Understanding the supportive care needs of parents of children with cancer: an approach to local needs assessment

The objective of this study was to conduct an assessment of supportive care needs from the perspective of parents of children diagnosed with cancer within an urban-rural region in Eastern Ontario, Canada. Guided by a conceptual framework for supportive care, the exploratory, mixed-method study used a standard needs survey and semistructured interviews. Fifteen parents completed (75% response rate) the survey, and 3 parents participated as key informants in the follow-up interview. Parents reported needs in all 6 of the need categories outlined within the Supportive Care Needs Framework. The proportion of parents expressing a need ranged from 23% to 39%. Dealing with the fear of their child's cancer spreading was frequently identified by parents. Emotional and informational needs were the 2 most frequently acknowledged categories of need. With further refinement, the use of the conceptual framework will provide a methodology for planning care based on the individual needs identified by parents of children with cancer.

The symptom of pain in individuals recently hospitalized for heart failure

The symptom of pain is not typically associated with heart failure. Yet, emerging evidence suggests that pain is an important issue for this population.

OBJECTIVES

(1) To determine whether pain was reported by a cohort of individuals with heart failure at the time of discharge from hospital, at 2 and 6 weeks postdischarge; (2) To examine the profile of individuals who reported pain at discharge and to determine if there were differences from individuals who did not report pain; (3) To determine whether there was a difference in health-related quality of life between reported pain and no pain groups.

METHODS

This study was part of a larger randomized controlled trial with a 3-month follow-up. Data were obtained from 169 individuals diagnosed with heart failure who completed the first 6 weeks of the follow-up period.

RESULTS

At time of discharge, 68% of the cohort reported pain. Both frequency and severity of pain fluctuated throughout the study for the entire cohort. There were no sociodemographic characteristics that distinguished those who reported pain from those who did not report pain. Differences in health-related quality of life were found between the reported pain and no pain groups at discharge and week 2. Depression, worry, feeling a loss of control over one's life, and feeling as if one was a burden to family were significantly more prevalent in individuals who reported pain. Differences were also found in self-rated health status, and number of prescription medications taken daily. Throughout the 6 weeks, 63 individuals (37%) consistently reported pain and 23 (14%) never reported pain.

CONCLUSION

Pain was a concern for this cohort of individuals diagnosed with heart failure and was noted to impact their health-related quality of life. Further research is needed into the nature of the pain and the role of pain in self-management once patients are discharged home.

Measurement of the Caregiving Experience in Caregivers of Persons Living With Heart Failure: A Review of Current Instruments

BACKGROUND

Current evidence suggests that caring for someone with heart failure (HF) often imposes physical and emotional demands on primary caregivers that may lead to emotional distress or impaired quality of life. The purpose of this literature review was to provide a comprehensive description of the measurement tools used for assessing the subjective experience of primary caregivers for persons living with HF.

METHODS

CINHAL, MEDLINE, EMBASE, PsychINFO, the Cochrane Collaboration, and PubMed databases (1985 to June 2006) were searched for studies that directly measured the caregiving experience.

RESULTS

Seven studies yielding 6 different instruments were reviewed. The majority of studies were cross-sectional, descriptive, and correlational designs. Caregivers were predominately female spouses with a mean age ranging from 54 to 63 years.

CONCLUSIONS

Limitations in study designs and nonstandardized approaches to measurement of caregiving limit the ability to confidently recommend a specific existing tool for measuring this construct in the population with HF. However, on the basis of the results from this review, the Caregiver Reaction Assessment tool seems to have the greatest potential for quantitatively measuring the subjective experience of caregiving in HF. Its ease of administration, strong psychometric properties in the medical populations, and attention to the positive and negative experiences associated with caregiving make it a most promising generic tool.

