The Role of Spirituality in Stroke Survivors and Their Caregivers: A Systematic Review

Although several studies have analyzed the effects of spirituality on stroke survivors' physical functioning and their caregiver's outcomes, no systematic review or meta-synthesis was found to identify the lived experiences of stroke survivors and caregivers regarding spirituality. For these reasons, this study aimed to analyze quantitively and qualitatively research relating to stroke survivors' and caregivers' experiences. The included studies were RCT studies, quasi-experimental studies, qualitative, descriptive, ethnographic, and phenomenological studies, and cross-sectional studies (n = 37), with a total of 6850 stroke survivors and 1953 caregivers enrolled. Spirituality appears to play an important role in improving the quality of life and decreasing anxiety and depression of both stroke survivors and their caregivers.

Burden among informal caregivers of individuals with heart failure: A mixed methods study

AIMS

To develop a comprehensive understanding of caregiver burden and its predictors from a dyadic perspective.

METHOD

A convergent mixed methods design was used. This study was conducted in three European countries, Italy, Spain, and the Netherlands. A sample of 229 HF patients and caregivers was enrolled between February 2017 and December 2018 from the internal medicine ward, outpatient clinic, and private cardiologist medical office. In total, 184 dyads completed validated scales to measure burden, and 50 caregivers participated in semi-structured interviews to better understand the caregiver experience. The Care Dependency Scale, Montreal Cognitive Assessment, and SF-8 Health Survey were used for data collection. Multiple regression analysis was conducted to identify the predictors and qualitative content analysis was performed on qualitative data. The results were merged using joint displays.

RESULTS

Caregiver burden was predicted by the patient's worse cognitive impairment, lower physical quality of life, and a higher care dependency perceived by the caregivers. The qualitative and mixed analysis demonstrated that caregiver burden has a physical, emotional, and social nature.

CONCLUSIONS

Caregiver burden can affect the capability of informal caregivers to support and care for their relatives with heart failure. Developing and evaluating individual and community-based strategies to address caregiver burden and enhance their quality of life are warranted.

The Impact of an Intervention to Improve Caregiver Contribution to Heart Failure Self-care on Caregiver Anxiety, Depression, Quality of Life, and Sleep

BACKGROUND

Better caregiver contribution to self-care in heart failure is associated with better patient outcomes. However, caregiver contribution to self-care is also associated with high anxiety and depression, poor quality of life, and poor sleep in caregivers. It is still unclear whether interventions that encourage caregivers to contribute more to patient self-care might increase caregivers' anxiety and depression and decrease their quality of life and sleep.

OBJECTIVE

The aim of this study was to assess the impact of a motivational interview intervention aimed at improving caregiver contribution to self-care in heart failure on caregivers' anxiety, depression, quality of life, and sleep.

METHODS

This is a secondary outcome analysis of the MOTIVATE-HF trial. Patients with heart failure and their caregivers were randomized into arm 1 (motivational interview to patients), arm 2 (motivational interview to patients and caregivers), and arm 3 (standard care). Data were collected between June 2014 and October 2018. The article has been prepared following the Consolidated Standards of Reporting Trials checklist.

RESULTS

A sample of 510 patient-caregiver dyads was enrolled. Over the year of the study, the levels of anxiety, depression, quality of life, and sleep in caregivers did not significantly change among the 3 arms.

CONCLUSIONS

Motivational interview aimed at improving caregiver contribution to self-care does not seem to increase caregiver anxiety and depression, nor decrease their quality of life and sleep. Thus, such an intervention might be safely delivered to caregivers of patients with heart failure, although further studies are needed to confirm our findings.

Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data

Introduction

In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs.

Objectives

The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes.

Methods

A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs.

Results

The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred.

Conclusion

NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.

