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Theeranut A, Methakanjanasak N, Lertsinudom S, Surit P, Panyaek N, Leeladapattarakul S, Nilpetch P, Kessomboon P, Chalermwat C, Rintara W, Khongtong W, Paktipat P, Banchonhattakit P, Chunlertrith D, Sharma A, Cha’on U, Anutrakulchai S. Integrated Care Model by the Village Health Volunteers to Prevent and Slow down Progression of Chronic Kidney Disease in a Rural Community, Thailand. J Prim Care Community Health 2024; 15:21501319241240355. [PMID: 38554000 PMCID: PMC10981849 DOI: 10.1177/21501319241240355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/24/2024] [Accepted: 03/01/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is a major health problem in Thailand and health behaviors are central to its risk and progression. Because of the shortage of healthcare personnel, village health volunteers (VHVs) have been collaborating in the primary health care system. However, the contribution of VHVs to CKD reduction has not been evaluated yet. This study aimed to evaluate the efficacy of the VHV-integrated model in preventing and slowing down CKD and its risk factors. METHODS The population-based cohort study was conducted in a rural community of Thailand between 2017 and 2019. Baseline clinical and behavioral characteristics including CKD, diabetes, hypertension, and other high-risk factors of the participants were collected. The integrated care model was initiated by the multidisciplinary care team that facilitated, empowered, and trained VHVs targeting risk factors of CKD, health literacy, and health promotion. Then the participants were educated and trained for lifestyle modification and were monitored continuously for 18 months by VHVs. Changes in the CKD risk factors, and kidney functions before and after the application of integrated care model were compared. RESULTS A total of 831 subjects participated in the study with an average age of 57.5 years, and 69.5% were female. Among them, 222 participants (26.7%) were diagnosed as having CKD, the vast majority (95%) of which were in the early stages (G1-G3 and A1-A2). CKD risk factors such as high salt intake, smoking, alcohol consumption, self-NSAID (non-steroidal anti-inflammatory drugs) use were significantly decreased after application of the care model. Also, hemoglobin A1c was significantly reduced in diabetic patients, and blood pressure was controlled better than before in the hypertensive patients. Most importantly, a decline of estimated glomerular filtration rate of the CKD group was improved and lower than the non-CKD group. CONCLUSION The integrated care model through VHV significantly attenuated the risk factors associated with CKD in the general and high-risk population and effectively slowed down the progression of CKD.
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Affiliation(s)
| | | | | | - Pattama Surit
- Guangxi University of Chinese Medicine, Nanning, Guangxi, China
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Holloway D, James S, Ekinci E, Craft J. Systematic review of the effectiveness of nurse-led care in reducing glycated haemoglobin in adults with Type 1 or 2 diabetes. Int J Nurs Pract 2023; 29:e13135. [PMID: 36733216 DOI: 10.1111/ijn.13135] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Type 1 and 2 diabetes care, especially within primary health-care settings, has traditionally involved doctor-led clinics. However, with increasing chronic disease burden, there is scope for nurses to expand their role in assisting diabetes self-management. AIMS This study aimed to determine the effectiveness of nurse-led care in reducing glycated haemoglobin in adults with Type 1 or 2 diabetes. METHODS Methodology from the Joanna Briggs Institute Method for Systematic Review Research and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, including identifying publications, assessing study quality, summarizing evidence and interpreting findings. The search strategy involved using the Medical Subject Headings and keyword variations when searching MEDLINE (Ovid), Scopus, PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Inclusion criteria were samples with Type 1 or 2 diabetes, mean age of ≥18 years, English language studies and publication date of January 2011-December 2021. RESULTS Overall, 34 articles from 16 countries met inclusion criteria. Though not always clinically significant, results indicated that nurse-led care had beneficial impacts on glycated haemoglobin values, with reductions from 0.03% to 2.0%. This was evident when nurses received formal training, used treatment algorithms, had limited medical support, utilized technology and offered defined culturally sensitive and appropriate diabetes care. CONCLUSIONS Findings support nurse-led Type 1 and 2 diabetes care. Although further research is required, changes may necessitate increased recognition of nurse-led care and funding. Nurse-led care models should differ according to health-care settings.
