Implementation of a complex intervention to improve care for patients whose situations are clinically uncertain in hospital settings: A multi-method study using normalisation process theory

Interventions for family involvement enhance end-of-life care for hospitalized patients: an integrative review

BACKGROUND

Integrating family members into the care of hospitalized end-of-life patients enhances patient-family-centered care and significantly influences the experiences of patients and their families. This study used the integrative review methodology to assess the scope and effectiveness of interventions designed to facilitate family involvement in end-of-life care. It identified gaps and consolidated existing knowledge to improve nursing practices.

METHODS

This integrative review encompasses both experimental and non-experimental studies. The process included problem identification, literature search, data evaluation, analysis, and integration. The literature search targeted studies describing interventions for family involvement in EOLC using databases such as PubMed, CINAHL, Embase, and Web of Science. Data evaluation was conducted by assessing the quality of the studies using the Mixed Methods Appraisal Tool. Data analysis and integration were conducted by synthesizing the results of the selected studies and identifying the elements of family involvement using the 'Components of Family Involvement' framework.

RESULTS

Of the 8,378 identified studies, 26 were eligible for inclusion. Interventions involving the families of patients with terminal illness varied, including programs to enhance communication among patients, families, and healthcare providers; family meetings; decision-making support; and digital visits and rounds. The findings show that these interventions improve patients' psychological and physical comfort, family satisfaction, and communication. However, some families reported increased distress. The most frequently addressed elements of family involvement were communication and receiving information, followed by decision-making and meeting care needs. Family presence and contribution to care were the least addressed elements in the interventions.

CONCLUSIONS

This integrative review highlights the effectiveness of interventions to increase family involvement in end-of-life care, demonstrating positive impacts on patient comfort, family satisfaction, and communication. Despite progress in incorporating families into communication and decision-making, further efforts are needed to ensure their presence and direct care involvement. Future research should focus on improving these interventions to enhance scalability and support comprehensive family involvement, including digital tools for participation.

Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review

BACKGROUND

Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present.

AIM

To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness.

DESIGN

Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory.

DATA SOURCES

Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development.

RESULTS

Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding.

CONCLUSIONS

Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.