Mistrust, misperceptions, and miscommunication: a qualitative study of preferences about kidney transplantation among African Americans

BACKGROUND

Kidney transplantation rates in the United States are lower among African Americans than among whites. Well-documented racial disparities in access to transplantation explain some, but not all, of these differences. Prior survey-based research suggests that African American dialysis patients are less likely than whites to desire transplantation, but little research has focused on an in-depth exploration of preferences about kidney transplantation among African Americans. Thus, the purposes of this study were to explore preferences and to compare patients' expectations about transplantation with actual status on the transplant list.

METHODS

We conducted semistructured interviews with 16 African Americans receiving chronic hemodialysis. We analyzed the interviews using the constant comparative method of qualitative analysis. We also reviewed the dialysis center's transplant list.

RESULTS

Four dominant themes emerged: (1) varied desire for transplant; (2) concerns about donor source; (3) barriers to transplantation; and (4) lack of communication with nephrologists and the transplantation team. A thread of mistrust about equity in the transplantation process flowed through themes 2-4. In 7/16 cases, patients' understanding of their transplant listing status was discordant with their actual status.

CONCLUSIONS

Our study suggests that many African Americans on hemodialysis are interested in kidney transplantation, but that interest is often tempered by concerns about transplantation, including misconceptions about the risks to recipients and donors. Mistrust about equity in the organ allocation process also contributed to ambivalence. The discordance between patients' perceptions of listing status and actual status suggests communication gaps between African American hemodialysis patients and physicians. Clinicians should avoid interpreting ambivalence about transplantation as lack of interest.

Assessing the educational needs and concerns of nursing home staff regarding end-of-life care

The purpose of this study was to explore and describe the educational needs and concerns of licensed nursing staff and certified nursing assistants (CNAs) regarding end-of-life (EOL) care. Focus group interviews were conducted at two nursing homes in the Pacific Northwest. Separate interviews were conducted for licensed staff (RNs and LPN/LVNs) and CNAs. A total of 15 licensed staff and 39 CNAs participated in the study. Interviews were transcribed and themes were extracted through consensus reached by three investigators. The major concerns of these nursing home staff focused on symptom management, communication and interactions, goals of care, role delineation, time constraints, self-care needs, and emotional attachment to residents. Although both groups described similar themes, specific issues within each topic often were different for licensed staff and CNAs. These findings can be used to guide the design of educational programs aimed at assisting nursing home staff in providing high level end-of-life care.

Factors hindering patients' use of medications for cancer pain

OBJECTIVES

The purpose of this study was to explore the reasons that cancer patients with pain find it difficult to adhere to analgesic therapy.

MATERIALS AND METHODS

Twenty-one patients with advanced cancer with pain were interviewed using a semistructured schedule of questions. Participants were asked to describe their decision making regarding analgesics and the factors that made it difficult for them to take analgesics prescribed for their pain. They also were asked to describe their relationships with their healthcare providers. Themes were identified and refined using qualitative analytic techniques. Two investigators independently coded all data to ensure that findings accurately reflected participants' experiences.

RESULTS

Findings reveal several factors that hindered analgesic use and the specific ways in which patients evaluated these factors in making decisions about taking pain medication. The provider-patient factors that impeded analgesic use also were described. Finally, the common use of nonpharmacologic methods of pain control offers insight into the role of these therapeutic strategies in achieving pain relief and decreasing analgesic use.

CONCLUSIONS

The findings underscore the importance of early intervention to address barriers to analgesic use. Some barriers may be overcome through educational efforts. The findings suggest, however, that consistent, repeated patient education often may not be sufficient to subdue patients' negative thoughts about taking the medication. Other approaches, such as changing medications or assisting the patient to use nonpharmacologic pain strategies, may prove more successful.

Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care

Nursing homes care for people at the end of life (EOL). There is evidence to suggest, however, that nursing staff in these settings is often unprepared to provide a high level of EOL care. This article reports the findings from three preliminary studies that investigated the needs of licensed staff and certified nursing assistants in nursing homes regarding EOL care. The studies involved needs assessment surveys, focus group interviews with staff members, and telephone interviews with nursing home administrators. Data show that the major needs included a lack of knowledge and skills in symptom management; communication difficulties; conflicts with families and physicians; and emotional distress in dealing with time constraints and attachment to residents. Implications for nursing home staff education are described.

Multicultural considerations in the use of advance directives

PURPOSE/OBJECTIVES

To describe advance directives and the Patient Self-Determination Act (PSDA), to explore the European American sociocultural values underlying advance directives, and to describe the ethical and cultural issues that arise when attempting to encourage and use advance directives in culturally diverse populations.

DATA SOURCES

Research articles, case studies, and theoretical articles from clinical and bioethical literature.

DATA SYNTHESIS

An overview of advance directives and the PSDA is provided. The European American cultural values underlying advance directives are reviewed and contrasted with sociocultural values of culturally diverse groups to raise the question of cross-cultural applicability of advance directives and European-based bioethics.