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Affiliation(s)
- Danielle Holloway
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Petrie, Queensland, Australia
| | - Elif Ekinci
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Judy Craft
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia
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Campbell ZC, Dawson JK, Kirkendall SM, McCaffery KJ, Jansen J, Campbell KL, Lee VW, Webster AC. Interventions for improving health literacy in people with chronic kidney disease. Cochrane Database Syst Rev 2022; 12:CD012026. [PMID: 36472416 PMCID: PMC9724196 DOI: 10.1002/14651858.cd012026.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear. OBJECTIVES This review looked the benefits and harms of interventions for improving health literacy in people with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes. MAIN RESULTS We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled. AUTHORS' CONCLUSIONS Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.
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Affiliation(s)
- Zoe C Campbell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jessica K Dawson
- Westmead Clinical School, The University of Sydney at Westmead, Westmead, Australia
- Department of Nutrition and Dietetics, St George Hospital, Kogarah, Australia
| | | | - Kirsten J McCaffery
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jesse Jansen
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Family Medicine, School Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
- Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, Netherlands
| | - Katrina L Campbell
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Vincent Ws Lee
- Westmead Clinical School, The University of Sydney at Westmead, Westmead, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- Department of Transplant and Renal Medicine, Westmead Hospital, Westmead, Australia
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Beetham KS, Krishnasamy R, Stanton T, Sacre JW, Douglas B, Isbel NM, Coombes JS, Howden EJ. Effect of a 3-Year Lifestyle Intervention in Patients with Chronic Kidney Disease: A Randomized Clinical Trial. J Am Soc Nephrol 2022; 33:431-441. [PMID: 34893535 PMCID: PMC8819984 DOI: 10.1681/asn.2021050668] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 11/19/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Supervised lifestyle interventions have the potential to significantly improve physical activity and fitness in patients with CKD. METHODS To assess the efficacy of a lifestyle intervention in patients with CKD to improve cardiorespiratory fitness and exercise capacity over 36 months, we conducted a randomized clinical trial, enrolling 160 patients with stage 3-4 CKD, with 81 randomized to usual care and 79 to a 3-year lifestyle intervention. The lifestyle intervention comprised care from a multidisciplinary team, including a nephrologist, nurse practitioner, exercise physiologist, dietitian, diabetes educator, psychologist, and social worker. The exercise training component consisted of an 8-week individualized and supervised gym-based exercise intervention followed by 34 months of a predominantly home-based program. Self-reported physical activity (metabolic equivalent of tasks [METs] minutes per week), cardiorespiratory fitness (peak O2 consumption [VO2peak]), exercise capacity (maximum METs and 6-minute walk distance) and neuromuscular fitness (grip strength and get-up-and-go test time) were evaluated at 12, 24, and 36 months. RESULTS The intervention increased the percentage of patients meeting physical activity guideline targets of 500 MET min/wk from 29% at baseline to 63% at 3 years. At 12 months, both VO2peak and METs increased significantly in the lifestyle intervention group by 9.7% and 30%, respectively, without change in the usual care group. Thereafter, VO2peak declined to near baseline levels, whereas METs remained elevated in the lifestyle intervention group at 24 and 36 months. After 3 years, the intervention had increased the 6-minute walk distance and blunted declines in the get-up-and-go test time. CONCLUSIONS A 3-year lifestyle intervention doubled the percentage of CKD patients meeting physical activity guidelines, improved exercise capacity, and ameliorated losses in neuromuscular and cardiorespiratory fitness.
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Affiliation(s)
- Kassia S. Beetham
- School of Behavioural and Health Science, Australian Catholic University, Brisbane, Queensland, Australia,School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Rathika Krishnasamy
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia,Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Tony Stanton
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia,School of Health and Sport Sciences, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia,School of Medicine, Griffith University, Sunshine Coast, Queensland, Australia
| | - Julian W. Sacre
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Bettina Douglas
- School of Nursing and Midwifery, The University of Queensland, Brisbane, Queensland, Australia
| | - Nicole M. Isbel
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Jeff S. Coombes
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Erin J. Howden
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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Collein I, Sitorus R, Yetti K, Hastono SP. Facilitators and barriers to self-management of patients chronic kidney disease. ENFERMERIA CLINICA 2021. [PMID: 33849202 DOI: 10.1016/j.enfcli.2020.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study explored the facilitators and barriers self-management of patients' early stages chronic kidney disease (CKD). This study used a descriptive phenomenological qualitative design, eight participants were recruited using a purposive technique sampling. The data collection instruments employed included in-depth interviews using semi-structured interview guidelines, field notes, and tape recorders. The Colaizzi method was used for data analysis. The results were two themes (1) facilitator of self-management: health status, self-motivation, and independence in activities; (2) barriers of self-management: personal characteristics of the patients, has a miss-perception about the disease, dependency and not compliance. This study identified facilitators and barriers of self-management patients with early stages of CKD. Therefore, nurses have an important role in conducting a comprehensive health assessment.
