A phenomenological study of fatigue in patients with primary biliary cirrhosis

Quality of life and unmet needs in patients with chronic liver disease: A mixed-method systematic review

Background & Aims

In an attempt to uncover unmet patient needs, this review aims to synthesise quantitative and qualitative studies on patients’ quality of life and their experience of having liver disease.

Methods

Three databases (CINAHL, Embase, and PubMed) were searched from January 2000 to October 2020. The methodological quality and data extraction of both quantitative and qualitative studies were screened and appraised using Joanna Briggs Institute instruments for mixed-method systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A convergent, integrated approach to synthesis and integration was used. Studies including patients with autoimmune and cholestatic liver disease, chronic hepatitis B and C, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma were considered.

Results

The searches produced 5,601 articles, of which 95 (79 quantitative and 16 qualitative) were included in the review. These represented studies from 26 countries and a sample of 37,283 patients. The studies showed that patients´ quality of life was reduced. Unmet needs for information and support and perceived stigmatisation severely affected patients’ quality of life.

Conclusions

Our study suggests changes to improve quality of life. According to patients, this could be achieved by providing better education and information, being aware of patients’ need for support, and raising awareness of liver disease among the general population to reduce misconceptions and stigmatisation.

Registration number

PROSPERO CRD42020173501.

Lay summary

Regardless of aetiology, patients with liver diseases have impaired quality of life. This is associated with disease progression, the presence of symptoms, treatment response, and mental, physical, and social factors such as anxiety, confusion, comorbidities, and fatigue, as well as limitations in daily living, including loneliness, low income, stigmatisation, and treatment costs. Patients highlighted the need for information to understand and manage liver disease, and awareness and support from healthcare professionals to better cope with the disease. In addition, there is a need to raise awareness of liver diseases in the general population to reduce negative preconceptions and stigmatisation.

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Patients with liver disease regardless of aetiology and severity have impaired quality of life.

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Patients call for better education and information to understand and manage their liver disease, and for increased awareness and support from healthcare professionals.

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Owing to the limited knowledge of liver diseases among the general population, patients experience stigmatisation, resulting in loneliness and social isolation.

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Addressing unmet needs of patients with liver disease could improve their quality of life.

"Stuck between a Rock and a Hard Place": How Mental Health Nurses' Experience Psychosocial interventions in Irish Mental Health Care Settings

WHAT IS KNOWN ON THE SUBJECT?: Psychosocial interventions (PSI) are recognized and recommended internationally as they primarily focus on improving a client's mental health and preventing relapse. Limited qualitative studies focus on the similarities and differences on offering PSI in practice across many countries. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This manuscript provides readers with qualitative findings of mental health nurses' (MHNs) experiences of using PSI in practice and the need for regular clinical supervision to increase MHNs confidence and enhance the offering of PSI. MHNs want PSI guidelines for the offering of these skills to their client groups across practice settings. MHNs require work release from practice to attend supplementary training on PSI so that they can do their job adequately. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study sheds light on the similarities and differences on PSI in Irish mental health services. It also highlights what MHNs recognize as important for PSI to be implemented. Clinical supervision and the development of PSI guidelines are necessary so that MHNs feel confident delivering these skills. They also need ongoing work release from practice to attend supplementary PSI training to provide best evidence to enhancing client experiences and positive PSI recovery outcomes. ABSTRACT: Description The paper will report on the interview data of trained MHNs' experiences of using PSI within the Irish context. This observational data will be reported elsewhere (Smyth et al. 2020-under review). Introduction This research is conducted when the current reform of Irish mental health governance demands clarification of key psychosocial skills (PSI) required for mental health nurses (MHNs) to embrace recovery-orientated ways of working. There is limited evidence about this important topic in Ireland and across countries. Aim To explore PSI-trained MHNs' experiences of using PSI within Ireland. Method A multiple case study methodology was used and situated within an interpretive paradigm. Data were gathered using semi-structured interviews with 40 PSI-trained MHNs. Findings Three overarching themes developed from the analysis. These included (a) PSI-trained MHNs' understanding and use of PSI; (b) facilitating factors supporting the use of PSI by PSI-trained MHNs; and (c) obstacles limiting the use of PSI by PSI-trained MHNs. Discussion MHNs recognize that regular clinical supervision is required to increase their confidence, along with PSI guidelines for the offering of these skills across practice settings. MHNs also need work release to attend supplementary training on PSI so that they can do their job adequately. Implications for practice This study suggests that MHNs are often stuck between a rock and a hard place when delivering PSI in practice. MHNs need to be aware that this can affect client outcomes. Relevance statement This research identified a gap in knowledge within the Irish context but also across the world on this important topic. MHNs need access to regular clinical supervision, PSI guidelines and ongoing PSI training to feel confident in order to keep abreast of the changes happening in mental health practice and research.

