Making decisions about amputation for chronic limb threatening ischaemia

INTRODUCTION

Chronic limb threatening ischaemia causes pain, loss of function and complex wounds, necessitating urgent interventions. While growing options for minimally invasive revascularisation make operating on frail and older persons safer, the challenge is knowing when to stop this option and offer amputation. Decisions about amputation are difficult for the person, or for the family who act as substitute decision-makers. Timely treatment decisions are important to optimise clinical outcomes but do not always align with outcomes that are acceptable to patients.

AIM

To provide a philosophically-based understanding of patient/family experiences of making decisions for chronic limb threatening ischaemia.

METHODS

Longitudinal qualitative study using Heideggerian phenomenology. Patient and family participants were recruited from three sites. Semi-structured interviews occurred at two time points: soon after advice to consider major amputation, and for those who experienced amputation, six-months post-operatively. The COnsolidated criteria for REporting Qualitative studies (COREQ) checklist guided this report.

FINDINGS

Variable timelines, disease progression, and interventions were encountered prior to confronting the possibility of amputation. Decision-making was interpreted as an initial irresoluteness (neglecting or renouncing decisions). For most, this was eventually followed by a resoluteness where participants either turned away or towards amputation, according to one's preferred mode of suffering, and thus owning the decision to turn. Those who opted for amputation often experienced better-than-anticipated outcomes.

CONCLUSION

Patients and families had difficulty making decisions about amputation. Clinicians may have been complicit in the neglecting and renouncing of decisions and have an important role in sharing decision-making through their authentic discourse.

IMPLICATIONS

Chronic limb threatening ischaemia requires complex discussions to support decisions and shared decision-making requires clinician presence and engagement in discourse. Patients and family members benefit from more time to experience and process the phenomenon as they move towards owning their decision about amputation.

Chronic limb-threatening ischaemia and confronting amputation: A Heideggerian derived understanding of Being-with and discourse

AIMS AND OBJECTIVES

To explore the notion of Being-with and authentic discourse for people making decisions about major amputation.

BACKGROUND

Chronic limb-threatening ischaemia is a devastating disease with a high burden of pain and complex wounds. Patients may deteriorate suddenly after multiple revascularisation procedures and, amputation is offered when further reperfusion is considered futile. Delayed decisions about amputation have negative consequences for patients, families and health systems, yet little attention is given to training clinicians for the sophisticated communication required. Clinicians need to engage in authentic discourse about amputation to create shared meaning and facilitate decision-making.

DESIGN

Qualitative study using hermeneutic Heideggerian phenomenology.

METHODS

Twelve patients offered major amputation, and 13 family participants from three vascular units in Australia engaged in 42 semi-structured interviews, representing 19 cases of chronic limb-threatening ischaemia. Hermeneutic phenomenology using the Heideggerian tenet of Being-with as an analytic framework, a philosophically based understanding of Being-with and Discourse related to treatment discussions and decisions was derived. The research was reported in accordance with the COREQ checklist.

FINDINGS

Effective discourse between the person and family was hampered by changed circumstances of Being-with, characterised by guilt, and a retreat from discourse through deficient discourse and filtering information. Clinician Being-with was hampered by discourse that was deficient, poorly delivered, discordant and disconnected through a lack of empathetic listening. There were also examples of enhanced clinician Being-with that made room for more constructive discourse and more timely decisions about amputation.

CONCLUSIONS

Heidegger's construct of Being-with provides a useful framework to reveal the role of authentic discourse in improving patient and family experience and decisions about treatment.

NO PATIENT OR PUBLIC CONTRIBUTION

This study did not engage consumers other than as patient and carer participants.

RELEVANCE TO CLINICAL PRACTICE

Decisions about amputation are often difficult for patients or family members who may be substitute decision-makers. A better understanding of the experience may assist clinicians in their interactions with patients and families.

Exercise Self-efficacy Improvements During Cardiac Rehabilitation: IMPACT OF SOCIAL DISPARITIES

PURPOSE

The objective of this study was to determine exercise self-efficacy improvements during cardiac rehabilitation (CR) and identify predictors of exercise self-efficacy change in CR participants.

METHODS

Patients with coronary heart disease at four metropolitan CR sites completed the Exercise Self-efficacy Scale at entry and completion. A general linear model identified independent predictors of change in exercise self-efficacy.

RESULTS

The mean age of patients (n = 194) was 65.9 ± 10.5 yr, and 81% were males. The majority (80%) were married or partnered, 76% were White, and 24% were from an ethnic minority background. Patients received CR in-person (n = 91, 47%) or remote-delivered (n = 103, 54%). Exercise self-efficacy mean scores improved significantly from 25.2 ± 5.8 at CR entry to 26.2 ± 6.3 points at completion ( P = .025). The majority of patients (59%) improved their self-efficacy scores, 34% worsened, and 7% had no change. Predictors of reduced exercise self-efficacy change were being from an ethnic minority (B =-2.96), not having a spouse/partner (B =-2.42), attending in-person CR (B =1.75), and having higher exercise self-efficacy at entry (B =-0.37) (adjusted R2 = 0.247).

CONCLUSIONS

Confidence for self-directed exercise improves in most, but not all, patients during CR. Those at risk for poor improvement (ethnic minorities, single patients) may need extra or tailored support, and screening for exercise self-efficacy at CR entry and completion is recommended. Differences identified from CR delivery mode need exploration using robust methods to account for complex factors.

What nursing chooses not to know: Practices of epistemic silence/silencing

Drawing from a keynote panel held at the hybrid 25th International Philosophy of Nursing Conference, this discussion paper examines the question of epistemic silence in nursing from five different perspectives. Contributors include US-based scholar Claire Valderama-Wallace, who meditated on ecosystems of settler colonial logics of nursing; American scholar Lucinda Canty discussed the epistemic silencing of nurses of colour; Canadian scholar Amelie Perron interrogated the use of disobedience and parrhesia in and for nursing; Canada-based scholar Ismalia De Sousa considered what nursing protects in its silences; and Australian scholar Janice Gullick spoke to trans invisibility in nursing.

Wearable Activity Trackers Objectively Measure Incidental Physical Activity in Older Adults Undergoing Aortic Valve Replacement

BACKGROUND

For older adults with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR), recovery of physical function is important, yet few studies objectively measure it in real-world environments. This exploratory study explored the acceptability and feasibility of using wearable trackers to measure incidental physical activity (PA) in AS patients before and after AVR.

