXT Three qualitative datasets including 32 interviews from previous studies with nurses working in palliative care in Portugal. ETHICAL CONSIDERATION Ethical approval was obtained from the Ethics Research Lab of the Instituto de Bioética (Ethics Research Lab of the Institute of Bioethics) (Ref.04.2015). Ethical procedures are thoroughly described. FINDINGS All participant nurses referred to autonomy as an ethical principle paramount in end-of-life decision-making. They were commonly involved in end-of-life decision-making. Palliative sedation and communication were the most mentioned disputed/controversial issues. DISCUSSION Autonomy was highly valued in end-of-life care and decision-making. Nurses expressed major concerns in assessing patients' preferences, wishes, and promoting advance care planning. Nurses working in palliative care in Portugal were highly involved in end-of-life decision-making. These processes embraced a collective, inclusive approach. Palliative sedation was the most mentioned disputed issue, which is aligned with previous findings. Communication also emerged as a sensitive ethical issue; it is surprising, however, that only three nurses referred to it. CONCLUSION While the Guide does not explicitly mention nurses in its content, this study shows that nurses working in palliative care in Portugal are involved in these processes. Further research is needed on nurses' involvement and practices in end-of-life decision-making.
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Affiliation(s)
| | - Emília Fradique
- Hospital de Santa Maria, Portugal; Instituto S. João de Deus, Portugal
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Martins Pereira S, Fradique E, Hernández-Marrero P. End-of-Life Decision Making in Palliative Care and Recommendations of the Council of Europe: Qualitative Secondary Analysis of Interviews and Observation Field Notes. J Palliat Med 2018; 21:604-615. [PMID: 29742044 PMCID: PMC6225077 DOI: 10.1089/jpm.2017.0403] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND End-of-life decisions (ELDs) are embedded in clinical, sociocultural, political, economic, and ethical concerns. In 2014, the Council of Europe (CoE) through its Committee on Bioethics launched the "Guide on the decision-making process regarding medical treatment in end-of-life situations," aiming at improving decision-making processes and empowering professionals in making ELDs. OBJECTIVE To analyze if end-of-life decision making in palliative care (PC) is consistent with this Guide and to identify if disputed/controversial issues are part of current ELDs. DESIGN Qualitative secondary analysis. SETTING/SUBJECTS Four qualitative datasets, including 44 interviews and 9 team observation field notes from previous studies with PC teams/professionals in Portugal. MEASUREMENTS An analysis grid based on the abovementioned guide was created considering three dimensions: ethical and legal frameworks, decision-making process, and disputed/controversial issues. RESULTS The majority of the professionals considered the ethical principle of autonomy paramount in end-of-life decision making. Justice and beneficence/nonmaleficence were also valued. Although not mentioned in the Guide, the professionals also considered other ethical principles when making ELDs, namely, responsibility, integrity, and dignity. Most of the interviewees and field notes referred to the collective interprofessional dimension of the decision-making process. Palliative sedation and the wish to hasten death were the most mentioned disputed/controversial issues. The nature, limitations, and benefits of qualitative secondary analysis are discussed. CONCLUSIONS End-of-life decision-making processes made by Portuguese PC teams seem to be consistent with the guidelines of the CoE. Further research is needed about disputed/controversial issues and the actual use, effectiveness, and impact of ethical guidelines for end-of-life decision making on professionals' empowerment and for all parties involved.
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Affiliation(s)
- Sandra Martins Pereira
- Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal
- UNESCO Chair in Bioethics, Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal
- CEGE: Research Centre in Management and Economics (Centro de Estudos em Gestão e Economia), Católica Porto Business School, Universidade Católica Portuguesa, Porto, Portugal
| | - Emília Fradique
- Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
- Casa São João d'Ávila, Instituto São João de Deus, Lisboa, Portugal
| | - Pablo Hernández-Marrero
- Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal
- UNESCO Chair in Bioethics, Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal
- CEGE: Research Centre in Management and Economics (Centro de Estudos em Gestão e Economia), Católica Porto Business School, Universidade Católica Portuguesa, Porto, Portugal
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Reid J, Noble HR, Adamson G, Davenport A, Farrington K, Fouque D, Kalantar-Zadeh K, Mallett J, McKeaveney C, Porter S, Seres DS, Shields J, Slee A, Witham MD, Maxwell AP. Establishing a clinical phenotype for cachexia in end stage kidney disease - study protocol. BMC Nephrol 2018; 19:38. [PMID: 29439674 PMCID: PMC5812213 DOI: 10.1186/s12882-018-0819-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 01/17/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Surveys using traditional measures of nutritional status indicate that muscle wasting is common among persons with end-stage kidney disease (ESKD). Up to 75% of adults undergoing maintenance dialysis show some evidence of muscle wasting. ESKD is associated with an increase in inflammatory cytokines and can result in cachexia, with the loss of muscle and fat stores. At present, only limited data are available on the classification of wasting experienced by persons with ESKD. Individuals with ESKD often exhibit symptoms of anorexia, loss of lean muscle mass and altered energy expenditure. These symptoms are consistent with the syndrome of cachexia observed in other chronic diseases, such as cancer, heart failure, and acquired immune deficiency syndrome. While definitions of cachexia have been developed for some diseases, such as cardiac failure and cancer, no specific cachexia definition has been established for chronic kidney disease. The importance of developing a definition of cachexia in a population with ESKD is underscored by the negative impact that symptoms of cachexia have on quality of life and the association of cachexia with a substantially increased risk of premature mortality. The aim of this study is to determine the clinical phenotype of cachexia specific to individuals with ESKD. METHODS A longitudinal study which will recruit adult patients with ESKD receiving haemodialysis attending a Regional Nephrology Unit within the United Kingdom. Patients will be followed 2 monthly over 12 months and measurements of weight; lean muscle mass (bioelectrical impedance, mid upper arm muscle circumference and tricep skin fold thickness); muscle strength (hand held dynamometer), fatigue, anorexia and quality of life collected. We will determine if they experience (and to what degree) the known characteristics associated with cachexia. DISCUSSION Cachexia is a debilitating condition associated with an extremely poor outcome. Definitions of cachexia in chronic illnesses are required to reflect specific nuances associated with each disease. These discrete cachexia definitions help with the precision of research and the subsequent clinical interventions to improve outcomes for patients suffering from cachexia. The absence of a definition for cachexia in an ESKD population makes it particularly difficult to study the incidence of cachexia or potential treatments, as there are no standardised inclusion criteria for patients with ESKD who have cachexia. Outcomes from this study will provide much needed data to inform development and testing of potential treatment modalities, aimed at enhancing current clinical practice, policy and education.