A Systematic Review of Patient-Reported Outcomes in Primary Biliary Cholangitis and Primary Sclerosing Cholangitis

Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are associated with decreased health-related quality of life and debilitating symptoms. These experiences can be defined as patient-reported outcome (PRO) concepts and measured using PRO instruments. We identified all PRO concepts and instruments used in the PBC and PSC literature. This systematic review identified PBC and/or PSC studies from January 1, 1990, to May 6, 2019, that measured at least one PRO concept. Study population, design, PRO concept, PRO instrument, and validation data for PRO instruments were investigated. We provided descriptive statistics of PRO concepts and instruments used, stratified by population type. Use of PRO concepts and instruments were assessed over time. The search yielded 318 articles (69% in PBC, 18% in PSC, 13% in both, and 24% in drug trials). Forty-nine unique PRO concepts were identified. The five most common PRO concepts included pruritus (25%), fatigue (19%), broad health-related quality of life (16%), gastrointestinal adverse events (6%), and physical adverse events (6%). Only 60% of PRO concepts were measured with a PRO instrument, most of which were nonvalidated visual analogue or numeric rating scales. Only three of 83 PRO instruments were developed with feedback from the target populations (one for PBC, one for PSC, and one for both), and only six documented any psychometric testing in the target populations. Use of PRO instruments increased over time from 30% in the 1990s to 67% by 2019. Conclusion: The overwhelming majority of PRO instruments used in PBC/PSC were nonspecific and lacked patient validation or empirical justification. Significant opportunities exist to use qualitative methods to better understand patient experiences, and translate this knowledge into meaningful, patient-driven study outcomes.

Barriers to implementation of stratified care in primary biliary cholangitis: a scoping exercise

Patients with primary biliary cholangitis (PBC) can be stratified into low-risk and high-risk groups based on their response to treatment. Newly published guidelines from the British Society of Gastroenterology suggest low-risk patients can be managed substantially in primary care. This represents a shift from existing practice and makes assumptions about service capacity and the willingness of both patients and health care practitioners (HCPs) to make this change. The aim of this paper is to identify possible barriers to the implementation of these new care pathways through review of the PBC-specific literature and by identifying the experiences of patients and HCPs managing a different condition with comparable patients and disease characteristics. Searches of MEDLINE, CINAHL and EMBASE were undertaken. Within the existing PBC literature there is little data surrounding stakeholder perspectives on place of care. Review of the breast cancer literature highlights a number of barriers to change including primary care practitioner knowledge and work load, communication between healthcare settings, and the significance of the established doctor-patient relationship. Further research is needed to establish the extent to which these barriers may surface when changing PBC care pathways, and the actions required to overcome them.

The Experience of Fatigue Across Long-Term Conditions: A Qualitative Meta-Synthesis

CONTEXT

Fatigue is a common and debilitating symptom associated with many long-term conditions and is reported to cause significant levels of distress for those individuals. There is a substantial body of literature related to the nature of fatigue; however, this has not been drawn together and compared across conditions.

OBJECTIVES

The aim of this review was to synthesize data on the nature of fatigue across long-term conditions.

METHODS

The review was designed as a qualitative meta-synthesis and followed the Joanna Briggs Institute guidelines for synthesizing qualitative research. The following databases were searched for the period January 1980 to January 2016, Ovid (Medline, Embase, CINAHL, and PsycINFO) and manual searching from the reference lists from articles identified by electronic search. Fifty-seven studies were included in the review, and findings related to the nature of fatigue were extracted and findings meta-synthesized.

