Describing an episode of home nursing care for elderly postsurgical cancer patients

Atuação do enfermeiro na atenção domiciliar: uma revisão integrativa da literatura

RESUMO Objetivo: analisar a produção científica acerca da atuação do enfermeiro na atenção domiciliar em saúde. Método: realizou-se uma revisão integrativa da literatura por meio de consulta às bases de dados LILACS, BDENF, IBECS e MEDLINE. Foram incluídos estudos em espanhol, inglês e português, não delimitando data de publicação. Resultados: analisados 48 artigos, identificou-se que a atuação do enfermeiro na atenção domiciliar possui complexidade e diversidade de ações com uso de tecnologias leves, leve-duras especialmente, e duras. Destaca-se que desafios relacionados ao processo formativo para a atenção domiciliar estão relatados na literatura. O enfermeiro utiliza conhecimento experiencial e recomendações científicas aliados à reflexão na prática. Conclusão: a atuação do enfermeiro no espaço domiciliar é fundamental e ampla. As ações relacionais e educacionais se destacam, sendo necessárias inclusive nos cuidados técnicos, predominando a necessidade de formação para a atenção domiciliar.

Readmission following pancreatectomy: what can be improved?

BACKGROUND

Readmissions after pancreatectomy, largely for the management of complications, may also occur as a result of failure to thrive or for diagnostic endeavours. Potential mechanisms to reduce readmission rates may be elucidated by assessing the adequacy of the initial disposition and the real necessity for readmission.

METHODS

Using previously identified categories of readmission following pancreatectomy, details of reasons for and results of readmissions were scrutinized using a root cause analysis approach.

RESULTS

Of 658 patients subjected to pancreatectomy between 2001 and 2010, 121 (18%) were readmitted within 30 days. The clinical course in 30% of readmitted patients was found to deviate from the pathway assumed on the initial admission. Patients were readmitted at a median of 9 days (range: 1-30 days) after initial discharge and had a median readmission length of stay of 7 days (mode = 4). Postoperative complications accounted for most readmissions (n = 77, 64%); 17 patients (14%) were readmitted for failure to thrive and 16 (13%) for diagnostics. Root cause analysis detailed subtextual reasons for readmission, including, for example, the initiation of new medications that could potentially have been ordered in an outpatient setting.

CONCLUSIONS

More than one quarter of readmissions after pancreatectomy occurred in the setting of failure to thrive or for diagnostic evaluation alone. Root cause analysis revealed potentially avoidable readmissions. The development of a system for stratifying patients at risk for readmission or the failure of the initial disposition, along with an alternative means of efficiently evaluating patients in an outpatient setting, could limit unnecessary readmissions and resource utilization.

Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers

BACKGROUND

Extensive evidence shows that well over 50% of people prefer to be cared for and to die at home provided circumstances allow choice. Despite best efforts and policies, one-third or less of all deaths take place at home in many countries of the world.

OBJECTIVES

1. To quantify the effect of home palliative care services for adult patients with advanced illness and their family caregivers on patients' odds of dying at home; 2. to examine the clinical effectiveness of home palliative care services on other outcomes for patients and their caregivers such as symptom control, quality of life, caregiver distress and satisfaction with care; 3. to compare the resource use and costs associated with these services; 4. to critically appraise and summarise the current evidence on cost-effectiveness.

SEARCH METHODS

We searched 12 electronic databases up to November 2012. We checked the reference lists of all included studies, 49 relevant systematic reviews, four key textbooks and recent conference abstracts. We contacted 17 experts and researchers for unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITSs) evaluating the impact of home palliative care services on outcomes for adults with advanced illness or their family caregivers, or both.

DATA COLLECTION AND ANALYSIS

One review author assessed the identified titles and abstracts. Two independent reviewers performed assessment of all potentially relevant studies, data extraction and assessment of methodological quality. We carried out meta-analysis where appropriate and calculated numbers needed to treat to benefit (NNTBs) for the primary outcome (death at home).