Fatigue and Physical Activity in Older Adults With Cancer

Cancer is a disease predominantly affecting older adults. Cancer fatigue is the most common and often most distressing symptom associated with cancer and its treatment, often persisting months to years after treatment. Untreated cancer fatigue may lead to significant reductions in physical activity, physical functioning, and quality of life and may interfere with patients' adherence to cancer treatment. Physical activity has the strongest supporting evidence as an intervention to reduce cancer fatigue, maintain physical function, and optimize quality of life. This article reviews the literature related to fatigue and physical activity in older adults with cancer. Nine experimental and 10 observational studies that enrolled subjects 65 years or older were synthesized in the review and provided evidence that physical activity may be an effective intervention for cancer fatigue in older adults. The generalizability of the findings to older adults was limited by the poor representation of this age group in the studies. Few studies provided an analysis of age-related effects of physical activity on fatigue, physical function, and quality of life.

The symptom of pain with heart failure: a systematic review

BACKGROUND

Pain is one of the most compelling reasons for seeking medical attention. Despite frequent hospitalizations and assessments, the symptom of pain is not often associated with heart failure (HF). The role of pain in exacerbations and hospitalization may be important. A systematic review to synthesize research related to reported pain in patients with HF was undertaken and factors considered to be related to the symptom of pain in this population were identified.

METHODS AND RESULTS

Relevant articles were identified using MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Included studies focused on patients with HF and reporting on pain. Nine descriptive studies were identified. Five studies focused specifically on patients with HF. The remaining studies examined a population of seriously ill patients including those with HF as an itemized subset. From 23% to 75% of patients with HF reported pain. Factors identified as related to pain include: anxiety, depression, quality of life rated as poor, dyspnea, and more dependencies in activities of daily living.

CONCLUSION

People with HF report having pain but as a complex health group, the symptom of pain is not well understood. Pain could be a contributing factor in the breakdown of self-management and the cycle of exacerbations and hospitalization.

Analysis of self-reported problematic tasks for pregnant women

The objective of this study was to identify major components of, and influential factors in, problematic tasks performed by pregnant women employed in education, health care and service areas. Seventy-two pregnant women were surveyed using specially designed questionnaires consisting of an Initial Survey, a Job Analysis Questionnaire and a Task Description Questionnaire. Forty-four subjects (60%) had difficulty performing at least one work task and reported 105 tasks that were problematic at work. Reaching above the head, bending forward, bending and twisting, pushing, repeating actions and working at a fast pace were identified as the task components requiring the greatest level of effort. Excessive effort, excessive time, getting tired, repetitive actions, stress and fear of injury were identified as factors that had strong associations with the six major task components. Findings of this study suggest that these task components and factors should be considered when designing, assigning or analysing tasks for working pregnant women.

Reproducibility of a task description questionnaire for working pregnant women

The objective of this study was to evaluate the reproducibility of a Task Description Questionnaire that was designed to investigate exposures to, and influential factors for, problematic tasks experienced by working pregnant women. The questionnaire comprised questions concerning 22 task components (covering working posture, manual material handling, work pace, prolonged postures and others), eight influential factors contributing to problematic tasks, discomfort (measured using a body map) and level of effort to perform the tasks. Reproducibility of the questionnaire was assessed by interviewing participants on two occasions one week apart for interviews at both 20 and 34 weeks of pregnancy. Eleven and 13 problematic tasks were reported by 21 working pregnant women at 20 and 34 weeks of pregnancy, respectively. These tasks were surveyed using the Task Description Questionnaire. Kappa statistics and correlation coefficients (supplemented by paired t-tests) were used to examine the reproducibility of responses to the questionnaire. The results showed that most of the variables were measured with very good or satisfactory reproducibility. The reproducibility of exposure to work posture was higher than that of exposure to manual material handling. There was no significant difference between test and retest means for the discomfort scores measured on the body map, except for the maximum discomfort score for the whole body in the 34 weeks survey. The study suggests that the questionnaire can be reliably used in the study of problematic tasks experienced by pregnant women. But an initial preview of the questions by the subjects and explanation of the questions given to the subjects by the interviewer may help to produce more reliable results.