Dyad Gender and Relationship Quality Influence Heart Failure Self-Care

Caregivers promote heart failure self-care, yet little is known about how relationship quality and dyad gender influences self-care. The purpose of this study was to evauluate the contribution of dyad gender and relationship quality on heart failure self-care. The study was a secondary analysis from a heart failure self-care intervention. Dyad gender was categorized by patient-caregiver gender as Male-Male (M + M), Female-Female (F + F), Female-Male (Fp + Mc), and Male-Female (Mp + Fc). The Self-Care of Heart Failure Index v.6.2 measured self-care. The Mutuality Scale assessed relationship quality. Univariate linear regression identified determinants of patient self-care maintenance and self-efficacy. The sample (n = 503) was 48% Mp + Fc, 27% F + F, 15% Fp + Mc, and 10% M + M. Better caregiver mutuality in M + M dyads was associated with lower self-care maintenance (b = -7.45, 95% CI [-13.80, -1.11]) and self-efficacy (b = -18.07, 95% CI [-29.11, -7.04]). Better patient mutuality was associated with higher self-efficacy for M + M dyads (b = 12.63, 95% CI [2.18, 23.09]). Mutuality and dyad gender appear important for self-care. Consider the role of gender in the dyad in behavioral interventions.

Effectiveness of Motivational Interviewing on contribution to self-care, self-efficacy, and preparedness in caregivers of patients with heart failure: a secondary outcome analysis of the MOTIVATE-HF randomized controlled trial

AIMS

Caregiver characteristics and behaviours are associated with patients' and caregivers' outcomes. However, there is scarce evidence on interventions aimed at improving caregiver contribution (CC) to patient self-care, caregiver self-efficacy, and caregiver preparedness in heart failure (HF). This study aims to evaluate the effect of Motivational Interviewing (MI) on CC to patient self-care, caregiver self-efficacy, and caregiver preparedness in HF.

METHODS AND RESULTS

This is a secondary outcome analysis of MOTIVATE-HF randomized controlled trial. Caregivers of patients with HF were randomized into three arms: Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers), and Arm 3 (standard care). The intervention consisted of one MI session plus three telephone contacts. Data were collected at baseline and after 3, 6, 9, and 12 months. A total of 510 patient and caregiver (median age 54 years, 76% females) dyads were enrolled, 235 caregivers and 238 patients completed the study until 12 months. Caregiver contribution to self-care maintenance and management and caregiver preparedness significantly improved over time, but without significant differences among the three arms. At 9 months, caregiver self-efficacy improved more in Arm 2 than Arm 3 [difference: 8.36, 95% confidence interval (CI) (3.13; 13.59), P = 0.001]. This improvement remained significant also at linear mixed model [β^ = 1.39, 95% CI (0.02; 2.75), P = 0.046].

CONCLUSION

Motivational Interviewing did not improve CC to patient self-care and caregiver preparedness. However, it increased caregiver self-efficacy, which is known to be a powerful mediator of CC to self-care.

REGISTRATION

Clinicaltrials.gov: NCT02894502.

Motivational Interviewing improves caregiver self-efficacy in heart failure: a secondary outcome analysis of the MOTIVATE-HF trial

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Center of Excellence for Nursing Scholarship, Rome, Italy.

Background

Caregiver self-efficacy, which is caregiver confidence in her own abilities to help the patient in performing self-care, directly influences caregiver contribution (CC) to self-care, while acting as a mediator between predictors of CC to self-care and CC to self-care itself. Although caregiver self-efficacy is associated with patient and caregiver outcomes, evidence on interventions aiming to improve this variable, as well as CC to self-care, is scarce.

Purpose

To evaluate the effect of Motivational Interviewing (MI) on caregiver self-efficacy and CC to self-care in heart failure.

Methods

Secondary outcome analysis of the MOTIVATE-HF RCT. A total of 235 caregivers and 238 patients completed the study. Participants were recruited from three centres in Italy and randomized into Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers), Arm 3 (standard care). The intervention consisted in one face-to-face MI session followed by three telephone contacts delivered to patients (Arm 1) or to patients and caregivers (Arm 2). Caregiver self-efficacy and CC to self-care were assessed with the Caregiver Contribution to Self-Care of HF Index. Data were collected at baseline, before the intervention, and after 3, 6, 9, 12 months from enrolment.

