Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper

AIMS

To highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic.

BACKGROUND

In acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses.

DESIGN

Discursive paper.

FINDINGS

Nursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures.

CONCLUSION

COVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive.

RELEVANCE TO CLINICAL PRACTICE

Objective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.

A picture is worth a thousand words: exploring the roles of caregivers and the home environment of ventricular assist device patients

AIMS

Caregivers of persons living with ventricular assist devices (VADs) are integrally involved in both medical and non-medical care. We sought to understand tasks caregivers perform after surgical recovery, ways the home is adapted for those tasks, and presence of home safety hazards.

METHODS AND RESULTS

We conducted semi-structured interviews with persons living with a VAD and their caregivers. Pictures were taken of areas in the home where: (i) caregiving activities occurred, (ii) VAD or medical supplies were kept, and (iii) home adaptations were made for VAD care. Pictures were described in written detail and analysed. A qualitative descriptive approach was used for analysis. The sample consisted of 10 dyads, with mostly spousal relationships (60%) between male patients (60%) and female caregivers (80%). Three themes were identified: (i) Evolution of Caregiving and Support: Patients gain independence, but caregivers are still needed, (ii) Adapting the Home Environment: Changes are focused on functional needs, and (iii) Hidden Dangers: Illumination of safety concerns by photographs. Assistance with bathing, driveline care, and medication management were common caregiving tasks. Most home adaptations occurred in the bathroom and bedroom including sleeping recliners, shower chairs, removable shower heads, and hanging hooks to hold VAD equipment. Safety hazards included minimal space for safe ambulation, infection risk, and home-made adaptations to the environment.

CONCLUSIONS

These findings describe key home caregiving tasks, home adaptations, and safety concerns that require further education and support. Utilizing pictures may be a feasible method for assessing VAD teaching, caregiving needs, and identifying potential risks.

A randomized controlled trial of motivational interviewing as a tool to enhance secondary prevention strategies in cardiovascular disease (MICIS study)

Physical activity/exercise has consistently been shown to improve objective measures of functional capacity, enhance quality of life, improve coronary risk profile, and reduce mortality for individuals with coronary heart disease. Despite the gains achieved by those who attend cardiac rehabilitation (CR) many individuals fail to maintain lifestyle changes.

The aims of this study were to evaluate the effectiveness of motivational interviewing as a strategy for promoting maintenance of cardiac risk factor modification in patients who had participated in standard, 6-week outpatient CR programs.

In a randomized controlled trail, participants in usual care and intervention group (Motivational interviewing supplemental to a standard 6-week CR program) were followed up at 6-weeks and 12-months. The primary outcome was distance walked on the six-minute walk test (6MWT), used as both an indicator of functional capacity and habitual physical activity. Secondary outcomes included modifiable coronary risk factors (smoking, self-reported physical activity, waist circumference, body mass index and medication adherence), psychological status (depression, anxiety, stress, perceived cardiac control, perceived social support, exercise self-efficacy) and quality of life.

Total 110 patients, usual care (n = 58) and intervention (n = 52), consented to participate in the study. Overall, demographic and clinical characteristics did not differ between groups at baseline. Motivational interviewing was no more likely to promote maintenance of cardiac risk factor modification (both primary and secondary outcomes) than a standard CR program alone. Both intervention and control groups maintained the gains achieved during CR at the 12-month follow-up except for weight loss.

Although both groups maintained the gains achieved during CR for physical activity, there was no effect of the intervention on maintenance of cardiac risk factor modification on both primary and secondary outcomes.

Attitudes and practices towards palliative care in chronic heart failure: a survey of cardiovascular nurses and physicians

BACKGROUND

Heart failure is a chronic condition with various implications for individuals and families. Although the importance of implementing palliative care is recommended in best practice guidelines, implementation strategies are less clear.