METHODS

Fifteen adults with severe AS wore an activity tracker at baseline, and ten at one month follow-up. Functional capacity (six-minute walk test, 6MWT) and HRQoL (SF 12) were also assessed.

RESULTS

At baseline, AS participants (n = 15, 53.3% female, mean age 82.3 ± 7.0 years) wore the tracker for four consecutive days more than 85% of the total prescribed time, this improved at follow-up. Before AVR, participants demonstrated a wide range of incidental PA (step count median 3437 per day), and functional capacity (6MWT median 272 m). Post-AVR, participants with the lowest incidental PA, functional capacity, and HRQoL at baseline had the greatest improvements within each measure; however, improvements in one measure did not translate to improvements in another.

CONCLUSION

The majority of older AS participants wore the activity trackers for the required time period before and after AVR, and the data attained were useful for understanding AS patients' physical function.

A peek behind the curtain: An integrative review of sexual harassment of nursing students on clinical placement

AIMS AND OBJECTIVES

This integrative review aimed at systematically searching, analysing and synthesising multiple sources of evidence, to build a temporal understanding of nursing students' experiences of sexual harassment whilst on clinical placement, and to discuss the social context which enables this.

BACKGROUND

Sexual harassment is highly prevalent in workplaces globally. Contemporary social understandings contextualise sexual harassment as a significant form of interpersonal violence. This is the first literature review to go beyond prevalence to synthesise the experience, implications and responses to sexual harassment encountered by student nurses on clinical placement.

DESIGN

Whittemore and Knafl's (2005) integrative review methodology is used to structure a rigorous analysis and synthesis of evidence.

METHODS

The PRISMA checklist supported sound reporting of the search strategy. Three databases (CINAHL, Scopus and Medline) were searched using a Boolean strategy. Papers with a significant focus on sexual harassment of nursing students in the clinical setting were included with no limitation on publication date. Papers were excluded if they were not published in English or were only published as abstracts.

RESULTS

A synthesis of 26 papers demonstrated that sexual harassment has significant impacts on student nurses and the nursing profession. The intimacy of close body care, dominant social perceptions of nursing as women's work and the sexualisation of nurses increase student vulnerability to sexual harassment. Workplace power imbalances further exacerbate sexual harassment and shape responses to incidents.

CONCLUSIONS

Sexual harassment of nursing students is widespread and impacts student well-being and learning.

RELEVANCE TO CLINICAL PRACTICE

Education is a strong protective factor and should target students, clinicians, clinical facilitators and academics. Attention to workplace culture, and processes that support disclosure and reporting, is also required to meaningfully address the sexual harassment of nursing students.

Philosophical underpinnings of intersubjectivity and its significance to phenomenological research: A discussion paper

Intersubjectivity is the proposition that human experience occurs in a world of shared and embodied understandings, mediated by culture and language. Nursing is fundamentally relational, and nursing research stems from an exchange between participants and researchers and indeed around the transaction of the patient and the nurse in the intersubjective space of clinical settings. Through the philosophical standpoints of Husserl, Merleau-Ponty, Heidegger, and Gadamer we examine these differing philosophical constructs of intersubjectivity and the contribution of these positions to phenomenological nursing inquiry. Particular framings of intersubjectivity should influence the way researchers interact with their participants and data so that the chosen philosophy sits coherently within a research plan and methodology. This exploration of philosophical standpoints is extended through examples of, and reflections upon, the authors' experiences of intersubjectivity in our published phenomenological nursing studies and through dynamic interactions that characterise interpretive activities within a research team.

Pushing to keep going, scared: a qualitative study exploring why transcatheter aortic valve implantation to treat aortic stenosis is a highly acceptable intervention to patients and carers

Funding Acknowledgements

Type of funding sources: None.

Background

Contemporary options to treat severe, symptomatic aortic stenosis (AS) include transcatheter and surgical approaches (TAVI and SAVR). Evidence continues to accumulate for minimally invasive TAVI to be used to treat AS for expanding patient groups, however patients experiences are seldom investigated.

Purpose

The aim of this study was to explore patients and carers perspectives of the acceptability of TAVI as a treatment option for AS, in the context of their values, attitudes, and the burden and effectiveness of intervention, to better guide expectations and management of recovery.

Methods

Older patients (n=18) and their carers (n= 8) were interviewed 4-6 months post TAVI. Data was themed deductively by applying the theoretical framework of acceptability (1) as an analytic lens, followed by inductive analysis to identify any further emergent themes.

Results

The mean age of patient participants was 85 ± 5 years and 33% were women. Patients experiences of severe AS symptoms (e.g., breathlessness and fatigue) resulted in growing emotions of ‘struggling and pushing to keep to going’ in their daily lives, a few thought they were ‘nearly gone’ and expressed feelings of being scared. Debilitating AS symptoms, and a challenge to the values of this older patient group were the major influencing factors informing high prospective acceptability of the TAVI. Patients and their carers perceived the TAVI procedure to be a ‘good operation’ because of a short hospital stay and minimal disruption to their lives. Low burden resulted in high levels of concurrent acceptability of TAVI. Most patients experienced gradual symptom relief and being able to ‘get back to normal’, be independent and reconnect with valued pastimes, leading to high retrospective acceptability of the intervention for both patients and carers.

Conclusion

Patients and carers perceive TAVI to have high prospective, concurrent, and retrospective acceptability as improved symptoms restored mental wellbeing, the procedure was uncomplicated and operative burden was low, and most patients regained functional capacity and a return to their normal lives. The need to assess acceptability of interventions, such as TAVI, from the perspectives of patients and carers is increasingly becoming important in health care, not only better support patients and carers but to inform effective implementation and sustainability of treatment modalities.

Objective risk assessment vs standard care for acute coronary syndromes-The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation

Background

Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the GRACE Risk Tool for stratification of ischaemic and bleeding risk in ACS. While hospitals in the active arm had a higher overall rate of invasive ACS management, there was neutral impact on important secondary prevention prescriptions/referrals, hospital performance measures, myocardial infarction and 12-month mortality leading to early trial cessation. Given the Grace Risk Tool is under investigation internationally, this process evaluation study provides important insights into the possible contribution of implementation fidelity on the AGRIS study findings.