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Affiliation(s)
- Irsanty Collein
- Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia; Palu Health Polytechnic of Health Ministry, Palu, Indonesia.
| | - Ratna Sitorus
- Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia
| | - Krisna Yetti
- Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia
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Ryder M, Jacob E, Hendricks J. An integrative review to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes. Int J Nurs Pract 2020; 26:e12901. [PMID: 33291184 DOI: 10.1111/ijn.12901] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 12/23/2022]
Abstract
AIMS This study aimed to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes. BACKGROUND Changing health-care delivery is synonymous with the nurse practitioner role. The literature is critical of the lack of research by nurse practitioners, reporting the effects of a change to health-care delivery. DESIGN This study used a systematic integrative review by using Torraco's approach. DATA SOURCES Databases Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Web of Science and SCOPUS were searched for peer-reviewed publications from 2000 to 2019. REVIEW METHODS A systematic approach was used to screen and analyse the literature. Inclusion/exclusion criteria were applied, and quality appraisal was undertaken by two reviewers. RESULTS Eighteen articles were selected. The research projects were across the community and acute care settings. Research methodologies varied including preintervention and postintervention studies, evaluation of quality improvement projects, randomized controlled trial and descriptive studies. Multiple data collection tools were used. Two major themes were identified including evidence-based practice champions and improved patient outcomes. CONCLUSION The nurse practitioner role is pertinent toward improving evidence-based practice in clinical settings. Positive patient outcomes and praise for clinical leadership are evident in the literature. Research by nurse practitioners to date has focused on individual services.
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Affiliation(s)
- Mary Ryder
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland.,Department of Nursing, St. Vincent's University Hospital, Dublin, Ireland
| | - Elisabeth Jacob
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Victoria, Australia.,School of Nursing and Midwifery, Edith Cowan University, Perth, WA, Australia
| | - Joyce Hendricks
- School of Nursing and Midwifery, Edith Cowan University, Perth, WA, Australia.,School of Nursing, Central Queensland University, Rockhampton, QLD, Australia
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Ovtcharenko N, Thomson BKA. Interventions to Improve Clinical Outcomes in Indigenous or Remote Patients With Chronic Kidney Disease: A Scoping Review. Can J Kidney Health Dis 2019; 6:2054358119887154. [PMID: 31798926 PMCID: PMC6859680 DOI: 10.1177/2054358119887154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Chronic kidney disease (CKD) associates with a significant health care burden with a disproportionate impact on indigenous persons or people living in remote areas. Although screening programs have expanded in these communities, there remains a paucity of evidence-based interventions to enhance clinical renal outcomes in these populations. Objective: The objective of this study was to identify evidence-based interventions to enhance renal outcomes in these populations. Design: A scoping review was conducted for studies in the Cochrane, MEDLINE, and Embase databases and from major nephrology meetings. Setting: Chronic kidney disease, including those on dialysis. Patients: Remote or indigenous populations Measurements: Studies that performed an intervention that was followed by measurement of renal outcomes or patient-centered outcomes (ie, quality of life) were included. Methods: All studies were described by study type, intervention, and clinical outcome, and trends were identified by both authors. Meta-analysis was not conducted due to study heterogeneity. Results: Thirty-two studies met inclusion criteria, only 2 (6.3%) of which were randomized controlled trials. Intervention types included multidisciplinary (34.4%), satellite (32.3%), telehealth (25.0%), or other (9.4%). All multidisciplinary interventions were performed in the CKD (non-dialysis) setting and reported improved patient travel time, waiting time, quality of life, kidney function, proteinuria, and blood pressure. Telehealth interventions improved program cost, patient attendance, hospitalization, and quality of life. Satellite interventions were performed in the hemodialysis setting, with 1 study evaluating acute hemodialysis. Satellite interventions improved patient travel time, dialysis clearance, quality of life, and survival, but increased program costs. Limitations: The study was restricted to interventional trials assessing clinical outcomes and to studies in developed countries, which likely excluded some research contributing to this field. Conclusions: There is significant heterogeneity among studies of interventions for patients with CKD who are indigenous or live remotely. Interventions were more likely to be successful when the remote or indigenous community was included in program development, with a culturally safe approach. More large, high-quality studies are needed to identify effective interventions to enhance clinical renal outcomes in indigenous or remote populations. Trial Registration: This trial is registered under PROSPERO, Registration Number 128453.