AIMS

This study sought to; (1) determine Australian and New Zealand cardiovascular nurses and physicians' end of life care attitudes and specialist palliative care referral in heart failure and; (2) determine self-reported delivery of supportive care and attitudes towards service names.

METHODS

An electronic survey was emailed to members of four peak bodies and professional networks. Participants were also recruited through social media. Paper-based versions of the survey were completed by attendees of the 66th Cardiac Society of Australia and New Zealand Annual Scientific Meeting, August 2018.

FINDINGS

There were 113 completed responses included in the analyses. Participants were nurses (n = 75), physicians (n = 32) and allied health professionals (n = 4). Most (67%) reported they were comfortable with providing end of life care; however, fewer respondents agreed they received support for their dying patients and one-third experienced a sense of failure when heart failure progressed. Most (84-100%) participants agreed they would refer a heart failure patient later in the illness trajectory. There was a more favourable attitude towards the service name 'supportive care' than to 'palliative care'.

CONCLUSION

Comfort with end of life discussions is encouraging as it may lead to a greater likelihood of planning future care and identifying palliative care needs. Peer support and supervision may be useful for addressing feelings of failure. The use of needs-based assessment tools, adopting the service name 'supportive care' and further research focusing on primary palliative team-based approach is required to improve palliative care access.

IMPACT STATEMENT

Cardiovascular nurses and physicians are comfortable providing end of life care, but referrals to palliative care in the later stages of heart failure persists.

Bibliotherapy for improving caregiving appraisal of informal caregivers of people with dementia: A pilot randomized controlled trial

Caregiving appraisal is a key driver to moderating caregiving outcomes. The caregiving appraisal of informal caregivers of people with dementia requires increased attention. This study aimed to explore the feasibility and acceptability of an evidence-based bibliotherapy protocol, and test the efficacy on improving caregiving appraisal. A two-arm pilot randomized controlled trial was adopted. Sixty informal caregivers were randomized to either the intervention group, receiving eight weekly professional-guided bibliotherapy sessions in addition to usual care; or the usual care group. The professional-guided bibliotherapy sessions were weekly sessions in which caregivers self-read the designated chapter and then received telephone coaching. Caregiving appraisal, coping, psychological well-being, positive aspects of caregiving, knowledge of dementia, and attitude toward dementia were assessed both at baseline and immediately after the intervention. Assessors were blinded to group allocation. Individual interviews among 10 participants from the intervention group were conducted to explorecaregivers' acceptance of the intervention. Descriptive statistics, χ ² test, Mann-Whitney U test, independent t test, generalized estimating equation, and content analysis were used for data analysis. This study pioneered the use of bibliotherapy among informal caregivers of people with dementia. The participant recruitment rate was 69.8%. The attrition rate of the intervention group was 20%. Bibliotherapy had a significant time-by-group interaction effect on caregiving appraisal (p < 0.001), coping (p = 0.003), positive aspects of caregiving (p = 0.001), knowledge of dementia (p = 0.017), and attitude toward dementia (p < 0.001). The effect on psychological well-being, however, was only significant on the personal growth subscale (p = 0.025). The acceptability was also confirmed. No adverse event was documented.

Leveraging the trust of nurses to advance a digital agenda in Europe: a critical review of health policy literature

This article is a critical and integrative review of health policy literature examining artificial intelligence (AI) and its implications for healthcare systems and the frontline nursing workforce. A key focus is on co-creation as essential for the deployment and adoption of AI. Our review hinges on the European Commission's White Paper on Artificial Intelligence from 2020, which provides a useful roadmap. The value of health data spaces and electronic health records (EHRs) is considered; and the role of advanced nurse practitioners in harnessing the potential of AI tools in their practice is articulated. Finally, this paper examines "trust" as a precondition for the successful deployment and adoption of AI in Europe. AI applications in healthcare can enhance safety and quality, and mitigate against common risks and challenges, once the necessary level of trust is achieved among all stakeholders. Such an approach can enable effective preventative care across healthcare settings, particularly community and primary care. However, the acceptance of AI tools in healthcare is dependent on the robustness, validity and reliability of data collected and donated from EHRs. Nurse stakeholders have a key role to play in this regard, since trust can only be fostered through engaging frontline end-users in the co-design of EHRs and new AI tools. Nurses hold an intimate understanding of the direct benefits of such technology, such as releasing valuable nursing time for essential patient care, and empowering patients and their family members as recipients of nursing care. This article brings together insights from a unique group of stakeholders to explore the interaction between AI, the co-creation of data spaces and EHRs, and the role of the frontline nursing workforce. We identify the pre-conditions needed for successful deployment of AI and offer insights regarding the importance of co-creating the future European Health Data Space.