Results

Among the three arms, caregivers median age was 55 years, they were mainly female (76%), married (72%), spouses (37%), employed (73.5%), with a high school level or higher education (55%), and living with the patients (60%). Patients median age was 74 years, they were mainly male (58%), retired (76%), in NYHA Class II (61.9%). Over the year of the study, caregiver self-efficacy significantly improved in all arms, and was significantly higher in Arm 2 compared to Arm 3 at 9-month follow-up (difference: 8.36, 95% CI (3.13; 13.59), p = 0.002). At 12-month follow-up, caregiver self-efficacy was still higher in Arm 2 compared to Arm 3, but this difference only approached statistical significance (difference: 6.59, 95% CI (-0.41; 13.60), p = 0.064). The longitudinal mixed linear model on self-efficacy, accounting for time, living with the patient, randomization arm and their interaction, confirmed a significantly higher improvement of caregiver self-efficacy in Arm 2 compared to Arm 3 (β ̂ = 1.39, 95% CI (0.02; 2.75), p = 0.046). CC to self-care significantly improved over time in all Arms, but without significant differences among the three Arms.

Conclusion

Our results show that MI was effective in improving caregiver self-efficacy, but not CC to self-care. This may indicate that MI was able to improve how well caregivers were supporting patients, as showed by improvements in self-efficacy, but not how much they were doing it, as showed by the lack of improvement in CC to self-care. Further studies need to better understand how caregiver self-efficacy affects CC to self-care, how caregiver self-efficacy can be further improved, and the necessary intensity of MI to improve CC to self-care.

Health Literacy in Patients’ Clinical Records of Hospital Settings: A Systematic Review

Introduction

Health literacy (HL) can be defined as the individual's ability to understand and process health information. A low level of HL can be viewed as a stronger predictor of a person's health status than age, education level, and race. Although HL is an important determinant of health, it is often underestimated. This systematic review investigates the evidence on HL assessment in hospital settings.

Methods

PubMed Medline, CINAHL, Scopus, Web of Science and Educational Resources Information Centre databases were searched, with the date last searched being 16 March 2020. The PRISMA guidelines were applied, and the protocol of the study was registered with PROSPERO (CRD42021236029). The quality of the included studies was appraised using the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

Results

Five studies reported HL assessments in hospital patients’ clinical records. Four main strategies were used to implement HL routine assessment in hospitals: multidisciplinary teams, stakeholders, training, and monitoring. Different performance measures were used to monitor the feasibility of incorporating HL assessment into electronic health records (EHRs).

Conclusion

This review examined how inpatients’ HL is recorded in hospital settings. HL is poorly measured in a hospital setting. These results guide hospital leadership in involving nurses in HL assessment implementation in hospitals and support nurses in creating a specific performance measure dashboard to monitor effective HL assessments in hospitals.

A Motivational Interviewing Intervention Improves Physical Symptoms in Patients with Heart Failure: A Secondary Outcome Analysis of the Motivate-HF Randomized Controlled Trial

CONTEXT

Heart failure (HF) patients experience high burden of physical symptoms during their disease trajectory.

OBJECTIVE

To evaluate the effects of Motivational Interviewing (MI) on the burden of physical symptoms in HF patients.

METHODS

We performed a secondary analysis of data from the MOTIVATE-HF randomized controlled trial. A sample of 510 patients (median 74 years, 58% male) and their caregivers (median 55 years, 75.5% female) was randomly allocated to Arm 1 (MI only for patients), Arm 2 (MI for patients and caregivers), and Arm 3 (standard of care). The MI intervention consisted of one face-to-face session plus three telephone calls conducted within two months from enrollment. Symptoms' burden was assessed with the Heart Failure Somatic Perception Scale (HFSPS) with the dimensions of Chest Discomfort, Dyspnea, Early and subtle and Edema. Data were collected at baseline and at 3, 6, 9, and 12 months after enrollment.

RESULTS

At 12 months, Chest Discomfort improved in Arms 1 and 2 vs Arm 3 (Δ: -8.13, 95% CI: -14.61; -1.65). Dyspnea improved in Arms 1 and 2 vs Arm 3 both at 9 and 12 months (Δ: -7, 95% CI: -13.18; -0.82 and -6.78, 95% CI: -13.19; -0.38); HFSPS total score improved in Arm 1 and Arm 2 vs Arm 3 at 9 months (Δ: -4.55, 95% CI: -9.05; -0.05). Over 1 year, Chest Discomfort and HFSPS total score in Arm 2 improved compared to Arm 3 (β= -2.61, 95% CI: -4.21; -1.00, P = 0.0015 and β=-1.35, 95% CI: -2.50; -0.21, P = 0.02).