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Affiliation(s)
- N Ovtcharenko
- Division of Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - B K A Thomson
- Division of Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada.,Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
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The French adaptation and validation of the Partners in Health (PIH) scale among patients with chronic conditions seen in primary care. PLoS One 2019; 14:e0224191. [PMID: 31644561 PMCID: PMC6808494 DOI: 10.1371/journal.pone.0224191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/08/2019] [Indexed: 12/25/2022] Open
Abstract
Objective Measuring self-management helps identify the degree of participation of people in the management of their chronic conditions and guides clinicians in determining person-centred priorities for providing support. The Partners in Health scale, a self-report generic questionnaire, was developed to capture the self-management of patients with chronic conditions. This study aimed to translate the Partners in Health scale into French and to examine its psychometric properties in French-speaking people with chronic conditions followed in primary care. Methods The Partners in Health scale was translated into French using Hawkins and Osborne’s method (2012). Content validity was evaluated through cognitive interviews (Think Aloud Method). Internal consistency was measured at baseline with Cronbach’s alpha. Test-retest reliability was evaluated at baseline and two weeks later using the intraclass correlation coefficient. Concurrent validity was measured at baseline with the Self-efficacy for Managing Chronic Disease (SEM-CD) and the Patient Activation Measure (PAM), using Spearman correlations. Results Cognitive interviews were conducted with 10 participants. During these interviews, most items were clearly understood and accepted as formulated; only a few terms were modified. To evaluate the psychometric properties of the French-language version of the Partners in Health scale, 168 participants (male = 34.5%; mean age = 58 years; mean number of chronic conditions = 4.1) completed the questionnaire at baseline and 47 of them completed the questionnaire two weeks later by telephone. Cronbach’s alpha for internal consistency was 0.85 (95% confidence interval: 0.81–0.88). The intraclass correlation coefficient for test-retest reliability was 0.77 (95% confidence interval: 0.58–0.87). Concurrent validity with spearman’s coefficient correlation of Self-efficacy for Managing Chronic Disease and Patient Activation Measure was 0.68 and 0.61 respectively. Conclusion The French-language version of the Partners in Health scale is a reliable and valid questionnaire for the measure of self-management in persons with chronic conditions seen in primary care.
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Clemens KK, Kalatharan V, Ryan BL, Reichert S. Nonconventional diabetes-related care strategies for patients with chronic kidney disease: A scoping review of the literature. JOURNAL OF COMORBIDITY 2019; 9:2235042X19831918. [PMID: 30891431 PMCID: PMC6416990 DOI: 10.1177/2235042x19831918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 12/04/2018] [Accepted: 01/07/2019] [Indexed: 12/23/2022]
Abstract
Background Patients with diabetes and chronic kidney disease (CKD) are at high risk of diabetes-related complications. Diabetes care can support these individuals, but outpatient clinic appointments can be difficult to attend, given their already high burden of multimorbidity. Methods We systematically searched the medical and grey literature for studies that evaluated the effect of nonconventional diabetes care strategies on diabetes-related outcomes in adults with stages 2-5 CKD or using dialysis (end of search December 30, 2017). We included both randomized-controlled trials and observational studies. Study selection and data extraction were completed by two independent reviewers. Diabetes-related outcomes included glycemic, blood pressure, and lipid control, along with microvascular complications, macrovascular complications, and death. Results After screening 2177 relevant citations, we identified 34 studies which met inclusion. The majority were observational studies. Studies were frequently small, single-centered, and excluded patients with more advanced CKD. Nonconventional diabetes care strategies included community-based care, unique self-management and education programs, nurse-led care clinics, dialysis-based diabetes programs, telemedicine, and interdisciplinary care clinics. Programs were most often developed by study investigators. Although there were limitations to several of the included studies, programs were described to have modest effects on physiologic outcomes, and in some cases, diabetes-related complications and death. Conclusions Nonconventional diabetes-related care might be helpful to patients with CKD. Prior to developing and implementing programs, however, it will be important to study them more rigorously, understand their acceptability to patients, and evaluate their costs and feasibility in a real-world setting.