International survey for assessing COVID-19's impact on fear and health: study protocol

INTRODUCTION

COVID-19, caused by the SARS-CoV-2, has been one of the most highly contagious and rapidly spreading virus outbreak. The pandemic not only has catastrophic impacts on physical health and economy around the world, but also the psychological well-being of individuals, communities and society. The psychological and social impacts of the COVID-19 pandemic internationally have not been well described. There is a lack of international study assessing health-related impacts of the COVID-19 pandemic, especially on the degree to which individuals are fearful of the pandemic. Therefore, this study aims to (1) assess the health-related impact of the COVID-19 pandemic in community-dwelling individuals around the world; (2) determine the extent various communities are fearful of COVID-19 and (3) identify perceived needs of the population to prepare for potential future pandemics.

METHODS AND ANALYSIS

This global study involves 30 countries. For each country, we target at least 500 subjects aged 18 years or above. The questionnaires will be available online and in local languages. The questionnaires include assessment of the health impacts of COVID-19, perceived importance of future preparation for the pandemic, fear, lifestyles, sociodemographics, COVID-19-related knowledge, e-health literacy, out-of-control scale and the Patient Health Questionnaire-4. Descriptive statistics will be used to describe participants' characteristics, perceptions on the health-related impacts of COVID-19, fear, anxiety and depression, lifestyles, COVID-19 knowledge, e-health literacy and other measures. Univariable and multivariable regression models will be used to assess the associations of covariates on the outcomes.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the local ethics committees in participating countries, where local ethics approval is needed. The results will be actively disseminated. This study aims to map an international perspective and comparison for future preparation in a pandemic.

A qualitative study of fourteen African countries' nursing workforce and labour market

AIM

The aim of this study was to describe factors affecting nursing education and labour markets in countries in East, Central, and Southern Africa, and critical areas for investment.

BACKGROUND

An understanding about the relationship between the supply of nurses (determined by types of educational programmes, and the quantity and quality of nurse graduates), and workforce demand is critical to health policy development.

METHODS

Six focus groups and 14 key informant interviews with nursing leaders and experts were conducted. Participants included government chief nursing officers, registrars of regulatory bodies, association leaders and heads of nursing education. The data were transcribed, coded and analysed using inductive techniques.

FINDINGS

Participants discussed challenges and strengths of nursing education, school and regulatory infrastructure, financing mechanisms for the nursing workforce, the state of nursing jobs and scope of nursing practice.

CONCLUSION

Strengthened regulations and leadership are needed to improve investment in nursing, the quality of nursing education, and working conditions and to promote the achievement of better health outcomes.

IMPLICATIONS FOR NURSING POLICY

Clarifying scope of practice for nurses in the health sector and creating competency-based requirements is important. Governments should establish positions that align with updated competencies and provide fair and safe working conditions. The current and ongoing investment case for nursing requires improved data systems and a commitment to use labour market data for decision-making.

"Talking Around It": A Qualitative Study Exploring Dyadic Congruence in Managing the Uncertainty of Living With a Ventricular Assist Device

BACKGROUND

Vital components of communicating goals of care and preferences include eliciting the patient and caregiver's definition of quality of life, understanding meaningful activities and relationships, and exploring wishes for care at the end of life. Although current literature suggests framing conversations regarding end of life through the lens of meaning and quality of life, there is limited literature exploring dyadic congruence surrounding these important constructs among patients with ventricular assist devices (VADs) and their caregivers.