CONCLUSION

MI reduces the burden of physical HF symptoms, particularly when caregivers are involved in the intervention.

Influence of mutuality on quality of life in heart failure patient with inadequate self-care and caregiver dyads: an actor-partner interdependence model analysis

AIMS

Mutuality, a positive quality of the relationship between patients and their informal caregivers characterized by love and affection, shared pleasurable activities, shared values, and reciprocity, influences several patient-caregiver outcomes in chronic-condition cases, but it remains unknown whether it influences the heart failure (HF) patient-caregiver dyad quality of life (QOL). The aim of this study was to evaluate the influence of mutuality and its four dimensions (love and affection, shared pleasurable activities, shared values, and reciprocity) on QOL in HF patient-caregiver dyads.

METHODS AND RESULTS

Cross-sectional study: Using the actor-partner interdependence model, we examined how an individual's mutuality influenced his/her own QOL (actor effect) and his/her partner's QOL (partner effect). Mutuality and physical and mental QOL were measured with the Mutuality Scale and Short Form 12, respectively. A total of 494 HF patient-caregiver dyads were enrolled in the study. Mutuality showed strong evidence of caregiver partner effects on the HF patients' physical QOL (total score B = 2.503, P = 0.001; shared pleasurable activities B = 2.265, P < 0.001; shared values B = 1.174, P = 0.420 and reciprocity B = 1.888, P = 0.001). For the mental QOL, mutuality and its four subscales had actor effects only on the patients' mental health (total mutuality B = 2.646, P = 0.003; love and affection B = 1.599, P = 0.360; shared pleasurable activities B = 2.599, P = 0.001; shared values B = 1.564, P = 0.001 and reciprocity B = 1.739, P = 0.020). In caregivers, mutuality had an actor effects on mental QOL (total score B = 1.548, P = 0.041 and reciprocity B = 1.526, P = 0.009).

CONCLUSION

Our results confirm the important role of mutuality in determining the physical and mental QOL in HF patient-caregiver dyads. Interventions aimed at improving the relationships within HF patient-caregiver dyads may have an impact on HF patients' and caregivers' QOL.

A motivational interviewing intervention improves the burden of physical symptoms in patients with heart failure: A secondary outcome analysis of a randomized clinical trial

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Center of Excellence for Nursing Scholarship, Rome, Italy

Background. Patients with heart failure (HF) experience a variety of physical symptoms. Symptoms are perceived by patients as burdensome and, as such, negatively affect  quality of life. Besides, physical symptoms are among the first reasons for seeking emergency care and hospitalization. Findings from the MOTIVATE-HF trial show that motivational interviewing (MI) leads to better self-care. However, whether MI also reduces the burden of physical symptoms is not yet known.

Purpose. To evaluate the effectiveness of MI on the burden of physical symptoms in patients with HF.

Methods. Secondary outcome analysis of the MOTIVATE-HF trial. The study was a three-arm, multicenter randomized controlled trial with a 12-month follow-up. Patients with HF and their informal caregivers were enrolled and randomly divided into three arms: MI performed only with patients (Arm 1); MI performed both with patients and caregivers (Arm 2); usual care (Arm 3). Patients with a diagnosis of HF in NYHA functional class II-IV were recruited in three Italian centers. Participants underwent one face-to-face MI session, followed by three phone calls within two months from enrollment. Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) with the dimensions of dyspnea, chest discomfort, early and subtle, and edema. Higher scores at the HFSPS and its dimensions indicate worse physical symptom. Data were collected at baseline, and 3 (T1), 6 (T2), 9 (T3) and 12 (T4) months after enrollment. T-test was used to compare differences in HFSPS scores in Arms 1 and 2 versus Arm 3 at each follow-up. Changes over time were analyzed with mixed linear longitudinal models.