The effect of unrestricted oral carbohydrate intake on labor progress

OBJECTIVE

To determine if unrestricted oral carbohydrate intake during labor reduced the incidence of dystocia in low-risk nulliparous women.

DESIGN AND SETTING

A randomized clinical trial at a university-affiliated hospital in southeastern Ontario. Low-risk nulliparous women were randomized between 30 and 40 weeks gestation to either an intervention or usual care group.

INTERVENTION

Women in the intervention group received, prenatally, guidelines about food and fluid intake during labor and were encouraged to eat and drink as they pleased during labor. Women in the usual care group received no prelabor information and were restricted to ice chips and water during labor in the hospital.

MAIN OUTCOME MEASURE

The incidence of dystocia, defined as a cervical dilatation rate of less than 0.5 cm/hr for a period of 4 hrs after a cervical dilatation of 3 cm.

RESULTS

Three hundred twenty-eight women were randomized to the intervention (n = 163) or usual care (n = 165) groups. Women in the intervention group reported a significantly different pattern of oral intake during early labor in the hospital (chi(2) = 40.7, p < .001). The incidence of dystocia was 36% (n = 58) in the intervention group and 44% (n = 72) in the usual care group and was not significantly different (OR = 0.71, 95% CI = 0.46, 1.11). There were no significant differences in the other secondary outcomes or in the incidence of adverse maternal or neonatal complications.

CONCLUSION

Eating and drinking early in labor had no significant impact on the incidence of dystocia and/or adverse maternal or neonatal outcomes.

Measuring the symptom experience of seriously ill cancer and noncancer hospitalized patients near the end of life with the memorial symptom assessment scale

The objectives of this study were twofold: (1) to explore and compare the symptom experience of seriously ill hospitalized cancer and noncancer patients near the end of life using the Memorial Symptom Assessment Scale (MSAS) and (2) to determine if the MSAS is a valid and useful measure of symptom distress for patients with noncancer conditions. This was a prospective cohort study of hospitalized patients with end-stage congestive heart disease, chronic pulmonary disease, cirrhosis, or metastatic cancer. Eligible patients were interviewed to ascertain symptom prevalence, severity and distress using the MSAS and levels of fatigue using the Piper Fatigue Scale (PFS). Sixty-six patients with metastatic cancer and 69 patients with end-stage disease were enrolled in the study. There was a significant difference in the prevalence of selected physical symptoms, but not psychological symptoms, between cancer and noncancer patients. There were no significant differences in symptom distress scores, a computed score of frequency, severity and distress, if the symptom was present. In both groups the principal components factor analysis with varimax rotation yielded one factor comprising psychological symptoms and a second factor comprising three subgroups of physical symptoms. Internal consistency was high for the psychological subscale (Cronbach alpha coefficients of 0.85 for the cancer group and 0.77 for the noncancer group) and for the physical subscale groupings, with coefficients ranging between 0.78 to 0.87. The symptom scores were significantly correlated with perceptions of fatigue. These findings show that both seriously ill cancer and noncancer patients experience symptom distress, and that the MSAS seems to be a reliable measure of symptom distress in noncancer patients, as well as with cancer patients.

The sleep experience of medical and surgical patients

This study described and compared the sleep experience of medical and surgical patients during a hospital stay. During 3 consecutive nights, patients (n = 110) self-reported sleep quality using the Verran and Snyder Sleep Scale (VSH) and potentially disruptive factors using items from the Factors Influencing Sleep Questionnaire (FISQ). Surgical patients, on the first night, received more procedural care (p = .001), less sedative medication (p < .001), reported more sleep disturbance (p = .02), less sleep effectiveness (p = .03), and more need for sleep supplementation (p = .03). Variance in sleep effectiveness was explained by the FISQ score, age, and length of time in hospital (F = 6.86, p < .001). The sleep experience of patients varies between diagnostic groupings and across the hospital stay. Unit environmental and personal factors, factors that are amenable to therapeutic interventions, strongly influence the sleep experience.