OBJECTIVES

The purpose of this study was to explore congruence of VAD patient and caregiver perspectives regarding end of life, definitions of quality of life, and meaning in life while managing the uncertainty of living with a VAD.

METHODS

We used thematic analysis to analyze semistructured qualitative interviews of 10 patient-caregiver dyads 3 to 12 months after VAD implantation.

RESULTS

Three major themes were identified: (1) differing trajectories of uncertainty and worry, (2) a spectrum of end-of-life perspectives, and (3) enjoying everyday moments and independence. Overall, patients and caregivers had differing perspectives regarding uncertainty and end of life. Within-dyad congruence was most evident as dyads discussed definitions of meaning or quality of life.

CONCLUSIONS

Dyadic perspectives on end of life, meaning in life, and quality of life can inform how palliative care and VAD teams approach conversations about planning for the end of life. Findings from this study can inform future shared decision-making interventions for patients living with VADs and their caregivers.

Medication Adherence Interventions for Cardiovascular Disease in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

The burden of cardiovascular diseases (CVD) is high in low- and middle-income countries (LMICs). Medications are integral to the management and control of CVD; however, suboptimal adherence impacts health outcomes. This systematic review aims to critically examine interventions targeted at improving medication adherence among persons with CVD in LMICs.

METHODS

In this systematic review, we searched online databases PubMed, Embase, and CINAHL for studies that evaluated a medication adherence intervention for CVD, reported adherence as an outcome measure, were conducted in LMICs and reported the strategy or tool used to measure adherence. We included articles published in English, available in full text, peer-reviewed, and published between 2010 and 2020.

RESULTS

We included 45 articles in this review. The majority of the studies implemented counseling and educational interventions led by nurses, pharmacists, or community health workers. Many of the studies delivered medication-taking reminders in the form of phone calls, text messages, short message services (SMS), and in-phone calendars. Multi-component interventions were more effective than unifocal interventions. Interventions involving technology, such as mobile phone calls, electronic pillboxes, and interactive phone SMS reminders, were more effective than generic reminders. The outcomes reported in the studies varied based on the complexity and combination of strategies. When interventions were implemented at both the patient level, such as reminders, and at the provider level, such as team-based care, the effect on medication adherence was larger.

CONCLUSION

In LMICs, medication adherence interventions among persons with CVD included a combination of patient education, reminders, fixed-dose combination therapy and team-based care approach were generally more effective than singular interventions. Among patients who had CVD, the medication adherence interventions were found to be moderately effective. Future studies focusing on improving medication adherence in LMICs should consider non-physician-led interventions and appropriately adapt the interventions to the local context.

Global digital social learning as a strategy to promote engagement in the era of COVID-19

AIMS AND OBJECTIVES

To assess formative and summative milestones in a digital course and the reach to low- and middle-income countries of a Massive Open Online Course focussing on supporting nurses dealing with an emerging pandemic.

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has ravaged the globe and increased the need for timely and accurate information from reliable sources. Access to reliable and accurate information, as well as support, is important in achieving health systems strengthening. Using a Massive Open Online Course format, an educational resource aimed at large-scale interactive participation via the Internet, and participants were engaged in a course focussing on nursing in a time of crisis and involved using social learning principles.

DESIGN

Observational descriptive study.

METHOD

Routinely collected data were collated during the period of 18 May-18 July 2020 focused on both formative and summative milestones in the course. Data were separated and classified by income in accordance with the publicly accessible 2020 World Bank Open Dataset.

RESULTS

During the 2-month period of observation (18 May-18 July 2020), 10,130 individuals from 156 countries enrolled in the course. More than 51% of participants were Active Learners. Thirty per cent completed over 90% of the course content by the end. There was widespread distribution of learners in low- and middle-income countries across Asia, Africa and Latin America.