Methods

Using maximum variation sampling, five hospitals were selected from the 12 centres enrolled in the active arm of AGRIS. From these facilities, 16 local implementation stakeholders (Cardiology advanced practice nurses, junior and senior doctors, study coordinators) consented to a semi-structured interview guided by the Theoretical Domains Framework. Directed Content Analysis of qualitative data was structured using the Capability/Opportunity/Motivation-Behaviour (COM-B) model.

Results

Physical capability was enhanced by tool usability. While local stakeholders supported educating frontline clinicians, non-cardiology clinicians struggled with specialist terminology. Physical opportunity was enhanced by the paper-based format but was hampered when busy clinicians viewed risk-stratification as one more thing to do, or when form visibility was neglected. Social opportunity was supported by a culture of research/evidence yet challenged by clinical workflow and rotating medical officers. Automatic motivation was strengthened by positive reinforcement. Reflective motivation revealed the GRACE Risk Tool as supporting but potentially overriding clinical judgment. Divergent professional roles and identity were a major barrier to integration of risk-stratification into routine Emergency Department practice. The cumulative result revealed poor form completion behaviors and a failure to embed risk-stratification into routine patient assessment, communication, documentation, and clinical practice behaviors.

Conclusions

Numerous factors negatively influenced AGRIS implementation fidelity. Given the prominence of risk assessment recommendations in United States, European and Australian guidelines, strategies that strengthen collaboration with Emergency Departments and integrate automated processes for risk-stratification may improve future translation internationally.

OUP accepted manuscript

Aims

Enforced suspension and reduction of in-person cardiac rehabilitation (CR) services during the coronavirus disease-19 (COVID-19) pandemic restrictions required rapid implementation of remote delivery methods, thus enabling a cohort comparison of in-person vs. remote-delivered CR participants. This study aimed to examine the health-related quality of life (HRQL) outcomes and patient experiences comparing these delivery modes.

Methods and results

Participants across four metropolitan CR sites receiving in-person (December 2019 to March 2020) or remote-delivered (April to October 2020) programmes were assessed for HRQL (Short Form-12) at CR entry and completion. A General Linear Model was used to adjust for baseline group differences and qualitative interviews to explore patient experiences. Participants (n = 194) had a mean age of 65.94 (SD 10.45) years, 80.9% males. Diagnoses included elective percutaneous coronary intervention (40.2%), myocardial infarction (33.5%), and coronary artery bypass grafting (26.3%). Remote-delivered CR wait times were shorter than in-person [median 14 (interquartile range, IQR 10–21) vs. 25 (IQR 16–38) days, P < 0.001], but participation by ethnic minorities was lower (13.6% vs. 35.2%, P < 0.001). Remote-delivered CR participants had equivalent benefits to in-person in all HRQL domains but more improvements than in-person in Mental Health, both domain [mean difference (MD) 3.56, 95% confidence interval (CI) 1.28, 5.82] and composite (MD 2.37, 95% CI 0.15, 4.58). From qualitative interviews (n = 16), patients valued in-person CR for direct exercise supervision and group interactions, and remote-delivered for convenience and flexibility (negotiable contact times).

Conclusion

Remote-delivered CR implemented during COVID-19 had equivalent, sometimes better, HRQL outcomes than in-person, and shorter wait times. Participation by minority groups in remote-delivered modes are lower. Further research is needed to evaluate other patient outcomes.

Pulled away: the experience of bilingual nurses as ad hoc interpreters in the emergency department

This study aimed to understand the experiences of bilingual nurses asked to interpret in the Emergency Department (ED), and the subsequent impact on safety climate. Australian ED clinicians assess and treat high numbers of linguistically diverse patients, many with limited English proficiency. New South Wales Health policy mandates the use of accredited interpreters when collecting personal and health information, and when obtaining consent for medical procedures. Semi-structured interviews with 12 nurses (representing 12 languages) from two metropolitan EDs were audio-recorded and analysed using qualitative content analysis, guided by Glendon & Stanton's model of organisational climate and culture. Analysis revealed widespread underlying assumptions that engaging interpreters is difficult, time-consuming and costly. Bilingual ED nurses with variable language fluency were used across organisations as the first choice due to clinical urgency, task urgency, and hospital workflow pressures. While the use of nurse interpreters facilitated timely assessment for the benefit of patients, it equally led to increased nurse workload, missed or misinterpreted information and subsequent perceived clinical risk. These practices were supported and facilitated by unit level managerial and multidisciplinary team practices, physician pressure and the nurses' own values and beliefs. While some, (but not all) participants were aware of the interpreter policy, they were torn between their acknowledgement of risky translation practices and their desire to support their colleagues to provide timely, culturally-competent assessment and care. Findings suggests a 'top-down' approach to translation policy has failed to influence the local safety culture and practices and does not address a climate created by clinical urgency and workflow. Formal training and accreditation of bilingual nurses, and/or embedded interpreters for common language groups may reduce risks for non-English speaking patients.

Long-Term Outcomes Following Rapid Access Chest Pain Clinic Assessment: First Australian Data

Australian guidelines recommend prompt evaluation of patients presenting to emergency departments with chest pain, found to be low risk for acute coronary syndromes, and cardiologist-led Rapid Access Chest Pain Clinics (RACPC) have been proposed as a model to provide such care. Initial Australian experience of RACPCs suggests excellent short-term outcomes, and that they are cost-beneficial, though little data exists examining longer-term outcomes. The present study therefore examines such longer-term outcomes to beyond 5 years following presentation to an RACPC in an Australian tertiary metropolitan centre.

Factors that influence whether patients with acute coronary syndromes undergo cardiac catheterisation

OBJECTIVE

To determine whether the availability of invasive coronary angiography at the hospital of presentation influences catheterisation rates for patients with acute coronary syndrome (ACS), and whether presenting to a catheterisation-capable hospital is associated with better outcomes for patients with ACS.

DESIGN, SETTING

Retrospective cohort study; analysis of Cooperative National Registry of Acute Coronary Events (CONCORDANCE) data.

SETTING, PARTICIPANTS

Adults admitted with ACS to 43 Australian hospitals (including 31 catheterisation-capable hospitals), February 2009 - October 2018.

MAIN OUTCOME MEASURES

Major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiogenic shock, cardiovascular death) and all-cause deaths in hospital and by six and 12- or 24-month follow-up.