Decision-making in the ICU: perspectives of the substitute decision-maker

OBJECTIVE

To describe the substitute decision-makers' perspectives related to decision-making in the intensive care unit (ICU) and to determine those variables associated with their overall satisfaction with decision-making.

DESIGN

Prospective, multicenter, cohort study.

SETTING

Six Canadian university-affiliated ICUs.

PATIENTS AND PARTICIPANTS

We distributed a validated, self-administered questionnaire assessing 21 key aspects of communication and decision-making to substitute decision-makers of ICU patients who were mechanically ventilated for more than 48 h.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

A group consisting of 1,123 substitute decision-makers received questionnaires; 789 were returned (70.3% response rate). Respondents were most satisfied with the frequency of communication with nurses and least satisfied with the frequency of communication with physicians. In terms of overall satisfaction with decision-making, 560 (70.9%) of the respondents were either completely or very satisfied. The majority (81.2%) of respondents preferred some form of shared decision-making process. Factors contributing the most to satisfaction with decision-making included: complete satisfaction with level of health care the patient received, completeness of information received, and feeling supported through the decision-making process. Satisfaction with decision-making varied significantly across sites.

CONCLUSIONS

In this multicenter observational study, we found that most substitute decision-makers for ICU patients wanted to share decision-making responsibility with physicians and that, overall, they were satisfied with their decision-making experience. Adequate communication, feeling supported, and achieving the appropriate level of care for their family member were key determinants of satisfaction with decision-making in the ICU.

Family satisfaction with care in the intensive care unit: results of a multiple center study

OBJECTIVE

To determine the level of satisfaction of family members with the care that they and their critically ill relative received.

DESIGN

Prospective cohort study.

SETTING

Six university-affiliated intensive care units across Canada.

METHODS

We administered a validated questionnaire to family members who made at least one visit to intensive care unit patients who received mechanical ventilation for >48 hrs. We obtained self-rated levels of satisfaction with 25 key aspects of care related to the overall intensive care unit experience, communication, and decision making. For family members of survivors, the questionnaire was administered while the patient was still in the hospital. For family members of nonsurvivors, the questionnaire was mailed out to the family member 3-4 wks after the patient's death.

MAIN RESULTS

A total of 891 family members received questionnaires; 624 were returned (70% response rate). The majority of respondents were satisfied with overall care and with overall decision making (mean +/- sd item score, 84.3 +/- 15.7 and 75.9 +/- 26.4, respectively). Families reported the greatest satisfaction with nursing skill and competence (92.4 +/- 14.0), the compassion and respect given to the patient (91.8 +/- 15.4), and pain management (89.1 +/- 16.7). They were least satisfied with the waiting room atmosphere (65.0 +/- 30.6) and frequency of physician communication (70.7 +/- 29.0). The variables significantly associated with overall satisfaction in a regression analysis were completeness of information received, respect and compassion shown to the patient and family member, and the amount of health care received. Satisfaction varied significantly across sites.

CONCLUSIONS

Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit. Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction.

The 2000 Helene Hudson Memorial Lecture. Decisional role in seriously ill hospitalized patients near the end of life: the patient's and provider's perspective

Decisions about whether or not to implement life-sustaining therapies are complex and are becoming more so as the ability to prolong life with advanced technologies and care increases. The objectives of this study were: (1) to determine seriously ill hospitalized patients' preferences for decisional role with respect to decisions about life-sustaining treatments, and (2) to determine if providers were aware of patients' preferences. This prospective, descriptive pilot study was conducted at an Ontario teaching hospital. One hundred and seventeen seriously ill adult patients admitted with cancer and non-cancerous conditions participated in a structured interview. Fifty-three nurses and 63 physicians responsible for the care of the participating patients also participated. Patients and providers were asked similar questions about end-of-life discussions and preference for decisional responsibility for life-sustaining treatments. Most patients (n = 89, 77%) had thought about end-of-life issues and were willing to discuss these with their physicians and nurses, but few (n = 37, 37%) reported such discussions. Preferences for decisional role varied; most indicated a preference for a shared role (n = 80, 80%) and there were no differences in patients with or without cancer. Generally, both physicians and nurses were not aware of or did not determine accurately patient preferences for decisional role. The findings from this study show that seriously ill hospitalized patients have thought about and are willing to share in discussions about end-of-life care with their providers, yet many have not.