Results. A sample of 510 patients (median 74 years, 58% male) and their caregivers (median 55 years, 75.5% female) were randomized to Arm 1 (n = 155), Arm 2 (n = 177) and Arm 3 (n = 178). Chest discomfort improved in Arms 1 and 2 versus Arm 3 at T4 (mean difference(Δ): -8.13, P = .014). Dyspnea also improved in Arms 1 and 2 than Arm 3 both at T3 and T4 (Δ: -7, P = .027 and Δ: -6.78, P = .038, respectively). HFSPS total score improved in Arms 1 and 2 versus Arm 3 at T3 (Δ: -4.55, P = .048). Over the year of observation, the mixed linear longitudinal models showed a significant improvement in Chest discomfort and total HFSPS score in Arm 2 versus Arm 3 (β = -2.61, P = .002 and, β = -1.35, P = .02).

Conclusions. The results of this secondary analysis indicate that MI may be effective in decreasing the burden of physical symptoms in HF patients, especially if also caregivers are involved in the intervention. Since symptom burden is among the first reasons for seeking emergency care and hospitalization in HF, MI might be a viable option to improve symptom burden via self-care.

Translation and cross-cultural adaptation of the Clinical Care Classification system

INTRODUCTION

The Clinical Care Classification (CCC) system is one of the standard nursing terminologies recognized by the American Nurses Association, developed to describe nursing care through electronic documentation in different healthcare settings. The translation of the CCC system into languages other than English is useful to promote its widespread use in different countries and to provide the standard nursing data necessary for interoperable health information exchange. The aim of this study was to translate the CCC system from English to Italian and to test its clinical validity.

METHODS

A translation with cross-cultural adaptation was performed in four phases: forward-translation, back-translation, review, and dissemination. Subsequently a pilot cross-mapping study between nursing activities in free-text nursing documentation and the CCC interventions was conducted.

RESULTS

All elements of the CCC system were translated into Italian. Semantic and conceptual equivalences were achieved. Altogether 77.8% of the nursing activities were mapped into CCC interventions.

CONCLUSIONS

The CCC system, and its integration into electronic health records, has the potential to support Italian nurses in describing and providing outcomes and costs of their care in different healthcare settings. Future studies are needed to strengthen the impact of the CCC system on clinical practice.

Effectiveness of motivational interviewing on health-service use and mortality: a secondary outcome analysis of the MOTIVATE-HF trial

Aims

Intense health‐care service use and high mortality are common in heart failure (HF) patients. This secondary analysis of the MOTIVATE‐HF trial investigates the effectiveness of motivational interviewing (MI) in reducing health‐care service use (e.g. emergency service use and hospitalizations) and all‐cause mortality.

Methods and results

This study used a randomized controlled trial. Patients and caregivers were randomized to Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers), or Arm 3 (control group). Data were collected at baseline and at 3, 6, 9, and 12 months. Face‐to‐face MI plus three telephone calls were performed in Arms 1 and 2. The sample consisted of 510 patient (median age 74 years, 58% male patients) and caregiver dyads (median age 55 years, 75% female patients). At 12 months, 16.1%, 17%, and 11.2% of patients used health‐care services at least once in Arms 1, 2, and 3, respectively, without significant difference. At 3 months, 1.9%, 0.6%, and 5.1% of patients died in Arms 1, 2, and 3, respectively. Mortality was lower in Arm 2 vs. Arm 3 at 3 months [hazard ratio (HR) = 0.112, 95% CI: 0.014–0.882, P = 0.04]; no difference was found at subsequent follow‐ups. Mortality was lower in Arm 1 vs. Arm 3 at 3 months but did not reach statistical significance (HR = 0.38, 95% CI: 0.104–1.414, P = 0.15).

Conclusion

This study suggests that MI reduces mortality in patients with HF if caregivers are included in the intervention. Further studies with a stronger intervention and longer follow‐up are needed to clarify the benefits of MI on health‐care service use and mortality.

The influence of dyadic congruence and satisfaction with dyadic type on patient self-care in heart failure

BACKGROUND

Chronic illness management is increasingly carried out at home by individuals and their informal caregivers (dyads). Although synergistic in concept, the nuances of dyadic congruence in caring for patients with heart failure are largely unexamined.