RESULTS

The proportion of women among the 5637 patients who presented to catheterisation-capable hospitals was smaller than for the 2608 patients who presented to hospitals without catheterisation facilities (28% v 33%); the proportion of patients diagnosed with ST elevation myocardial infarction was larger (32% v 20%). The proportions of patients who underwent catheterisation (81% v 70%) or percutaneous coronary intervention (49% v 35%) were larger for those who presented to catheterisation-capable hospitals. The baseline characteristics of patients who underwent catheterisation were similar for both presentation hospital categories, as were rates of major adverse cardiovascular events and all-cause death in hospital and by 6- and 12- or 24-month follow-up.

CONCLUSIONS

Although a larger proportion of patients who presented to catheterisation-capable hospitals underwent catheterisation, patients with similar characteristics were selected for the procedure, independent of the hospital of presentation. Major outcomes for patients were also similar, suggesting equitable management of patients with ACS across Australia.

Combining structured and unstructured data in EMRs to create clinically-defined EMR-derived cohorts

Background

There have been few studies describing how production EMR systems can be systematically queried to identify clinically-defined populations and limited studies utilising free-text in this process. The aim of this study is to provide a generalisable methodology for constructing clinically-defined EMR-derived patient cohorts using structured and unstructured data in EMRs.

Methods

Patients with possible acute coronary syndrome (ACS) were used as an exemplar. Cardiologists defined clinical criteria for patients presenting with possible ACS. These were mapped to data tables within the production EMR system creating seven inclusion criteria comprised of structured data fields (orders and investigations, procedures, scanned electrocardiogram (ECG) images, and diagnostic codes) and unstructured clinical documentation. Data were extracted from two local health districts (LHD) in Sydney, Australia. Outcome measures included examination of the relative contribution of individual inclusion criteria to the identification of eligible encounters, comparisons between inclusion criterion and evaluation of consistency of data extracts across years and LHDs.

Results

Among 802,742 encounters in a 5 year dataset (1/1/13–30/12/17), the presence of an ECG image (54.8% of encounters) and symptoms and keywords in clinical documentation (41.4–64.0%) were used most often to identify presentations of possible ACS. Orders and investigations (27.3%) and procedures (1.4%), were less often present for identified presentations. Relevant ICD-10/SNOMED CT codes were present for 3.7% of identified encounters. Similar trends were seen when the two LHDs were examined separately, and across years.

Conclusions

Clinically-defined EMR-derived cohorts combining structured and unstructured data during cohort identification is a necessary prerequisite for critical validation work required for development of real-time clinical decision support and learning health systems.

Chronic wound care delivery in wound clinics, community nursing and residential aged care settings: A qualitative analysis using Levine's Conservation Model

AIMS AND OBJECTIVES

To explore patient experience of chronic wound care across diverse models of outpatient wound care delivery.

BACKGROUND

Chronic wounds represent a significant personal, family and healthcare system burden. Evidence suggests specialist wound clinics are more effective and less expensive, however, most outpatient wound care is delivered by general community nurses. There is little understanding of how patients experience diverse models of wound care delivery and the subsequent impact on their capacity to adapt to imbalances in their internal/external environment.

DESIGN

Descriptive, qualitative study.

METHODS

Eighteen patients with chronic wounds from three wound services were engaged in semi-structured interviews. Initial inductive analysis was refined deductively using Levine's Conservation Model.

RESULTS

Chronic wounds lead to imbalances and subsequent adaptions in energy conservation and personal, social and structural integrity. Nursing process and wound care system responses suggest specialist wound clinics provide access to the right person and care at the right time, with less care variation. The community nursing model is most effective with a small team of nurses and a documented care plan, with specialist wound nurse oversight. Residential aged care facilities emerged as important sites for wound care delivery revealing higher variance in care and less specialist wound oversight.

CONCLUSIONS

The application of Levine's conservation model provides a theoretical understanding and important insights into the patient experience of nurse and system elements across diverse models of wound care delivery. Specialist oversight by expert wound nurses with the capacity for medical specialist referral is the cornerstone of good wound care. A frequently reviewed wound care plan and skill development for nurses in primary, aged care and community settings are vital.

RELEVANCE TO CLINICAL PRACTICE

Shared care between specialist and primary care should include evidence-based pain assessment, clear referral pathways, collaborative relationships, telehealth capacity, patient-held wound plans and upskilling of frontline clinicians.

Chronic limb-threatening ischaemia and reframing the meaning of 'end'

INTRODUCTION

The possibility of amputation and/or death from chronic limb-threatening ischaemia (CLTI) is real, and deeper understandings of the person and family's capacity and preparedness for limb loss and clinical interventions (active or palliative) are required.

BACKGROUND

The lead-in period to the surgeon's recommendation for amputation for CLTI may be sudden or protracted; the number/invasiveness of previous revascularisation interventions varies, and limb loss and end-of-life considerations frame the experience.

METHOD

This prospective, longitudinal, interpretative phenomenological study in three vascular surgical units involved 19 CLTI journeys. Participants were interviewed when making decisions about amputation (15 patients, 12 family members) and, where applicable, 6-months postamputation (8 patients, 7 family members). Hermeneutic interpretation using Heidegger's philosophical construct of Being-towards-death guided the analysis. The COREQ checklist ensured rigour in research reporting.

FINDINGS

Some participants were unable to face the possibility of death and metaphorically 'fled', either through productive optimism or through hoping for more time (Heidegger's inauthentic positioning towards death). For others, authentic positionings of Being-towards-death were understood as: the confrontation of the certainty of their death by making choices about how to die; the indefiniteness of death where treatment choices influenced timing, yet the time for death remained unknown; the nonrelational nature of death, as the journey could only be lived by the person; and death as not to be outstripped, where for some, there was a freeing of oneself for amputation and/or death.

DISCUSSION

The term 'end of limb' to denote the futility of the limb is a useful marker that emphasises the noncurative nature of CLTI. This may help to instigate and support discussions about end of life to support palliation care planning and the person and family's existential preparation for death.

CONCLUSION

Death frames the experience of CLTI. Using 'end-of-limb' and 'end-of-life' terminology may facilitate a family/patient-centred approach to possible amputation and other conservative or palliative strategies.