CONCLUSIONS

The sociocultural values of many culturally diverse groups conflict with the values on which the use of advance directives is based. Thus, working with end-of-life decisions and advance directives for people from culturally diverse groups may be problematic.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should be sensitive to sociocultural beliefs that influence decisions affecting end-of-life care, especially the use of advance directives. Practitioners must incorporate this knowledge to increase flexibility of institutional practices and standards of care in the application of advance directives.

Education of advanced practice nurses. Serving vulnerable populations

Vulnerable populations are camouflaged, stigmatized, and often lacking in health care services. They may also be distrustful of assistance from traditional health care providers. To better serve vulnerable populations, professionals guiding intervention programs need specialized knowledge and skills as well as problem-solving abilities.

Quality of life in women with ovarian cancer

Despite growing interest in quality of life (QOL) as an important variable in nursing and health care, little research focuses on QOL in women with ovarian cancer (OVCA). The purpose of this study was to examine QOL in OVCA survivors. The convenience sample consisted of 152 women in all disease stages. Quantitative data were collected using the QOL-Cancer Survivors tool and a demographic sheet. Qualitative data were collected by asking participants to write their definitions and experiences of QOL since their diagnosis. Reliability and validity of all data and findings were established. Findings reveal that QOL is moderately high for this group of cancer survivors, despite some specific negative facets of the illness and treatment experience. Qualitative analysis elaborates the four domains of Ferrell's QOL model: physical, psychological, social, and spiritual well-being. Qualitative data also reflect the complexity of the cancer experience.

Priority ethical issues in oncology nursing: current approaches and future directions

PURPOSE/OBJECTIVES

To describe ethical issues determined to be highly important to oncology nurses and to discuss strategies by which the Oncology Nursing Society (ONS) can address these priority concerns.

DATA SOURCES

Survey on oncology nurses regarding ethical issues; nursing literature.

DATA SYNTHESIS

Nine priority ethical issues of oncology nurses are identified. Past, current, and future ONS activities that address these priority issues are discussed.

IMPLICATIONS FOR NURSING PRACTICE

ONS must support activities to increase the knowledge, confidence, and involvement of oncology nurses in discussions and decision making related to the ethical issues.

CONCLUSIONS

The top three priority ethical issues for oncology nurses are assisted suicide, end-of-life decisions, and pain management. Efforts should be made to increase ethics expertise among the ONS membership.

Alternative methods for formal literature review and meta-analysis in AHCPR Patient Outcomes Research Teams. Agency for Health Care Policy and Research

Formal literature review and synthesis is an important component of Patient Outcomes Research Teams (PORTs) and the development of clinical practice guidelines supported by the Agency for Health Care Policy and Research (AHCPR). Investigators face unresolved methodological issues and practical problems in carrying out this work because the use of such systematic reviews is relatively new in medicine. In addition, standard meta-analytic methods may not readily be applied to the literature pertinent to most PORTs. Representatives of the InterPORT Work Group on Literature Review and Meta-Analysis exchanged information to identify and assess their respective approaches to these challenges. All 12 PORTs used systematic approaches to identifying relevant studies and to gather and analyze data abstracted from these studies. Most PORTs had undertaken or made plans for several separate reviews, which focused on a specific question about the outcomes of therapeutic health care services or procedures, diagnosis, prevention or prognosis. The descriptive information provided by PORTs reveals substantial commonalities in their methods for searching literature and organizing bibliographic databases. However, there was considerable variation in other aspects of reviews, such as selection/exclusion criteria, the use of blinding, and the techniques used to assess the quality of studies. Alternative approaches to literature review and synthesis warrant further examination because they have implications for research and health policy both in terms of the substantive conclusions and efficiency of reviews.

Patient outcomes after lumbar spinal fusions

OBJECTIVES

To determine success and complication rates for lumbar spinal fusion surgery, predictors of good outcomes, and whether fusion improves success rates of laminectomy for specific low back disorders.

DATA SOURCES

English-language journal articles published from 1966 through April 1991, identified through MEDLINE searching (spinal fusion plus limiting terms), bibliography review, and expert consultation.

STUDY SELECTION

Articles were selected only if they reported at least 1 year of follow-up data enabling the classification of clinical outcomes as satisfactory or unsatisfactory for at least 30 patients.

DATA EXTRACTION

Two reviewers independently extracted data on patient characteristics, surgical methods, patient outcomes, and quality of study methods.

DATA SYNTHESIS

Of 47 articles, there were no randomized trials. Four nonrandomized studies compared surgery with and without fusion for herniated disks; three found no advantage for fusion. On average, 68% of patients had a satisfactory outcome after fusion, but the range was wide (16% to 95%), and the satisfactory outcome rate was lower in prospective than in retrospective studies. The most frequently reported complications were pseudarthrosis (14%) and chronic pain at the bone graft donor site (9%). Clinical outcomes did not differ by diagnosis or fusion technique, but were worse in studies with a greater number of previously operated patients.