AIMS

The purpose of this study was to examine the role of dyadic-type congruence on patient self-care (maintenance, symptom perception, and management) while controlling for actor and partner effects.

METHODS

This secondary data analysis of 277 dyads consisted of a series of multilevel models to examine the impact of dyadic congruence on a patient's self-care maintenance, symptom perception, and self-care management. Patient-level and caregiver-level data were input into each model simultaneously to account differential appraisals of factors related to the dyad.

RESULTS

Bivariate analyses yielded dyad congruence which was associated with better patient self-care maintenance, symptom perception and management. However, after multilevel models were constructed, dyad congruence was found to be a significant predictor of patient's symptom perception scores, but not self-care maintenance or management scores. Caregiver's satisfaction with the dyad was differentially and significantly associated with self-care - it was inversely associated with patient self-care maintenance and positively associated with patient self-care management.

CONCLUSION

This is the first study, to our knowledge, reporting that congruence in heart failure dyads is associated with better patient symptom perception and this advances our prior hypothesis that dyad typologies could be used to predict patient self-care performance. Since symptom perception is the key to preventing heart failure exacerbation, screening heart failure patient and caregiver dyads for congruence is important in clinical settings.

The Self-Care of Heart Failure Index version 7.2: Further psychometric testing

Clinicians and researchers need valid and reliable instruments to evaluate heart failure (HF) self-care. The Self-Care of Heart Failure Index (SCHFI) is a theoretically driven instrument developed for this purpose. The SCHFI measures self-care with three scales: self-care maintenance, measuring behaviors to maintain HF stability; symptom perception, measuring monitoring behaviors; and self-care management, assessing the response to symptoms. After the theory underpinning the SCHFI was updated, the instrument was updated to version 7.2 but it was only tested in the United States. In this study we tested the psychometric characteristics (structural and construct validity, internal consistency, and test-retest reliability) of the SCHFI v.7.2 in an Italian population of HF patients. We used a cross-sectional design to study 280 HF patients with additional data collected after 2 weeks for test-retest reliability. Adults with HF (mean age 75.6 (±10.8); 70.8% in New York Heart Association [NYHA] classes II and III) were enrolled from six centers across Italy. Confirmatory factor analysis showed supportive structural validity in the three SCHFI v.7.2 scales (CFI from 0.94 to 0.95; RMSEA from 0.05 to 0.07). Internal consistency reliability estimated with Cronbach's α and composite reliability ranged between .73 and .88; test-retest reliability ranged between 0.73 and 0.92. Construct validity was supported with significant correlations between the SCHFI v.7.2 scale scores and quality of life, brain natriuretic peptide levels and NYHA class. This study further supports the psychometric characteristics of the SCHFI v.7.2, illustrating that it can be used in clinical practice and research also in an Italian population.

Predictive factors of a prolonged length of stay in a community Nursing-Led unit: A retrospective cohort study

AIMS AND OBJECTIVES

To describe the care provided to patients admitted into a community Nursing-Led inpatient unit and to identify factors predicting a length of stay exceeding an established threshold.

BACKGROUND

Few studies have been conducted to describe the care provided in a Nursing-Led unit. No studies have investigated factors affecting length of stay in these services.

DESIGN

Retrospective cohort study.

METHODS

Consecutive patients admitted to a community Nursing-Led unit between 2009-2015 were enrolled. Sociodemographic, medical and nursing care (diagnoses and activities) variables were collected from electronic health records. Descriptive analysis and a backward stepwise logistic regression model were applied. The study followed the STROBE guidelines.

RESULTS

The study enrolled 904 patients (mean age: 77.7 years). The most frequent nursing diagnoses were bathing self-care deficit and impaired physical mobility. The nursing activities most provided were enteral medication administration and vital signs measurement. Approximately 37% of the patients had a length of stay longer than the established threshold. Nine covariates, including being discharged to home, having an impaired memory nursing diagnosis or being treated for advanced wound care, were found to be independent predictors of prolonged length of stay. Variables related to medical conditions did not affect the length-of-stay threshold.

CONCLUSIONS

The length of stay in the community Nursing-Led unit was mainly predicted by conditions related to sociodemographic factors, nursing complexity and functional status. This result confirms that the medical and nursing needs of a community Nursing-Led unit population substantively differ from those of hospitalised acute patients.