MAIN RESULTS

We identified 23 studies (16 RCTs, 6 of high quality), including 37,561 participants and 4042 family caregivers, largely with advanced cancer but also congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/AIDS and multiple sclerosis (MS), among other conditions. Meta-analysis showed increased odds of dying at home (odds ratio (OR) 2.21, 95% CI 1.31 to 3.71; Z = 2.98, P value = 0.003; Chi(2) = 20.57, degrees of freedom (df) = 6, P value = 0.002; I(2) = 71%; NNTB 5, 95% CI 3 to 14 (seven trials with 1222 participants, three of high quality)). In addition, narrative synthesis showed evidence of small but statistically significant beneficial effects of home palliative care services compared to usual care on reducing symptom burden for patients (three trials, two of high quality, and one CBA with 2107 participants) and of no effect on caregiver grief (three RCTs, two of high quality, and one CBA with 2113 caregivers). Evidence on cost-effectiveness (six studies) is inconclusive.

AUTHORS' CONCLUSIONS

The results provide clear and reliable evidence that home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without impacting on caregiver grief. This justifies providing home palliative care for patients who wish to die at home. More work is needed to study cost-effectiveness especially for people with non-malignant conditions, assessing place of death and appropriate outcomes that are sensitive to change and valid in these populations, and to compare different models of home palliative care, in powered studies.

Readmission after major pancreatic resection: a necessary evil?

BACKGROUND

Hospital readmission is under increased scrutiny as a quality metric for surgical performance, yet its relevance after elective, high-acuity operations is poorly understood. We sought to define the clinical nature and economic impact of readmission after major pancreatic resection.

STUDY DESIGN

From 2001 to 2009, 578 pancreatic resections followed standardized perioperative care. Clinical and economic outcomes were evaluated and predictors of readmission were identified by regression analysis.

RESULTS

One hundred and eleven (19%) patients required readmission within 30 days (median 8 days post discharge), with only 12 more readmitted between 31 and 90 days. Twenty-three (21%) patients were readmitted multiple times. Reasons for readmission were procedure-specific complications (48%), general postoperative complications/infections (18.0%), failure to thrive (12%), or medical problems (9%). An additional 14% were readmitted solely for diagnostic evaluation of symptoms without cause. Neither preoperative demographics/acuity nor intraoperative factors influenced readmission. Instead, readmission was predicted by any (odds ratio = 2.24) or major (odds ratio = 2.19) complications, and clinically relevant (odds ratio = 5.05) or latent (odds ratio = 4.04) pancreatic fistula. Patient survival was negatively, but not significantly, associated with readmissions. Overall hospital stay and costs were markedly affected by readmission, as readmitted patients cost an average of $16,000 more.

CONCLUSIONS

In this practice-based analysis, readmissions after pancreatic resection were frequent, early, costly, and largely related to procedure-specific complications. As initial hospital stay continues to decline in high-acuity surgery, readmissions might be required for optimal management of complications, which often manifest later in the recovery course. Clinical pathway deviations predict potential readmissions, and might prompt adjustments in management and disposition of patients at risk for returning to the hospital.

Psychological Distress during Ovarian Cancer Treatment: Improving Quality by Examining Patient Problems and Advanced Practice Nursing Interventions

Background/Significance. Ovarian cancer patients are prone to psychological distress. The clinical significance and best practices for distress among this population are poorly understood. Method. Secondary analysis of research records from a six month randomized control trial included 32 women with primary ovarian cancer. All received 18 advanced practice nurse (APN) visits over six months. Three sub-samples were determined by distress level (high/low) and mental health service consent for high distress. Demographic, clinical factors, patient problems and APN interventions obtained through content analysis and categorized via the Omaha System were compared. Results. Clinically-significant psychiatric conditions were identified in 8/18 (44%) high distress subjects consenting to mental health intervention. High distress subjects who refused mental health intervention had more income and housing problems than the other subjects, received the fewest interventions at baseline, and progressively more throughout the study, exceeding the other sub-samples by study completion. Conclusions. Highly-distressed women not psychologically ready to work through emotional consequences of cancer at treatment onset may obtain support from APNs to manage cancer problems as they arise. Additional studies may identify best practices for all highly-distressed women with cancer, particularly those who do not accept mental health services for distress, but suffer from its effects.