RELEVANCE TO CLINICAL PRACTICE

Understanding of CLTI illness experience. Decisions about revascularisation, amputation or conservative care. End-of-life care for CLTI.

Heideggerian structures of Being-with in the nurse-patient relationship: modelling phenomenological analysis through qualitative meta-synthesis

Heideggerian philosophy is frequently chosen as a philosophical framing, and/or a hermeneutic analytical structure in qualitative nursing research. As Heideggerian philosophy is dense, there is merit in the development of scholarly resources that help to explain discrete Heideggerian concepts and to uncover their relevance to contemporary human experience. This paper uses a meta-synthesis methodology to pool and synthesise findings from 29 phenomenological research reports on Being-with in the nurse-patient relationship. We firstly considered and secured the most relevant Heideggerian elements to nurse-patient Being-with (Dasein-with, circumspection, solicitude, and discourse). Under these deductive codes, we then inductively developed sub-themes that seemed to explain the multifaceted nature of Being-with, through a secondary analysis and synthesis of published data from 417 patient, carer and nurse participants. Dasein-with was enhanced when nurses had first-hand experience with a phenomenon. Nurses moved between the inauthentic they-mode (task-orientated busyness, existential abandonment, rough handling and deficient modes of concern in potentially violent encounters), and the authentic self-mode (seeking connection [knowing], and openness [unknowing], which exposed their emotional vulnerability). Through circumspection (making room for, deseverance and directionality), technology and people were encountered environmentally feeding into nursing attention, assessment and communication. Nursing as a social arrangement (solicitude) was expressed through either leaping-in care (also perceived as 'power over') or leaping-ahead care (moving the patient towards independence). There was a place for both inauthentic (idle talk) and authentic discourse (including non-verbal and spiritual discourse) that nurses wove through the ontic everydayness of nursing tasks.

Exploring the influence of socio-cultural factors and environmental resources on the health related quality of life of children and adolescents after congenital heart disease surgery: parental perspectives from a low middle income country

BACKGROUND

Health related quality of life (HRQOL) is an important indicator of long-term well-being, influenced by environmental factors such as family, culture, societal norms and available resources. This study aimed to explore parental perspectives on the influence of socio-cultural factors and environmental resources on the HRQOL of children and adolescents after congenital heart disease (CHD) surgery.

METHODS

Using a descriptive, qualitative design, semi-structured interviews of children/adolescents who had CHD surgery in this low-middle income country (LMIC) were collected between July to December 2017. There were 20 families enrolled, which included 18 parent dyads (mother and father) and two single mothers, making a total of 38 participants. Initial inductive analysis was further refined using the Social Ecological Model as an analytic lens.

RESULTS

At the intrapersonal level, unrealistic expectations of surgery, residual CHD symptoms and difficulty maintaining educational progress were of great concern. There were low levels of health literacy and understanding about CHD among family and friends, however, strong kinship ties were an important resource at the interpersonal level. These families lived in poverty and mothers often carried the sole burden of care for their sick children. At the institutional level, there were unclear expectations of the child's needs at school, and parents had poor access to psychological, family-planning and genetic counselling, and poor access to CHD education resources. At a sociocultural level, religion and trust in God were important coping factors, however, CHD was a gendered experience with particular concerns around scarring and the marriageability of girls. Parents noted the deficit of antenatal and specialist CHD services and felt the consequence of a lack of a universal health care system at the public policy level.

CONCLUSION

Socio-ecological factors have the potential to explain the issues and challenges that children living in LMIC experience with CHD after surgery. The study findings will help to inform future interventions to be implemented in countries like Pakistan.

Heideggerian hermeneutic phenomenology as method: modelling analysis through a meta-synthesis of articles on Being-towards-death

While the richness of Heideggerian philosophy is attractive as a healthcare research framework, its density means authors rarely utilise its fullest possibilities as an hermeneutic analytic structure. This article aims to clarify Heideggerian hermeneutic analysis by taking one discrete element of Heideggerian philosophy (Being-towards-death), and using it's clearly defined structure to conduct a meta-synthesis of Heideggerian phenomenological studies on the experience of living with a potentially life-limiting illness. The findings richly illustrate Heidegger's philosophy that there is either an inauthentic positioning towards death, or an authentic positioning towards death with a proposition that (1) death is certain; (2) death is indefinite; (3) death is non-relational; and (4) death is not-to-be-outstripped. None of the 29 included studies on the experience of a confrontation with death fully utilised this framework, despite claiming a grounding in Heideggerian thought. This demonstrates the value in modelling how Heideggerian existential structures can be used proactively as analytical 'hooks' for data in research claiming a basis in this philosophy and/or method. By modelling the potential application of an important Heideggerian philosophical construct to published qualitative data, this meta-synthesis has revealed new domains and more nuanced understandings of the temporal structure of Being-towards-death. Such an approach helps to more fully unveil the existential concerns of people at the core of interpretative phenomenological enquiry and may provide a blueprint to map either primary or synthesised data to other key ontological existentials.

Acceptability of external jugular venepuncture for patients with liver disease and difficult venous access

BACKGROUND

Difficult venous access (DVA) is common in liver patients requiring blood collection using traditional peripheral approaches. This study aimed to understand the experience of DVA for liver patients and the acceptability of peripheral venepuncture versus external jugular venepuncture (EJV). A secondary aim was to explore the impact of EJV on local resource utilization.

METHODS

Semistructured interviews with liver outpatients with DVA (n = 10) requiring venepuncture were firstly themed inductively. We then deductively applied the acceptability framework of Sekhon et al. as a further analytic lens. Audit data from DVA encounters (n = 24) allowed analysis of issues from multiple perspectives. The Consolidated Criteria for Reporting Qualitative Research reporting checklist guides this report.

RESULTS

Peripheral venepuncture had poor prospective, concurrent, and retrospective acceptability, requiring significant mental and physical preparation. Fear, stigma, pain and distress, poor continuity of care, and poor effectiveness led to service disengagement. While EJV caused initial trepidation, it had high concurrent and retrospective acceptability. The significant improvement in patient experience was corroborated by audit data for both procedure duration (5 versus 15 minutes) and first attempt success (100 versus 28.5%) for EJV versus peripheral venepuncture, respectively. While EJV required a recumbent position, it required less staff.