RESULTS

The perceived nature of fatigue across long-term conditions was encompassed in one synthesis; the fatigue experience is without precedent, with four categories: a different fatigue to any experienced before, the intensity of fatigue is overwhelming, the trajectory of fatigue, and impact on sleep and sleep disturbance. Just over half of the participants in the included studies were diagnosed with cancer. Patterns in the experience of fatigue by condition were found for cancer-related fatigue and post-stroke fatigue where data were able to be synthesized.

CONCLUSION

Although similarities in the nature of the fatigue experienced were found across conditions, differences were also evident and could be mapped for cancer-related fatigue and post-stroke fatigue. Further qualitative research on the experience of fatigue across a wide range of chronic conditions would further contribute to understanding similarities and differences across conditions and inform both research and practice in relation to assessment and management.

Knowledge, attitudes, and beliefs of patients with chronic liver disease

OBJECTIVES

To explore knowledge, attitudes, behaviors, and barriers to care among patients with chronic liver disease (CLD).

METHODS

Three separate, one-time-only, 60-minutes focus group sessions were audio-recorded, transcribed, and analyzed using an editing style of analysis.

RESULTS

In total, 13 focus group participants provided 254 discrete comments. Emerging themes included: negative lifestyles/behaviors, lack of CLD knowledge, negative attitudes/emotions, stigma and negativity, health insurance, inaccessible/high cost medical care, drug/alcohol abuse, and discriminately sharing CLD diagnoses.

CONCLUSIONS

Participants felt lack of CLD knowledge was a key factor in how patients perceived prevention, risks, causes, and treatment. These findings contribute to the important, yet limited, base of knowledge about CLD and provide a benchmark for future, more extensive studies and interventions.

The patient experience of fatigue in motor neurone disease

Aims: This paper is a qualitative investigation that aims to investigate the lived experience of fatigue in patients with motor neurone disease—a progressive and fatal neurological condition.

Background: Fatigue is a disabling symptom in motor neurone disease (MND) that affects a large number of patients. However, the term “fatigue” is in itself imprecise, as it remains a phenomenon without a widely accepted medical definition. This study sought to investigate the phenomenon of fatigue from the perspective of the MND patient.

Methods: Ten patients with MND participated in semi-structured recorded interviews at a regional neuroscience center in Liverpool, UK. Transcripts analysis was broadly informed by the principles of interpretative phenomenological analysis (IPA).

Findings: Fatigue was unanimously explained to be disabling and progressive phenomenon. Participants described two forms of fatigue: whole-body tiredness or use-dependent reversible muscle weakness related to exertion of limb and bulbar muscles. Both weakness and whole-body tiredness could be experienced simultaneously, and patients used the terms “fatigue” and “tiredness” interchangeably. Alongside descriptions of fatigue themes of Adaptation, Motivation, Avoidance, Frustration and Stress were revealed. Fatigue could be defined as “reversible motor weakness and whole-body tiredness that was predominantly brought on by muscular exertion and was partially relieved by rest.”

Conclusion: The results of this study support a multi-dimensional model of fatigue for patients with MND. Fatigue appears to be experienced and explained in two ways, both as an inability to sustain motor function and as a pervasive tiredness. Fatigue was only partially relieved by rest and tended to worsen throughout the day. It is crucial that MND care practitioners and researchers appreciate the semantic dichotomy within fatigue.

Experiences living with fatigue in Iranian veterans chemically injured by sulfur mustard gas: a phenomenological study

PURPOSE

Fatigue affects the quality of life. Evidence shows that the phenomenon of fatigue is experienced differently depending on the type of disease and its consequences. The aim of the study was to explicate the meanings of the experience of living with fatigue in chemically injured veterans.

METHODS

The hermeneutic phenomenology approach was used in this study, with an emphasis on Van Mennen's viewpoint and approach. According to Van Mennen, six overlapping dynamic activities are recommended to conduct a phenomenological study. During unstructured interviews, the participants were asked to describe their daily living experiences with fatigue. The participants were individuals who were chemically injured due to exposure to mustard gas. After examining every statement in the interview text, extractions of the meaning units, clustering, and themes were performed.

RESULTS

The data explication was based on the third to sixth stages of Van Mennen's approach. The experience living with fatigue was classified into four essential themes: fatigue as a chronic condition, as an unstable and affected situation, as a physical condition of the entire individual, and as a mental condition of the entire individual.