CONCLUSION

The COVID-19 pandemic has underscored the importance of reliable and valid information sources. The use of Massive Open Online Course format can facilitate dissemination.

RELEVANCE TO CLINICAL PRACTICE

In the context of a dynamic global pandemic, leveraging digital resources to allow access to reliable information and resources is important. Incentivising participation through recognition of learning is important. Engaging in a social learning platform also has the power for reflection, promotion of resilience and capacity for health systems strengthening.

Improving hypertension knowledge, medication adherence, and blood pressure control: A feasibility study

AIMS AND OBJECTIVES

To examine the feasibility of a culturally tailored education programme for Haitian immigrants diagnosed with hypertension.

BACKGROUND

Hypertension is a major public health problem, impacting more than 26% of the global population. The overall prevalence of hypertension is 45.4% in the United States with nearly 80,000 deaths due to hypertension in 2015. African Americans and other Black populations living in the U.S. are disproportionally affected by hypertension.

DESIGN

Pre-test and post-test feasibility study.

METHODS

A convenience sample of forty-four participants who identified as Haitian immigrants was enrolled in this evidence-based education programme. The intervention included culturally tailored education focused on improving knowledge, medication adherence and blood pressure. Outcomes were measured using the Hill-Bone Medication Adherence Scale and Hypertension Knowledge Test. The SQUIRE 2.0 guidelines were used for reporting outcomes.

RESULTS

Of the participants that completed the study (N=42), the mean age was 61.95 (± 9.75) years and 59% were female. Baseline systolic and diastolic blood pressures were 143 (±18.15) and 85 (±7.23), respectively. Six weeks after the intervention, there was a significant decrease in mean systolic, 126 (±12.07) and diastolic 78.50 (± 7.23) blood pressures. An increase in medication adherence and hypertension knowledge was also noted at the six-week follow-up period.

CONCLUSION

The feasibility of healthcare provider implementation of a culturally tailored intervention to manage hypertension has been demonstrated. However, future research is warranted to gain a more in-depth understanding of how to approach hypertension management among Haitians and other Black immigrant communities.

RELEVANCE TO CLINICAL PRACTICE

Advanced practice nurses are uniquely qualified to implement evidence-based programmes that improve patient knowledge and adherence to hypertension management. Through tailoring and adopting an evidence-based methods for educating patients about medication adherence and adequate blood pressure management, there is a potential to see improvements in patient outcomes.

Perceived unmet needs for community-based long-term care services among urban older adults: A cross sectional study

The purpose of this study was to explore the perceived unmet needs for community-based long-term care services among older urban adults in China. We analyzed the cross-sectional data of 5,201 urban community respondents ≥65 years of age from the seventh wave of the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). The chi-squared automatic interaction detection technique was used to examine the variables associated with older adults' unmet needs for four common types of community-based services: personal care, grocery shopping, home visits, and psychological consulting. We found that the majority of the older adults perceived that they needed the four services, but only 9%-27.4% of the respondents reported that their perceived needs were met. There was a high prevalence of unmet community-based service needs (51.3%-55.5%) among urban older adults in China. Factors associated with unmet needs included depression status, ADL (activities of daily living) limitations, self-rated health, number of surviving children, educational attainment, and marital status. The results suggest that policy makers should develop services targeting specific segments of the older population, increasing the adequacy of services provided.