CONCLUSIONS

EJV is highly acceptable to patients, using less time and staff resources. EJV protocols and staff training should be considered where DVA presentations are common. Individualized care plans and careful care coordination could divert DVA patients needing venepuncture to services that use EJV preferentially. HIGHLIGHTS Peripheral venepuncture results in fear, stigma, pain, & distress for those with DVA. This poor acceptability of traditional venepuncture leads to service disengagement. External jugular venepuncture is highly acceptable & improves resource utilization.

Understanding Prevention and Management of Coronary Heart Disease Among Chinese Immigrants and Their Family Carers: A Socioecological Approach

Introduction: Health disparities among immigrants exist across socioecological domains. While Chinese immigrants face increased risk for coronary heart disease (CHD) after migration, the reasons are not well understood. Method: This descriptive qualitative study collected 18 semistructured interviews with Chinese immigrants with CHD and family carers from two Australian hospitals. Analysis was guided by the social–ecological model. Results: Poor knowledge and limited English proficiency increased CHD risk and difficulty navigating health care systems/resources. Interpersonal and family factors positively influenced health-seeking behaviors, acceptance of cardiac procedures, adoption of secondary preventive behaviors and information acquisition through social networks. A lack of culturally specific health information and programs in Chinese languages was described. Ethnic concordance between Chinese doctors and patients improved health literacy and engendered trust. Discussion: Culturally specific interventions could include health promotion materials in Chinese, inclusion of family in educational programs, and Chinese-focused public health campaigns about warning signs of heart attack.

Health-related quality of life in surgical children and adolescents with congenital heart disease compared with their age-matched healthy sibling: a cross-sectional study from a lower middle-income country, Pakistan

OBJECTIVE

Inconsistencies have been reported in health-related quality of life (HRQOL) in postoperative congenital heart disease (CHD). Despite the need for lifelong care due for residual symptoms, only a few studies have explored cardiac-related HRQOL but none in lower middle-income countries (LMIC). This study therefore addresses the gap by exploring HRQOL and its associated predictors in postoperative CHD in Pakistan.

OUTCOME MEASURES

General and cardiac-related HRQOL, associated predictors.

METHODS

This cross-sectional study recruited patients with CHD and age-matched healthy siblings as controls (n=129 each) at a single centre in Pakistan. Patients and their siblings completed HQROL surveys (PedsQL 4.0 Generic Core, PedsQL Cognitive Functioning). Patients only completed PedsQL 3.0 Cardiac module. Generalised linear models identified predictors.

RESULTS

The sample mean age was 8.84±3.87 years and 70% were below the poverty line for an LMIC. The majority (68%) had their first surgery after 1 year of age and were interviewed at a mean 4.08±1.91 years postoperatively.Patients with CHD had lower HRQOL in all domains compared with their age-matched siblings, with the biggest differences for total HRQOL (effect size, d=-1.35). Patients with complex CHD had lower HRQOL compared with simple to moderate CHDs in cardiac-related HRQOL. The lowest scores were for treatment problems (effect size, d=-0.91). HRQOL was worse for patients who were on cardiac medications, had complex CHD, longer cardiopulmonary bypass time, re-operations and were female.

CONCLUSIONS

HRQOL issues persist in postoperative patients with CHD in LMIC, Pakistan. Solutions are needed to address poor HRQOL and lifelong concerns of patients and their parents.

Health-related quality of life in congenital heart disease surgery in children and young adults: a systematic review and meta-analysis

BACKGROUND

As survival improves in the congenital heart disease (CHD) population, health-related quality of life (HRQOL) outcomes become increasingly important. While surgery improves survival, poor HRQOL occurs postoperatively and cardiac-related HRQOL outcomes are rarely reported.

OBJECTIVE

To conduct a systematic review and meta-analyses of general and cardiac-related HRQOL in CHD surgical children and young adults.

METHOD

Medline, CINAHL and EMBASE were searched. Quantitative designs with a minimum of 80% CHD surgical patients and mean age ≤18 years compared with healthy controls were included in the review. Data were analysed in RevMan V.5.3 using a random effects model.

OUTCOME MEASURES

General and cardiac-related HRQOL.

RESULTS

Studies (n=20) were conducted in high-income countries and included 3808 patients plus 2951 parental reports of patients. HRQOL was worse in postoperative patients with CHD versus healthy controls in all domains with the largest difference seen for physical function (standard mean difference (SMD) of -0.56, 95% CI -0.82 to -0.30). Cardiac-related HRQOL was worse in complex compared with simple CHD with the largest SMD (-0.60, 95% CI -0.80 to -0.40) for symptoms. Heterogeneity ranged from 0% to 90%.

CONCLUSIONS

CHD surgical patients have substantially worse HRQOL compared with age-matched healthy controls. Strategies should focus on improving HRQOL in this subgroup. Results may not be applicable to low/middle-income countries given the dearth of relevant research.

Improving patient adherence to secondary prevention medications 6 months after an acute coronary syndrome: observational cohort study

BACKGROUND

Most patients are recommended secondary prevention pharmacotherapies following an acute coronary syndromes (ACS).

AIM

To identify predictors of adherence at 6 months and strategies to improve adherence to these therapies.

METHODS

Patients in the CONCORDANCE registry who were discharged on evidence-based medications were stratified into those receiving ≥75% ('adherent') or <75% ('non-adherent') of indicated medications at 6 months. Baseline characteristics, hospital and post-discharge care were compared between groups. Multivariable logistic analysis identified independent predictors of adherence. The relative contribution of each clinical or treatment factor to 'adherence' was determined using an adequacy measure method.

RESULTS

Follow-up data were available for 6595 patients, 4492 (68.1%) of whom were 'adherent'. Clinical factors predictive of adherence included previous stroke, percutaneous coronary intervention (PCI) and hypertension (odds ratios (OR) 1.36-1.56); factors predictive of non-adherence included discharge diagnosis of non-ST-segment elevation myocardial infarction (vs unstable angina) (OR 0.51) and atrial fibrillation (OR 0.59). Discharge on ≥75% of indicated medications was a strong predictor of adherence at 6 months (OR 10.23, 95% confidence interval 7.89-13.27); in-hospital management factors predicting non-adherence were medical management alone (OR 0.34) and coronary artery bypass graft (OR 0.50) (both vs PCI). Post-discharge predictors of adherence included cardiac rehabilitation (OR 1.36) and general practitioner attendance (OR 1.40).