Advanced practice nurses core competencies: a framework for developing and testing an advanced practice nurse discharge intervention

The purpose of this paper was to describe evidenced-based interventions as implemented by advanced practice nurses (APNs) conducting intervention research with a vulnerable population of blood and marrow transplant patients. In addition, each of the 6 core competencies of the APN role identified by Hamric are outlined and applied using a patient case study. These competencies are the following: direct clinical practice, expert coaching and advice, consultation, research skills, clinical and professional leadership, collaboration, and ethical decision making. This article chronicles a typical patient's journey through a post-hospital discharge nursing research study involving APNs as "intervention nurses" and discusses the various aspects of the APN core competencies throughout the process.

How Do Nurse Case Managers Care for Older Women With Breast Cancer?

PURPOSE/OBJECTIVES

To describe how nurse case managers care for older women with breast cancer.

DESIGN

A randomized, prospective trial.

SETTING

Thirteen community hospitals and two public hospitals in southeastern Texas.

SAMPLE

335 older women aged 60-89 years newly diagnosed with breast cancer and being cared for by 60 surgeons. Most participants were Caucasian. A total of 166 women were in the control group, and 159 were in the intervention nurse case management group.

METHODS

The nurses implemented multiple nursing interventions in each nursing process phase over a period of 12 months.

MAIN RESEARCH VARIABLES

Independent variables were participants' demographic characteristics, depressive symptomatology, and cognitive impairment. Nurse case management contact was a dependent variable.

FINDINGS

In each nursing phase, a greater number of nurse case management contacts were made in the first quarter. Bivariate analysis illustrated statistical differences among race, income, education, and living alone with respect to the mean amount of nurse case management. Multivariate analysis revealed that age, income, living alone, and stage of cancer predicted more nurse case management contact.

CONCLUSIONS

Nurse case managers may play a role in helping older women with breast cancer achieve positive health outcomes.

IMPLICATIONS FOR NURSING

Based on the findings of this study, nurses can develop specific nursing interventions to meet the needs of older women with breast cancer. Nurses can use the Model of Nurse Case Management to plan and manage care for older women with breast cancer.

Gero-Oncology Nursing Research

PURPOSE/OBJECTIVES

To analyze the development of gero-oncology research through a critical review of nursing and other relevant research as well as the present state of practice.

DATA SOURCES

Journal articles, book chapters, and personal experience.

DATA SYNTHESIS

Cancer in older adults is viewed through two investigative perspectives. The assumptions, questions, theoretical frames, and research design that follow from these investigative perspectives do not adequately meet the need to examine the interplay of responses to aging, cancer, and nursing practice. The mismatch of need, knowledge, and resources marks older adults with cancer as a special population in need of far more sophisticated research. With the synthesis of a new perspective, gero-oncology nursing research becomes age focused, more precisely shaping theoretical, methodologic, and analytic approaches.

CONCLUSIONS

Uniform attachment of chronologic age or other simple age-related variables to investigations, which is the primary consideration of age-related research, is irrelevant for older adults who are diagnosed with, treated for, live with, survive, and die from cancer. Shaping the next phase of gero-oncology research with a focus on age precisely integrates theoretical, methodologic, and analytic approaches through language specific to older adults and cancer.

IMPLICATIONS FOR NURSING

Shifting perspectives in gero-oncology nursing research will better inform future practice.

Advanced practice nursing outcomes: a review of selected empirical literature

PURPOSE/OBJECTIVES

To review selected empirical literature examining outcomes of advanced practice nursing with a specific focus on the work of oncology advanced practice nurses (APNs).

DATA SOURCES

Published articles (descriptive and data-based) and books.