The effect of staff nurse participation in a clinical nursing research project on attitude towards, access to, support of and use of research in the acute care setting

The purpose of this study was to determine the effect of participation in research on staff nurses' attitude towards, access to, perceived support of and reported use of research in practice. Six medical surgical units in a southeastern Ontario teaching hospital were randomly assigned to receive 3 different levels of exposure to research: high, low and usual. On the high participation units, a clinical research group consisting of the investigator and interested nurses (n = 18) critiqued research literature related to an important clinical issue (i.e., patterns of sleep) and designed and implemented a clinical research study. On the low participation units, a similar clinical research group (n = 10) met once and were involved, solely, in the design and implementation of the clinical research protocol. On the control units, there were no formalized research groups or activities. All registered nurses (n = 235), including the research group participants, on the 6 units were surveyed with a research utilization questionnaire (RUQ) pre and post participant intervention. The RUQ scores were higher on the high participation units at baseline and post intervention in comparison to the low and control units. Nurses who participated directly in the clinical research groups (high and low) reported similar RUQ scores post intervention and higher scores in comparison to all nurses. All RUQ scores were higher post intervention. Nurses with clinical expertise but minimal research expertise participated meaningfully in clinical research. While participation had an individual effect there was no unit effect, suggesting other factors, such as organizational support and culture, are important determinants of research use.

Measuring family satisfaction with care in the intensive care unit: the development of a questionnaire and preliminary results

PURPOSE

To develop and test the feasibility of administering a questionnaire to measure family members' level of satisfaction with care provided to them and their critically ill relative.

MATERIALS AND METHODS

To develop the questionnaire, existing conceptual frameworks of patient satisfaction, decision making, and quality of end-of-life care were used to identify important domains and items. We pretested the questionnaire for readability, clarity, and sensibility in 21 family members and 16 professionals. To assess validity, we measured the correlation between satisfaction with overall care and satisfaction with decision making. To assess the reliability of the questionnaire, we administered the questionnaire to next of kin of surviving patients on discharge and 7 to 10 days later.

RESULTS

Questionnaires were mailed out to 33 family members of nonsurvivors; 24 were returned completed but only 22 (66%) were usable.Twenty-five family members of eligible surviving critically ill patients participated in the test-retest part of this study. Of the 47 respondents, 84% were very satisfied with overall care and 77% were very satisfied with their role in the decision making. There was good correlation between satisfaction with overall care and satisfaction with decision making (correlation coefficient =.64). The assessment of overall satisfaction with care was shown to be reliable (correlation coefficient =.85).

CONCLUSIONS

This questionnaire has some measure of reliability and validity and is feasible to administer to next of kin of critically ill patients.

Who knows best: the patient or the provider? A nursing perspective

Who knows best: the patient or the provider? My opinion, based on a review of the literature and practical experience, is that the patient, the provider and the system each offer a unique perspective that we can draw upon in ensuring quality care across the continuum. Nurses have a unique body of knowledge and skill that they bring to each interaction with the patient. They must have an awareness of the patient's and the system's expectations and interact and negotiate realistic expectations for each. The maintenance of balanced expectations and the measurement of effectiveness will continue to be a challenge. However, patients should be involved in and direct aspects of their care and feel satisfied with the process. Ultimately, nurses and the hospitals in which they work are responsible for providing effective and satisfying care. I would like to end by reinforcing the importance of the patient's voice in the provision of compassionate care. It is disheartening to read about patients' experiences of "discompassionate healthcare" (Holloway 1999). Yet I am reassured when I read or experience examples of compassionate and effective care such as that outlined by Valerie McDonald. (Hospital Quarterly Winter 1999/2000) Ms. McDonald, a former social worker and adult educator, is the mother of three daughters, one who had Burkitt's lymphoma diagnosed in 1994 and a second who had acute lymphostatic leukemia diagnosed in 1997 and who died recently in 1999. McDonald provided a wonderful perspective about her hospital experiences--the good and the bad. There would be no denying from this report that patients know the key qualities necessary for effective and compassionate care and that this mother recognized the energy and time it took to provide this care. "I hope," she states, "as the dust settles from restructuring and cutbacks that hospital staff will still have the time, energy and flexibility to practice the art of healing as they did with my children" (p. 24). I too reinforce that we must ensure nurses (and others) have the resources, the flexibility within their roles and the knowledge and skill to practise both the art and science of nursing.