CONCLUSION

Failure to discharge patients on indicated therapies is the most important modifiable predictor of adherence failure 6 months after an ACS. Implementing protocols to automate prescription of indicated discharge therapies, has the potential to reduce non-adherence dramatically in the 6 months following discharge.

The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation

AIMS AND OBJECTIVES

To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI).

BACKGROUND

CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning.

DESIGN

Longitudinal qualitative study using Heideggerian phenomenology.

METHODS

Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed.

RESULTS

Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity).

CONCLUSIONS

Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy.

RELEVANCE TO CLINICAL PRACTICE

A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.

A Rapid Access Chest Pain Clinic (RACPC): Initial Australian Experience

BACKGROUND

Chest pain is the second most common presenting symptom to emergency departments (ED) in Australia, although up to 85% of these patients do not have an acute coronary syndrome (ACS). Cardiologist-led rapid access chest pain clinics (RACPC) have been proposed overseas to assist in the management of such patients, with prompt outpatient assessment if patients are deemed low risk and discharged from the ED. The use of RACPCs in Australia has been only recently proposed; we therefore sought to examine one such RACPC in an Australian context.

METHODS AND RESULTS

1133 consecutive patients were seen at a metropolitan RACPC, between August 2008 and February 2017. There was a high preponderance of cardiovascular risk factors. Exercise stress testing (EST) was the default investigation upon discharge from ED, with a total of 1038 ESTs performed in 1113 patients (93%), with low numbers of other functional tests, and a small, but increasing number of coronary computed tomography (CT) scans performed over this period. Eighteen patients subsequently underwent revascularisation (1.6% of the total cohort), and none of these patients were readmitted at any time with an ACS between the interval of their index ED presentation to these investigations or treatments. Five (0.4%) patients represented to ED within 48hours, none due to a cardiovascular cause. A total of 24 (2.1%) patients represented between 2 and 28 days, with none of these due to an ACS.

CONCLUSIONS

Following ED assessment of acute chest pain as low risk-with direct ED referral for exercising testing followed by RACPC review-results in very low readmission rates at 48hours and at 28 days. Moreover, these readmissions were almost always not of cardiovascular aetiology, and occurred despite relatively longer waiting periods for both EST (8 days) and between EST and RACPC review (11 days), than the prespecified 72 to 96hours as defined by the clinic protocol. Further investigation into this model of care in Australia is suggested.

Experiences of giving and receiving care in traumatic brain injury: An integrative review

AIMS AND OBJECTIVES

To synthesise the literature on the experiences of giving or receiving care for traumatic brain injury for people with traumatic brain injury, their family members and nurses in hospital and rehabilitation settings.

BACKGROUND

Traumatic brain injury represents a major source of physical, social and economic burden. In the hospital setting, people with traumatic brain injury feel excluded from decision-making processes and perceive impatient care. Families describe inadequate information and support for psychological distress. Nurses find the care of people with traumatic brain injury challenging particularly when experiencing heavy workloads. To date, a contemporary synthesis of the literature on people with traumatic brain injury, family and nurse experiences of traumatic brain injury care has not been conducted.

DESIGN

Integrative literature review.

METHODS

A systematic search strategy guided by the PRISMA statement was conducted in CINAHL, PubMed, Proquest, EMBASE and Google Scholar. Whittemore and Knafl's (Journal of Advanced Nursing, 52, 2005, 546) integrative review framework guided data reduction, data display, data comparison and conclusion verification.

RESULTS

Across the three participant categories (people with traumatic brain injury/family members/nurses) and sixteen subcategories, six cross-cutting themes emerged: seeking personhood, navigating challenging behaviour, valuing skills and competence, struggling with changed family responsibilities, maintaining productive partnerships and reflecting on workplace culture.

CONCLUSIONS

Traumatic brain injury creates changes in physical, cognitive and emotional function that challenge known ways of being in the world for people. This alters relationship dynamics within families and requires a specific skill set among nurses.

RELEVANCE TO CLINICAL PRACTICE

Recommendations include the following: (i) formal inclusion of people with traumatic brain injury and families in care planning, (ii) routine risk screening for falls and challenging behaviour to ensure that controls are based on accurate assessment, (iii) formal orientation and training for novice nurses in the management of challenging behaviour, (iv) professional case management to guide access to services and funding and (v) personal skill development to optimise family functioning.

A proposed clinical research support career pathway for noninvestigators

AIM

To discuss the international experience of clinical research support for noninvestigator roles and to propose a new pathway for Australia, to promote a sustainable research support workforce capable of delivering high-quality clinical research.

BACKGROUND

Noninvestigator research support roles are currently characterized by an ad hoc approach to training, with limited role delineation and perceived professional isolation with implications for study completion rates and participant safety. A focused approach to developing and implementing research support pathways has improved patient recruitment, study completion, job satisfaction, and research governance.

DATA SOURCES

The Queensland and New South Wales state-based Nurses' Awards, the Australian Qualifications Framework, and a University Professional (Research) Staff Award. Research nurses in the clinical environment improve study coordination, adherence to study protocol, patient safety, and clinical care.

CONCLUSION

A career pathway that guides education and outlines position descriptions and skill sets would enhance development of the research support workforce. This pathway could contribute to changing the patient outcomes through coordination and study completion of high-quality research. A wide consultative approach is required to determine a cost-effective and feasible approach to implementation and evaluation of the proposed pathway.

Health-related quality of life in congenital heart disease surgery patients in Pakistan: protocol for a mixed-methods study

INTRODUCTION

Reduced health-related quality of life (HRQOL) has been reported in postoperative patients with congenital heart disease (CHD). However, there is a paucity of data from low-income and middle-income countries (LMIC). Differences in sociodemographics and sociocultural contexts may influence HRQOL. This protocol paper describes a study exploring HRQOL in surgical patients with CHD from a tertiary hospital in Pakistan. The study findings will assist development of strategies to improve HRQOL in a resource-constrained context.