RELEVANCE TO CLINICAL PRACTICE

The nursing complexity and related nursing care to be provided may be adopted as a criterion to establish the appropriate length of stay in the community Nursing-Led unit for each individual patient.

Motivational interviewing to improve self-care in heart failure patients (MOTIVATE-HF): a randomized controlled trial

AIMS

Self-care, an essential component of heart failure (HF) treatment, is inadequate in most patients. We evaluated if motivational interviewing (MI) (i) improves patient self-care maintenance (primary endpoint; e.g. taking medications), self-care management (e.g. responding to symptoms) and self-care confidence (or self-efficacy) 3 months after enrolment; (ii) changes self-care over 1 year, and (iii) augments patient self-care if informal caregivers are involved.

METHODS AND RESULTS

Parallel randomized controlled trial (1:1:1). A sample of 510 patients (median 74 years, 58% male) and caregivers (median 55 years, 75% female) was randomized to Arm 1 (MI only for patients), Arm 2 (MI for patients and caregivers), or Arm 3 (usual care). The intervention in Arms 1 and 2 consisted of one face-to-face MI session with three telephone contacts. Self-care was evaluated with the Self-Care of HF Index measuring self-care maintenance, management, and confidence. Scores on each scale range from 0 to 100 with higher scores indicating better self-care; ≥70 is considered adequate. At 3 months, self-care maintenance improved 6.99, 7.42 and 2.58 points in Arms 1, 2, and 3, respectively (P = 0.028). Self-care maintenance was adequate in 18.4%, 19.4%, and 9.2% of patients in Arms 1, 2 and 3, respectively (P = 0.016). Over 1 year, self-care maintenance, management, and confidence scores in Arms 1 and 2 were significantly higher than in Arm 3 in several follow-ups. Over 1 year, Arm 2 had the best scores in self-care management.

CONCLUSIONS

MI significantly improved self-care in HF patients. Including caregivers may potentiate the effect, especially in self-care management. ClinicalTrial.gov, identifier: NCT02894502.

[The nursing-led in-patient unit: a descriptive study of nursing care delivered]

Chronic diseases require continuous healthcare that is not fully guaranteed by the Italian Health System which is more oriented towards acute care. In the Lazio region (city of Palombara Sabina), a Nursing-Led in-patient unit is present with the aim to care for patients affected by chronic diseases. The aim of this study was to describe the type of healthcare delivered by this unit. A descriptive-comparative design was used. All 290 patients admitted to the Nursing-Led Unit, during 2014 and 2015 participated in the study. The following variables were analyzed: socio-demographic characteristics of patients, reasons for admission, nursing diagnoses and interventions, medical diagnoses and interventions, Barthel index, length of stay, mortality rate, and discharge rate to acute care hospitals. The mean age of participants was 78 years old (SD 11,4) and the most frequent reason for admission was the need to receive a medium-high intensity nursing care (14,5%). The most frequent nursing diagnoses were bathing/hygiene self-care deficit (78,3%) and impaired physical mobility (74,8%). Hypertensive heart disease was the most frequent medical diagnosis (32,4%). The mean length of stay was 19 days, the mortality rate was 2,1% and the discharge rate to an acute care hospital was 9%. Significant improvements in patient dependency levels, as measured by the Barthel index, were observed at discharge with respect to admission (p &lt; 0,001). The NursingLed Unit seems to be strategic in the delivery of care to older adults affected by multiple chronic diseases, in some phases of their condition. The results of this study indicate that the Palombara Sabina's nursing-led unit may contribute in reducing hospital admissions and achieving favorable patient outcomes when additional nursing interventions are needed.

[Clinical audit as a quality improvement tool in the emergency setting. A systematic review of the literature]

According to the National Institute for Health and Care Excellence, "Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change…Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery". According to the scientific literature, clinical audit is more commonly used in secondary care with respect to primary care, probably because of the high variability that characterizes the latter. The aim of this study was to investigate, through a systematic literature review, the use and effectiveness of clinical audit in a particular field such as that of healthcare emergency.