CONCLUSIONS

For several low back disorders no advantage has been demonstrated for fusion over surgery without fusion, and complications of fusions are common. Randomized controlled trials are needed to compare fusion, surgery without fusion, and nonsurgical treatments in rigorously defined patient groups.

The process of maintaining hope in adults undergoing bone marrow transplantation for leukemia

The purpose of this qualitative study was to explore the processes of hoping in adults undergoing bone marrow transplantation (BMT) for leukemia. Grounded theory methodology was used to elicit the experience of hoping in 10 men and 10 women, ages 20-58, who had undergone BMT. The central process described by participants was that of maintaining hope. The core categories used to describe this process were Dealing With It and Keeping It in Its Place. Dealing With It is defined as the process of confronting the negative possibilities inherent in the illness experience and allowing the full range of thoughts, behaviors, and emotions resulting from this confrontation. Keeping It in Its Place is defined as the process of managing the impact of the illness by controlling or limiting one's response to the disease and therapy. The relationship between these two contradictory core categories is explained by The Dialectic of Maintaining Hope. This dialectic is defined as the synthesis of the antithetical strategies of Dealing With It and Keeping It in Its Place in which people are able to transcend each strategy and sustain hope. The findings provide a nascent, explanatory model and information for nurses regarding an important adaptive process.

Does the Millon Behavioral Health Inventory (MBHI) predict lumbar laminectomy outcome? A comparison with the Minnesota Multiphasic Personality Inventory (MMPI)

Response to surgery for low-back pain is influenced by psychosocial as well as physical factors. However, no psychosocial measure has yet been found to be highly accurate in predicting surgical outcome for individual patients. The purpose of this prospective study was to assess the usefulness of the Millon Behavioral Health Inventory (MBHI) in predicting outcome of laminectomy for lumbar disc herniation or spinal stenosis. Its use was compared with that of the Minnesota Multiphasic Personality Inventory. The influence of several demographic, clinical, and radiographic variables was also investigated. One hundred twenty-seven patients were assessed at an average of 24 months postsurgery. Ninety-three patients had a good outcome, 20 had a fair outcome, and 14 had a poor outcome. The MBHI scales as a group were not associated with surgical outcome.

Ways of Knowing Among Beginning Students in Nursing

Twenty-one students in their first quarter of nursing school were interviewed to determine the utility of the typology for ways of knowing developed by Belenky, Clinchy, Goldberger, and Tarule (1986) for understanding the cognitive development of nursing students; the differences in epistemological perspectives by gender, age, and ethnicity; and the forces in nursing school that encourage developmental transitions. The typology was found to be applicable for Caucasian women and provided important insights on differences among groups of students. Some of the implications for providing supportive educational environments are presented.

Examining the process and dilemmas of reality negotiation

Reality negotiation is the process people use to examine information from their environment and make judgments about the accuracy and importance of that information. Although this process has been found to be inaccurate, nurses often express discomfort when clients hold perceptions of reality that run counter to their own views. Nurses in these circumstances see the client as denying or as having unrealistic hopes. This article examines reality negotiation in light of this clinical dilemma, focusing on three areas: 1) the assumptions made regarding the nature of reality; 2) the potential and real outcomes of different types of reality negotiation; and 3) the process by which reality is redefined and how unrealistic perceptions are threatened and/or abandoned. These issues are explored as they relate to nursing research and practice.

Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature

A meta-analysis was undertaken to determine the effects of surgery for lumbar spinal stenosis on pain and disability. Seventy-four journal articles met inclusion criteria and were independently reviewed by two readers. On average, 64% of patients treated surgically for lumbar spinal stenosis were reported to have good-to-excellent outcomes. However, there was wide variation across studies in the percentage with good outcomes. Few patient characteristics were found to predict outcome. Major deficits in study design, analysis, and reporting were common, and these precluded firm conclusions.

How children cope with mother's breast cancer

Few studies have focused on the child of a parent with cancer. Family systems and cognitive development theories suggest that the mother's illness affects the children and that families take action to help them. This study describes the ways in which school-age children cope with the mother's breast cancer and the ways in which their families help them cope. The results are based on semistructured interviews with 81 children 6-20 years old whose mothers had been diagnosed with breast cancer within the past two-and-a-half years. Interviews were tape-recorded, transcribed, and content analyzed. Eighty-four percent agreement on interrater reliability was achieved using three independent trained coders. Children and families used four types of strategies: acted as though they were in her shoes, carried on business as usual, tapped into group energy, and put her illness on the table. Parents, other family members, the children's friends, and adult friends helped the children. The results suggest ways that clinicians can understand the effect of the mother's breast cancer from the child's perspective and thus facilitate both the child's coping and the family's attempts to help the children.