Nesprins are mechanotransducers that discriminate epithelial-mesenchymal transition programs

LINC complexes are transmembrane protein assemblies that physically connect the nucleoskeleton and cytoskeleton through the nuclear envelope. Dysfunctions of LINC complexes are associated with pathologies such as cancer and muscular disorders. The mechanical roles of LINC complexes are poorly understood. To address this, we used genetically encoded FRET biosensors of molecular tension in a nesprin protein of the LINC complex of fibroblastic and epithelial cells in culture. We exposed cells to mechanical, genetic, and pharmacological perturbations, mimicking a range of physiological and pathological situations. We show that nesprin experiences tension generated by the cytoskeleton and acts as a mechanical sensor of cell packing. Moreover, nesprin discriminates between inductions of partial and complete epithelial–mesenchymal transitions. We identify the implicated mechanisms, which involve α-catenin capture at the nuclear envelope by nesprin upon its relaxation, thereby regulating β-catenin transcription. Our data thus implicate LINC complex proteins as mechanotransducers that fine-tune β-catenin signaling in a manner dependent on the epithelial–mesenchymal transition program.

A single educational intervention on heart failure self-care: Extended follow-up from a multisite randomized controlled trial

BACKGROUND

Heart failure outcomes remain poor, and little is known about the causes and predictors of these outcomes in Lebanon.

AIM

The purpose of this article is to report the causes and predictors of the 6- and 12-month readmission and mortality of previously recruited patients to the Family focused Approach to iMprove Heart Failure care In LebanonQualitY intervention (FAMILY) study.

METHODS

A multi-site block randomized controlled trial in three tertiary medical centers in Beirut. Initially, participants were randomized to either the control or the intervention group. The latter group, with their family caregivers, received heart failure self-care resources and an educational intervention on self-care and symptom management during their index admission. Participants from the FAMILY study were followed up with through phone calls for readmission and mortality at 6 and 12 months following their hospital discharge.

RESULTS

A total of 218 (85%) patients were followed up with for this evaluation. There was a significant difference between the intervention group and the control group in terms of mortality at 6 months (n=18 (16%) versus n=36 (33%); p<0.05) and 12 months (n=29 (26%) versus n=45 (42%); p<0.05) post the index discharge. Mortality at 6 and 12 months was associated with aging, lower body mass index scores and readmission at 30 days post the index admission. Results of a logistic regression for mortality at 6 months showed hypertensive etiology of heart failure and 30-day readmission to be the only significant predictors.

CONCLUSION

A single session intervention was associated with lower mortality, even after an extended period of time, possibly mediated by other variables. Future studies should be powered for such outcomes while also addressing the cultural needs and literacy levels of the patients using multi-session trials and more frequent follow-ups.

A review of inpatient nursing workload measures

BACKGROUND

Fiscal constraints, an ageing populations and the increasing burden of chronic conditions are stressing health systems internationally. Nurses are the linchpin of effective healthcare delivery and their success is dependent on adequate staffing models, which must align knowledge, skills and competencies with workload.

OBJECTIVES

To compare measures of nursing workload in adult inpatient settings.

DESIGN, DATA SOURCES AND REVIEW METHOD

A review of published studies characterising nursing workload measures was undertaken. Databases-PubMed and CINHAL-were used to identify published studies. A description of the psychometric properties of each measure and its use in an inpatient setting was required for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to guide and report the review.

RESULTS

Of the 1,422 studies identified, 15 met the inclusion criteria. Nursing workload was measured in the intermediate care unit (n = 6), overall hospital (n = 7), emergency department (n = 1) and burn unit (n = 1) settings and also by mailed survey (n = 1). Eleven different workload measures were identified. The National Aeronautics and Space Administration Task Load Index (n = 3), Therapeutic Intervention Scoring System (n = 3) and Nursing Activities Score (n = 2) were the most common nursing workload measures identified with reported psychometric properties.

CONCLUSION

Researchers, clinicians and hospital administrators should carefully identify and assess the psychometric properties of nursing workload measures before using these in routine practice.

RELEVANCE TO CLINICAL PRACTICE

Gaining a consensus on effective nursing workload measures is a crucial step in designing appropriate staffing models and policies, improving nurse productivity and well-being, as well as enhancing patient health outcomes in inpatient settings.