DATA SYNTHESIS

Well-designed, methodologically sound investigations offer clear and compelling evidence that APNs are effective in improving outcomes in diverse populations and settings. Data on outcomes of oncology APNs are more limited but do demonstrate statistically significant improvements in clinical outcomes in the homecare and ambulatory settings. The increase in oncology APNs and the evolution of viable roles for oncology APNs across cancer practice settings offer opportunities to further assess the outcomes of advanced practice nursing.

CONCLUSIONS

Understanding the effects of oncology advanced practice nursing on clinical, cost, and satisfaction outcomes is critical. These data will help to explain how APNs can be used most effectively in the healthcare system to ensure the delivery of quality cancer care.

IMPLICATIONS FOR NURSING

Assessing the outcomes of advanced practice nursing care has been identified as a priority by the Oncology Nursing Society. Expansion of APN roles in oncology creates myriad opportunities to investigate this issue. APNs should be cognizant of the work that has been done in this area and use this knowledge as a foundation from which to launch further investigations.

Nursing and the informatics revolution

The Institute of Medicine's quality initiatives have collectively emphasized the importance of information technology to the transformation of health care. Not coincidentally, federal initiatives in 2004 have signaled the start of "the decade of health information technology." Building on those reports, this article describes the informatics revolution in process, and nursing's readiness to move in that direction. The promise of informatics in reshaping practice is sketched out in terms of seven aims for improvement, followed by a listing of some of the issues that must be addressed for nursing to realize those possibilities. In similar fashion, changes in academia are discussed both in terms of the promise of informatics applications and the barriers to achieving that preferred future. The article ends with some policy recommendations and reflections on opportunities at hand, particularly the growing emphasis on patient self-management support.

Home care nursing for older adults: state of the science

This article describes the state of the science of home care nursing for older adults and its implications for clinical practice. Selected peer-reviewed research articles published since 1990 were reviewed and categorized into five broad areas: nursing classification studies, critical transitions in the illness trajectory, family education and support, specific conditions prevalent in home care, and population diversity. The science of home care nursing has progressed considerably since 1990 with increasing sophistication of research conceptualization and design and increasing numbers of studies published.

Narrative research: a viable methodology for clinical nursing

TOPIC

Narrative research provides a reasonable methodology for gathering rich, multidimensional data in the clinical setting.

PURPOSE

To familiarize nurses with the concept of narrative research, review pertinent narrative research literature, and identify some ways this methodology can be integrated into clinical nursing.

SOURCES

A review of published literature from psychology, sociology, anthropology, and nursing, with citations from women with breast cancer.

CONCLUSIONS

Narrative research can make a valid contribution to nursing science in language familiar to nurses and other healthcare professionals.

Health Problems Encountered by Dying Patients Receiving Palliative Home Care Until Death

Many of the studies reviewing the needs of the dying patient have used specified time points rather than following the patients through the last span of their lifetime, until death. This prospective study, using clinical records and nursing anecdotes, examined the health problems encountered by dying patients receiving home care from referral to home care until death. Thirty-two subjects were recruited in the study. The clinical records were content-analyzed using the Omaha system, and the anecdotes of the nurses were used to illuminate the numerical findings. This study reveals that patients who were discharged home were living in good environmental and social conditions. The physical symptoms were generally well controlled, except for dyspnea. The psychological aspects caused the most concern to patients, families, and healthcare professionals. The severity of the psychological signs and symptoms was moderate at the time of the initial visits, but improved toward the final visits. Understanding the needs of palliative home care patients can facilitate the healthcare team to plan care to support "good dying" of these patients.

Establishing a nursing research agenda in gero-oncology

Expanding the evidence base of cancer in the elderly is critical to advance the specialty of geriatric oncology nursing. This article will propose topics for nursing investigation relative to prevention and early detection, response to disease and treatment, and psychosocial responses in the elderly at risk for, or having cancer. International considerations for undertaking nursing research with this special population are also described. Current dilemmas requiring investigation and future demographic implications are highlighted.