Dying in Canada: is it an institutionalized, technologically supported experience?

Although preliminary evidence shows that people generally prefer to die at home, very little is known about where Canadians die. Understanding the epidemiology of dying in Canada may illuminate opportunities to improve quality of end-of-life care and related health policy. We conducted a cross-sectional analysis of death records in Canada to determine the proportions of deaths occurring in hospitals and special care units. Our analysis found that deaths in Canada occur in hospitals with provincial and territorial proportions ranging from 87% in Quebec to 52% in the Northwest Territories. In hospitals recording deaths in special care units, 18.64% of all deaths occurred in special care units. The proportion of deaths in special care units ranged from 25% in Manitoba to 7% in the Northwest Territories. The proportion of deaths in special care units varied by size and nature (teaching vs. non-teaching) of hospitals. It increased with the size of the hospital from 8% in hospitals with 1-49 beds, to 23% for hospitals with 400 or more beds. In teaching hospitals, 27% of deaths occurred in special care units, and in non-teaching hospitals the proportion was 15%. In conclusion, the majority of deaths in Canada occur in hospitals and a substantial proportion occur in special care units, raising questions about the appropriateness and quality of current end-of-life care practices in Canada.

Fetal responses to maternal strength conditioning exercises in late gestation

Cardiovascular responses to strength conditioning exercises were examined in 12 healthy pregnant women and their unborn fetuses during the third trimester. A group of 12 healthy nonpregnant women of similar ages, parity, body height, and pre-pregnant body mass was also studied. Maternal heart rate and blood pressure and fetal heart rate (FHR) responses were measured in both the supine (30 degrees tilt) and seated postures during handgrip (HG), single-leg extension (SL), and double-leg extension (DL) exercise. Subjects performed 3 sets of 10 reps at 50, 70, and 90% of their 10-repetition maximum (10-RM) for each exercise in both postures. Pregnant subjects exhibited higher heart rates but similar blood pressure responses to control subjects under all experimental conditions. Significant increases were observed for the frequency of FHR accelerations (0.10 to 0.27/min) from rest to DL in the sitting posture at 90% RM. Moderate fetal bradycardia was observed occasionally in the tilted supine posture at rest and both during (SL, DL) and following (HG, SL, DL) exercise, suggesting that this posture should be avoided in late gestation. The results support the safety of moderate strength conditioning exercises in healthy pregnancy.

The emergence of a culture that promotes evidence based clinical decision making within an acute care setting

Nursing research programs within acute care hospitals are essential to the development and integration of nursing knowledge, difficult to implement and rarely evaluated. The purpose of this paper is three fold: (1) to describe the development, structures, and processes of a nursing research program within an acute care teaching hospital and (2) to describe selected evaluation outcomes and (3) to discuss future directions.

A nursing research utilization strategy for staff nurses in the acute care setting

The importance of research-based nursing practice is well recognized. However, typically, strategies to incorporate research findings into nursing practice have not been evaluated in terms of staff nurse outcomes. Thus, the purpose of this project was to evaluate the effectiveness of a research utilization strategy for staff nurses in the neonatal intensive care unit of a community teaching hospital. This project was intended to serve as a model for the incorporation of research findings into nursing practice on other nursing units in the acute care setting.