A Call to Action to Address Disparities in Palliative Care Access: A Conceptual Framework for Individualizing Care Needs

Palliative care is a values-driven approach for providing holistic care for individuals and their families enduring serious life-limiting illness. Despite its proven benefits, access and acceptance is not uniform across society. The genesis of palliative care was developed through a traditional Western lens, which dictated models of interaction and communication. As the importance of palliative care is increasingly recognized, barriers to accessing services and perceptions of relevance and appropriateness are being given greater consideration. The COVID-19 pandemic and recent social justice movements in the United States, and around the world, have led to an important moment in time for the palliative care community to step back and consider opportunities for expansion and growth. This article reviews traditional models of palliative care delivery and outlines a modified conceptual framework to support researchers, clinicians, and staff in evaluating priorities for ensuring individualized patient needs are addressed from a position of equity, to create an actionable path forward.

Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer: A Systematic Review

Importance

Breathlessness is a frequent and debilitating symptom in patients with advanced cancer. Often, in the context of breathlessness, aggressive cancer treatment is not beneficial, feasible, or aligned with goals of care. Targeted symptom-focused interventions may be helpful in this scenario.

Objective

To evaluate the advantages and harms of nonpharmacological interventions for managing breathlessness in adults with advanced cancer.

Evidence Review

PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception through May 2020 for published randomized clinical trials (RCTs), nonrandomized controlled trials, and observational studies of the advantages and/or harms of nonpharmacological interventions on alleviating breathlessness in adults with advanced cancer. Only English-language studies were screened for eligibility, titles, abstracts, and full text. Risk of bias and strength of evidence (SOE) were independently assessed. The key outcomes reported in studies were breathlessness, anxiety, exercise capacity, health-related quality of life, and harms. Data were analyzed from October 1, 2019, to June 30, 2020.

Findings

A total of 29 RCTs (2423 participants) were included. These RCTs evaluated various types of interventions, such as respiratory (9 RCTs), activity and rehabilitation (7 RCTs), behavioral and psychoeducational (3 RCTs), integrative medicine (4 RCTs), and multicomponent (6 RCTs). Several nonpharmacological interventions were associated with improved breathlessness, including fan therapy (standardized mean difference [SMD], -2.09; 95% CI, -3.81 to -0.37; I2 = 94.3%; P for heterogeneity = .02; moderate SOE) and bilevel ventilation (estimated slope difference, -0.58; 95% CI, -0.92 to -0.23; low SOE), lasting for a few minutes to hours, in the inpatient setting. In the outpatient setting, nonpharmacological interventions associated with improved breathlessness were acupressure and reflexology (integrative medicine) (low SOE) and multicomponent interventions (combined activity and rehabilitation, behavioral and psychoeducational, and integrative medicine) (low SOE) lasting for a few weeks to months. Five of the 29 RCTs (17%) reported adverse events, although adverse events and study dropouts were uncommon.

Conclusions and Relevance

Findings of this review include the safety and association with improved breathlessness of several nonpharmacological interventions for adults with advanced cancer. Guidelines and clinical practice should evolve to incorporate nonpharmacological interventions as first-line treatment for adults with advanced cancer and breathlessness.

Sociodemographic Disparities in Access to Hospice and Palliative Care: An Integrative Review

BACKGROUND

There is growing evidence of disparities in access to hospice and palliative care services to varying degrees by sociodemographic groups. Underlying factors contributing to access issues have received little systematic attention.

OBJECTIVE

To synthesize current literature on disparities in access to hospice and palliative care, highlight the range of sociodemographic groups affected by these inequities, characterize the domains of access addressed, and outline implications for research, policy, and clinical practice.

DESIGN

An integrative review comprised a systematic search of PubMed, Embase, and CINAHL databases, which was conducted from inception to March 2020 for studies outlining disparities in hospice and palliative care access in the United States. Data were analyzed using critical synthesis within the context of a health care accessibility conceptual framework. Included studies were appraised on methodological quality and quality of reporting.