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Affiliation(s)
- Kristin K Clemens
- Department of Medicine, Division of Endocrinology, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Ontario, Canada.,St Joseph's Health Care, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | | | - Bridget L Ryan
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Family Medicine, Western University, London, Ontario, Canada
| | - Sonja Reichert
- St Joseph's Health Care, London, Ontario, Canada.,Department of Family Medicine, Western University, London, Ontario, Canada
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Havas K, Douglas C, Bonner A. Meeting patients where they are: improving outcomes in early chronic kidney disease with tailored self-management support (the CKD-SMS study). BMC Nephrol 2018; 19:279. [PMID: 30342487 PMCID: PMC6195997 DOI: 10.1186/s12882-018-1075-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/05/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To achieve optimal health outcomes, people with chronic kidney disease must make changes in their everyday lives to self-manage their condition. This can be challenging, and there is a need for self-management support interventions which assist people to become successful self-managers. While interventions have been developed, the literature in this area is sparse and limited by lack of both individualisation and sound theoretical basis. The aim of this study was to implement and evaluate the Chronic Kidney Disease-Self-Management Support intervention: a theory-based, person-centred self-management intervention for people with chronic kidney disease stages 1-4. METHODS A single-sample, pre-post study of an individualised, 12-week intervention based upon principles of social-cognitive theory and person-centred care was conducted with patients attending outpatient renal clinics in Queensland, Australia (N = 66). Data were collected at T0 (pre-intervention) and T1 (post-intervention). Primary outcomes were self-efficacy and self-management behaviour. RESULTS There were significant, small-to-medium improvements in primary outcomes (self-efficacy: mean difference + 0.8, 95% CI 0.3-1.2, d = 0.4; self-management behaviour: mean difference + 6.2, 95% CI 4.5-7.9, d = 0.8). There were further significant improvements in secondary outcomes (blood pressure, disease-specific knowledge, physical activity, fruit and vegetable consumption, alcohol consumption, health-related quality of life, psychological distress, and communication with healthcare providers), with effect sizes ranging from negligible to large (all ps < .05). CONCLUSIONS Social-cognitive theory shows promise as a framework for providing effective person-centred self-management support to patients within this population, and longer-term evaluation is needed. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12618000066280 . Retrospectively registered 17/01/2018.
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Affiliation(s)
- Kathryn Havas
- School of Nursing, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Brisbane, QLD 4059 Australia
- NHMRC Chronic Kidney Disease Centre for Research Excellence, University of Queensland, St Lucia, Australia
| | - Clint Douglas
- School of Nursing, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Brisbane, QLD 4059 Australia
| | - Ann Bonner
- School of Nursing, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Brisbane, QLD 4059 Australia
- NHMRC Chronic Kidney Disease Centre for Research Excellence, University of Queensland, St Lucia, Australia
- Visiting Research Fellow, Kidney Health Service, Metro North Hospital and Health Service, Brisbane, Australia
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Chan RJ, Marx W, Bradford N, Gordon L, Bonner A, Douglas C, Schmalkuche D, Yates P. Clinical and economic outcomes of nurse-led services in the ambulatory care setting: A systematic review. Int J Nurs Stud 2018. [DOI: 10.1016/j.ijnurstu.2018.02.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Donald M, Kahlon BK, Beanlands H, Straus S, Ronksley P, Herrington G, Tong A, Grill A, Waldvogel B, Large CA, Large CL, Harwood L, Novak M, James MT, Elliott M, Fernandez N, Brimble S, Samuel S, Hemmelgarn BR. Self-management interventions for adults with chronic kidney disease: a scoping review. BMJ Open 2018; 8:e019814. [PMID: 29567848 PMCID: PMC5875600 DOI: 10.1136/bmjopen-2017-019814] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To systematically identify and describe self-management interventions for adult patients with chronic kidney disease (CKD). SETTING Community-based. PARTICIPANTS Adults with CKD stages 1-5 (not requiring kidney replacement therapy). INTERVENTIONS Self-management strategies for adults with CKD. PRIMARY AND SECONDARY OUTCOME MEASURES Using a scoping review, electronic databases and grey literature were searched in October 2016 to identify self-management interventions for adults with CKD stages 1-5 (not requiring kidney replacement therapy). Randomised controlled trials (RCTs), non-RCTs, qualitative and mixed method studies were included and study selection and data extraction were independently performed by two reviewers. Outcomes included behaviours, cognitions, physiological measures, symptoms, health status and healthcare. RESULTS Fifty studies (19 RCTs, 7 quasi-experimental, 5 observational, 13 pre-post intervention, 1 mixed method and 5 qualitative) reporting 45 interventions were included. The most common intervention topic was diet/nutrition and interventions were regularly delivered face to face. Interventions were administered by a variety of providers, with nursing professionals the most common health professional group. Cognitions (ie, changes in general CKD knowledge, perceived self-management and motivation) were the most frequently reported outcome domain that showed improvement. Less than 1% of the interventions were co-developed with patients and 20% were based on a theory or framework. CONCLUSIONS There was a wide range of self-management interventions with considerable variability in outcomes for adults with CKD. Major gaps in the literature include lack of patient engagement in the design of the interventions, with the majority of interventions not applying a behavioural change theory to inform their development. This work highlights the need to involve patients to co-developed and evaluate a self-management intervention based on sound theories and clinical evidence.