METHODS AND ANALYSIS

This prospective, concurrent triangulation, mixed-methods study aims to compare HRQOL of postsurgery patients with CHD with age-matched healthy siblings and to identify HRQOL predictors. A qualitative component aims to further understand HRQOL data by exploring the experiences related to CHD surgery for patients and parents. Participants include patients with CHD (a minimum of n~95) with at least 1-year postsurgery follow-up and no chromosomal abnormality, their parents and age-matched, healthy siblings. PedsQL 4.0 Generic Core Scales, PedsQL Cognitive Functioning Scale and PedsQL 3.0 Cardiac Module will measure HRQOL. Clinical/surgical data will be retrieved from patients' medical files. Student's t-test will be used to compare the difference in the means of HRQOL between CHD and siblings. Multiple regression will identify HRQOL predictors. A subsample of enrolled patients (n~20) and parents (n~20) from the quantitative arm will be engaged in semistructured qualitative interviews, which will be analysed using directed content analysis. Anticipated challenges include patient recruitment due to irregular follow-up compliance. Translation of data collection tools to the Urdu language and back-translation of interviews increases the study complexity.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from The Aga Khan University, Pakistan (3737-Ped-ERC-15). Study findings will be published in peer-reviewed journals and presented at national and international conferences.

Acculturation is associated with higher prevalence of cardiovascular disease risk-factors among Chinese immigrants in Australia: Evidence from a large population-based cohort

Background Acculturation is associated with increased prevalence of cardiovascular disease (CVD) risk-factors among immigrants in Western countries. Little is known about acculturation effects on CVD risks among Chinese immigrants, one of the fastest growing populations in Western countries. In this study, we aim to examine the association between acculturation and CVD risk-factors among Chinese immigrants, Australia's third-largest foreign-born group. Methods We accessed a subsample of Chinese immigrants ( n = 3220) within the 45-and-Up Study (2006-2009). Poisson regression model with a robust error variance examined the association between acculturation and CVD risk-factors, and prevalence ratios were reported, adjusted for socio-demographic characteristics. Indicators of acculturation included age at migration, length of Australian residence and language spoken at home. The outcomes were self-reported CVD diagnosis and six risk-factors (hypertension, diabetes, high cholesterol, smoking, overweight/obesity, physical inactivity). Results Mean age of Chinese participants was 58.9-years (SD = 10.7) and 55.5% were women. Chinese migrating to Australia aged <18 years were significantly more likely to report diabetes (prevalence ratio = 1.71; p < 0.01), overweight/obesity (prevalence ratio = 1.49; p < 0.001) and ≥ 3 CVD risk-factors (prevalence ratio = 1.47; p < 0.05) compared with those who migrated after 18-years-old. Chinese immigrants who lived in Australia for ≥ 30 years were significantly more likely to have diabetes (prevalence ratio = 1.84; p < 0.01) and ≥ 3 CVD risk-factors (prevalence ratio = 1.84; p < 0.01). There were no significant differences by language spoken at home. The association between indicators of acculturation and CVD risk-factors appeared to differ by sex. Conclusion Greater acculturation was associated with adverse CVD risk-factors among Chinese immigrants in Australia.

A phenomenological construct of caring among spouses following acute coronary syndrome

The aim of this study was interpret the existential construct of family caring following Acute Coronary Syndrome. Family support is known to have a positive impact on recovery and adjustment after cardiac events. Few studies provide philosophically-based, interpretative explorations of carer experience following a spouse's ischaemic event. As carer experiences, behaviours and meaning-making may impact on the quality of the support they provide to patients, further understanding could improve both patient outcomes and family experience. Fourteen spouses of people experiencing Acute Coronary Syndrome in Sydney, Australia were engaged in a single, semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Data were analysed using hermeneutic interpretation within a Heideggerian phenomenological framework. Acute Coronary Syndrome disrupts lived temporality, and the projected potential for carers' being-alongside. Carers experienced an existential uncertainty that arose from difficulty in diagnosis, and situated fear as an attuned, being-towards-death. They constructed protective strategies to insulate their partner and themselves from further stress and risk, however, unclear boundaries for protection heightened carer anxiety. The existential structure of care included one of two possible Heideggerian modes: leaping-in care was a dominating mode that required a high level of carer vigilance; leaping-ahead care was a metaphorical walking alongside, as carers gave back control, freeing opportunities for the person to 'own' care. Supporting carers through the intensive phase of leaping-in care, and equipping them for informed leaping-ahead care should be a focus in both the acute and post-discharge care phases.

An integrative review of health-related quality of life in patients with critical limb ischaemia

AIMS AND OBJECTIVES

To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life.

BACKGROUND

Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation.

DESIGN

The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al.

RESULTS

The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia.

CONCLUSIONS

Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required.

RELEVANCE TO CLINICAL PRACTICE

A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients.

Compartmentalising time and space: a phenomenological interpretation of the temporal experience of commencing haemodialysis

AIMS AND OBJECTIVES

To interpret the spatio-temporal experience of people with end-stage kidney disease and their families in the first months of haemodialysis.

BACKGROUND

While dialysis is the mainstay of end-stage kidney disease management, the actual initiation of treatment is often unexpected by people and families. Poor biopsychosocial preparation means haemodialysis commencement is experienced as a crisis. While previous phenomenological studies suggest that over time, a habitual incorporation of dialysis into one's self-concept is possible, the spatio-temporal experience of people new to haemodialysis is not well understood.

DESIGN

A phenomenological study.

METHODS

Following purposive sampling, 18 participants were recruited either during an inpatient admission or while attending a public hospital-based haemodialysis unit in Sydney, Australia. Eleven people who had commenced haemodialysis within the previous three months and five close family members were separately engaged in semistructured interviews. Hermeneutic interpretation within a Heideggerian framework occurred through a backward-and-forward analysis between the early haemodialysis experience and its relationship to Being.

RESULTS

Themes that related to a temporal and spatial understanding of Being-in-the-world as a new haemodialysis patient or carer included the following: 'compartmentalising life into dialysis and non-dialysis days' (lost time, clock time and lived time); 'compartmentalising before, now and future' (normalising the 'before', dealing with the 'now' and the 'foreverness' of dialysis); and finally, 'compartmentalising space'.

CONCLUSIONS

In the months after dialysis commencement, patients and family carers compartmentalise time and space with a loss of continuity of meaningful, lived time that had framed people's past sense of normal.

RELEVANCE TO CLINICAL PRACTICE

Resource enhancement activities should focus on social connectivity and provision of personnel and/or infrastructure to reduce boredom, to facilitate engagement with meaningful tasks and, where appropriate, to support the continuation of work activities during the dialysis period.