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Affiliation(s)
- Joanne Reid
- School of Nursing and Midwifery, Queen's University Belfast Medical Biology Centre, 97 Lisburn Rd, Belfast, BT9 7BL, UK.
| | - Helen R Noble
- School of Nursing and Midwifery, Queen's University Belfast Medical Biology Centre, 97 Lisburn Rd, Belfast, BT9 7BL, UK
| | - Gary Adamson
- School of Psychology, Ulster University Magee Campus, Londonderry, BT48 7JL, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG, UK
| | - Ken Farrington
- East and North Hertfordshire University NHS Trust, Lister Hospital, Coreys Mill Lane, Stevenage, SG1 4AB, UK
| | - Denis Fouque
- Department of Nephrology, Université de Lyon, UCBL, Carmen, Centre Hospitalier Lyon Sud, F-69495, Pierre-Bénite, France
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Pediatrics and Public Health, University of California, Los Angeles, USA
| | - John Mallett
- School of Psychology, Ulster University Magee Campus, Londonderry, BT48 7JL, UK
| | - C McKeaveney
- School of Nursing and Midwifery, Queen's University Belfast Medical Biology Centre, 97 Lisburn Rd, Belfast, BT9 7BL, UK
| | - S Porter
- Department of Social Sciences and Social Work, Bournemouth University, Poole, UK
| | - David S Seres
- Columbia University Medical Centre, NY Presbyterian Hospital, New York, USA
| | - Joanne Shields
- Regional Nephrology Unit, Belfast City Hospital, Belfast HSC Trust, Belfast, UK
| | - Adrian Slee
- UCL, Faculty of Medical Sciences, Gower St, Bloomsbury, London, WC1E 6BT, UK
| | - Miles D Witham
- School of Medicine, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Alexander P Maxwell
- School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast and Regional Nephrology Unit, Belfast City Hospital, Belfast HSC Trust, Belfast, UK
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Cortés YI, Arcia A, Kearney J, Luchsinger J, Lucero RJ. Urban-Dwelling Community Members' Views on Biomedical Research Engagement. QUALITATIVE HEALTH RESEARCH 2017; 27:130-137. [PMID: 26825482 PMCID: PMC5166984 DOI: 10.1177/1049732315627650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
In this study, we explore community members' overall understanding and experience with biomedical research engagement. We conducted a qualitative analysis to explore a concept that emerged but was not specifically addressed in a pre-existing dataset obtained using four focus group sessions with 30 urban-dwelling community members. Transcripts were read in an iterative process, and an emergent content analysis was performed. Five main themes were identified: (a) engaging in research to contribute to personal or greater good, (b) hierarchy of trust, (c) the importance of disclosure and transparency, (d) practical barriers to research engagement, and (e) fear of research procedures. Community members view research engagement as a collaborative process whereby community members and researchers are involved in all stages of the investigation. Focusing on research engagement, and not merely participation, may enhance community knowledge of the research process and advance scientific knowledge.
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Affiliation(s)
| | | | - Joan Kearney
- Yale School of Nursing, West Haven, Connecticut, USA
| | | | - Robert J Lucero
- University of Florida, Gainesville, Florida, USA
- VA HSR&D Center of Innovation on Disability and Rehabilitation Research, Gainesville, Florida, USA
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Tang WR, Hong JH, Rau KM, Wang CH, Juang YY, Lai CH, Fujimori M, Fang CK. Truth telling in Taiwanese cancer care: patients' and families' preferences and their experiences of doctors' practices. Psychooncology 2016; 26:999-1005. [DOI: 10.1002/pon.4257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 06/24/2016] [Accepted: 08/05/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Woung-Ru Tang
- School of Nursing, College of Medicine; Chang Gung University; Taoyuan Taiwan
- Department of Psychiatry; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Ji-Hong Hong
- Department of Radiation Oncology; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Kun-Ming Rau
- Department of Hematology; Chang Gung Memorial Hospital; Kaohsiung Taiwan
| | - Cheng-Hsu Wang
- Department of Hematology; Chang Gung Memorial Hospital; Keelung Taiwan
| | - Yeong-Yuh Juang
- Department of Psychiatry; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Chien-Hong Lai
- Department of Hematology; Chang Gung Memorial Hospital; Keelung Taiwan
| | - Maiko Fujimori
- Center for Suicide Prevention, National Institute of Mental Health; National Center for Neurology & Psychiatry; Tokyo Japan
| | - Chun-Kai Fang
- Department of Psychiatry, Suicide Prevention Center & Hospice and Palliative Care Center; MacKay Memorial Hospital; Taipei Taiwan
- Department of Medicine; MacKay Medical College; New Taipei Taiwan
- Department of Thanatology and Health Counseling; National Taipei University of Nursing and Health Sciences; Taipei Taiwan
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