RESULTS

Of the articles included, 80% employed non-experimental study designs. Study measures varied, but 70% of studies described differences in outcomes by race, ethnicity, or socioeconomic status. Others revealed disparate access based on variables such as age, gender, and geographic location. Overall synthesis highlighted evidence of disparities spanning 5 domains of access: Approachability, Acceptability, Availability, Affordability, and Appropriateness; 60% of studies primarily emphasized Acceptability, Affordability, and Appropriateness.

CONCLUSIONS

This integrative review highlights the need to consider various stakeholder perspectives and attitudes at the individual, provider, and system levels going forward, to target and address access issues spanning all domains.

Discrepancies between proxy estimates and patient reported, health related, quality of life: minding the gap between patient and clinician perceptions in heart failure

PURPOSE

Health related quality of life (HRQoL) is rarely routinely measured in the clinical setting. In the absence of patient reported data, clinicians rely on proxy and informal estimates to support clinical decisions. This study compares clinician estimates (proxy) with patient reported HRQoL in patients with advanced heart failure and examines factors influencing discrepancies.

METHODS

Seventy-five patients with heart failure, (22 females, 53 males) completed the EQ-5D-5L questionnaire. Thirty-nine clinicians (11 medical, 23 nursing, 5 allied health) completed the proxy version (V1) producing 194 dyads. Correlation was assessed using Spearman's rank tests, systematic bias was examined with Bland-Altman analyses. Inter-rater agreement at the domain level, was investigated using linear weighted Kappa statistics while factors influencing the IRG were explored using independent student t-tests, analysis of variance and regression.

RESULTS

There was a moderate positive correlation between clinician HRQoL estimates and patient reported utility (r = 0.38; p < .0005). Mean clinician estimates were higher than patient reported utility (0.60 vs 0.54; p = 0.008), with significant underestimation of reported problems apparent in three of the five EQ-5D-5L domains. Patient sex (female), depressed mood and frailty were all associated with an increased inter-rater gap.

CONCLUSION

Clinicians in this sample overestimated HRQoL. Factors affecting the inter-rater gap, including sex and depression, support formal HRQoL screening to enhance clinical conversations and decision making. The discrepancy also supports regulatory restriction on the use of expert opinion in the development of QALYs in health economic analysis.

Investing in Skilled Specialists to Grow Hospital Infrastructure for Quality Improvement

OBJECTIVES

Hospitals can reduce labor costs by hiring lowest skill possible for the job, stretching clinical hours, and reducing staff not at bedside. However, these labor constraints designed to reduce costs may paradoxically increase costs. Specialty staff, such as board-certified clinicians, can redesign health systems to evaluate the needs of complex patients and prevent complications. The aim of the study was to evaluate whether investing in skilled specialists for supporting hospital quality infrastructure improves value and performance.

METHODS

We evaluated pressure injury rates as an indicator of performance in a retrospective observational cohort of 55 U.S. academic hospitals from the Vizient clinical database between 2007 and 2012. Pressure injuries were defined by U.S. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 3 (PSI-03) for stage 3, 4, and unstageable pressure injuries not present on admission in hospitalized adults. We compared ratios of board-certified wound care nurses per 1000 hospital beds to hospital-acquired pressure injury rates in these hospitals using mixed-effects regression of hospital quarters.

RESULTS

High-performing hospitals invested in prevention infrastructure with skilled specialists and observed performance improvements. Regression indicated that by adding one board-certified wound care nurse per 1000 hospital beds, hospitals had associated decreases in pressure injury rates by -17.7% relative to previous quarters, controlling for other interruptions. Highest performers supplied fewer skilled specialists and achieve improved outcomes.

CONCLUSIONS

Skilled specialists bring important value to health systems as a representation of investment in infrastructure, and the proportion of these specialists could be scaled relative to the hospital's patient capacity. Policy should support hospitals to make investments in infrastructure to drive down patient costs and improve quality.