CONCLUSION

Due to unique social interactions and pathogenicity, victims of mustard gas experience fatigue differently than patients with other chronic diseases.

Chronic Fatigue

Because of the widespread nature of chronic fatigue, health care providers need a common understanding of chronic fatigue to enable effective communication. To aid this understanding a concept analysis was undertaken using a modified version of Rodger’s evolutionary method of concept analysis. The literature review yielded many resources focused on defining fatigue and relating it to many diverse chronic conditions. This article also discusses the differences between chronic fatigue and acute episodes of fatigue. Chronic fatigue is a subjective, unpleasant, changeable, and exhausting experience that adversely affects quality of life. Whereas rest or sleep often relieves acute fatigue, chronic fatigue is unrelenting. Chronic fatigue has multiple antecedents and is a component of a diverse array of chronic diseases.

'Post antibiotic apocalypse': discourses of mutation in narratives of MRSA

In this paper we will consider the question of mutation as it is manifested in press coverage of MRSA in UK hospitals. This represents a fertile field of discourse which brings into focus issues relating to microbes, people and working practices as well as the concepts of risk and vulnerability. A regular feature of reporting has been the presence of explanations for drug resistance involving repeated random mutations of the microbe to achieve progressively greater resistance and versatility, largely through a Darwinian process which is 'clever' at overcoming human attempts at elimination. More recently a discourse has emerged which foregrounds also the vulnerability of patients who are very young, old or otherwise immunocompromised, or whose own genetic makeup might put them at risk from the microbe. The hospital is decentred as a source of infection, and attention is turned instead to nursing homes and gymnasia as sources of infection in the community. This latter development mitigates the responsibilities of hospitals and statutory healthcare providers and turns the risk back towards the individual as a responsible actor in an ecology of mutation.

Chronic fatigue: an evolutionary concept analysis

AIM

This paper is a report of a concept analysis of chronic fatigue.

BACKGROUND

Fatigue is a prevalent symptom encompassing both acute and chronic manifestations. It is chronic fatigue that is most problematic because of its duration and impact on life quality. The rise in prevalence of chronic conditions will result in a need to address coexistent symptoms, clarification of which is needed. Chronic fatigue is one of the most common symptoms in chronic illness. Clarification of the concept and an understanding of its use by discipline are needed.

DATA SOURCES

The evolutionary method of concept analysis was used to ascertain the attributes, antecedents, consequences and surrogate terms for chronic fatigue. A review of the literature published between 1966 and 2007 was carried out to determine the contextual use of the concept of chronic fatigue among disciplines. Sources used for this analysis included CINAHL, Medline, PsychINFO and Social Work Abstracts and the search yielded 66 papers.

RESULTS

The chronic fatigue experience is associated with a multitude of physical, psychological and social factors. The defining attributes of chronic fatigue are constancy, abnormality, whole-body experience, inexplicability and disabling. The antecedents of chronic fatigue are physical disease, psychopathology, female gender and a history of abuse. Consequences found include social isolation and stigmatization, physical inactivity, psychological disturbances and a reduced quality of life.

CONCLUSION

Further research is needed to identify the aetiology of chronic fatigue and to address the social context of living with this disabling symptom.

Professional identity in community mental health nursing: A thematic analysis

AIM

The study aimed to explore how community mental health nurses (CMHNs) UK perceived their working lives. This was subdivided into questions related to: How do nurses perceive their professional status in terms of public image compared with their understanding of their working lives? How does the relationship between professional aspirations and experiences of working life affect their feelings about their work and their self image?

BACKGROUND

In a rapidly changing organizational context CMHNs face the challenge of achieving a coherent professional identity.

METHOD

An interview study was conducted and analyzed using semi-structured interviews and a thematic analysis to identify categories and themes in 34 CMHN's accounts of their working lives.

FINDINGS

The data were classified into four major themes: (i) The client focus: the public service identity of the profession; (ii) Not being a profession: skepticism, doubt and uncertainty; (iii) Growing out of the role: professional development as exit strategy; (iv) Waiting to be discovered: the search for recognition.

CONCLUSIONS

The metaphor of nurses searching for recognition has demonstrated its usefulness as a means of illuminating the quest undertaken by CMHNs to establish the legitimacy of their work, and achieve acknowledgment and appreciation. This underlies the search for professional identity in community mental health nursing.