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Affiliation(s)
- Maoliosa Donald
- Department of Medicine, University of Calgary, Calgary, Canada
- Interdisciplinary Chronic Disease Collaboration, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Heather Beanlands
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Canada
| | - Sharon Straus
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Paul Ronksley
- Interdisciplinary Chronic Disease Collaboration, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales
| | - Allan Grill
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | | | | | - Claire L Large
- Can-SOLVE CKD Network, Patient Partner, Pouce Coupe, Canada
| | | | - Marta Novak
- Centre for Mental Health, University Health Network, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Matthew T James
- Department of Medicine, University of Calgary, Calgary, Canada
- Interdisciplinary Chronic Disease Collaboration, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Meghan Elliott
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | | | - Scott Brimble
- Department of Medicine, McMaster University, Ontario, Canada
| | - Susan Samuel
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Canada
- Interdisciplinary Chronic Disease Collaboration, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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Xu H, Mou L, Cai Z. A nurse-coordinated model of care versus usual care for chronic kidney disease: meta-analysis. J Clin Nurs 2017; 26:1639-1649. [PMID: 27549431 DOI: 10.1111/jocn.13533] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Haidan Xu
- Shenzhen Domesticated Organ Medical Engineering Research and Development Center; Shenzhen Second People's Hospital; First Affiliated Hospital of Shenzhen University; Shenzhen China
| | - Lisha Mou
- Shenzhen Domesticated Organ Medical Engineering Research and Development Center; Shenzhen Second People's Hospital; First Affiliated Hospital of Shenzhen University; Shenzhen China
| | - Zhiming Cai
- Shenzhen Domesticated Organ Medical Engineering Research and Development Center; Shenzhen Second People's Hospital; First Affiliated Hospital of Shenzhen University; Shenzhen China
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14
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Van Laecke S, Van Biesen W. Smoking and chronic kidney disease: seeing the signs through the smoke? Nephrol Dial Transplant 2017; 32:403-405. [DOI: 10.1093/ndt/gfw448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 02/04/2023] Open
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Reilly R, Evans K, Gomersall J, Gorham G, Peters MDJ, Warren S, O'Shea R, Cass A, Brown A. Effectiveness, cost effectiveness, acceptability and implementation barriers/enablers of chronic kidney disease management programs for Indigenous people in Australia, New Zealand and Canada: a systematic review of mixed evidence. BMC Health Serv Res 2016; 16:119. [PMID: 27048280 PMCID: PMC4822249 DOI: 10.1186/s12913-016-1363-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 03/23/2016] [Indexed: 11/16/2022] Open
Abstract
Background Indigenous peoples in Australia, New Zealand and Canada carry a greater burden of chronic kidney disease (CKD) than the general populations in each country, and this burden is predicted to increase. Given the human and economic cost of dialysis, understanding how to better manage CKD at earlier stages of disease progression is an important priority for practitioners and policy-makers. A systematic review of mixed evidence was undertaken to examine the evidence relating to the effectivness, cost-effectiveness and acceptability of chronic kidney disease management programs designed for Indigenous people, as well as barriers and enablers of implementation of such programs. Methods Published and unpublished studies reporting quantitative and qualitative data on health sector-led management programs and models of care explicitly designed to manage, slow progression or otherwise improve the lives of Indigenous people with CKD published between 2000 and 2014 were considered for inclusion. Data on clinical effectiveness, ability to self-manage, quality of life, acceptability, cost and cost-benefit, barriers and enablers of implementation were of interest. Quantitative data was summarized in narrative and tabular form and qualitative data was synthesized using the Joanna Briggs Institute meta-aggregation approach. Results Ten studies were included. Six studies provided evidence of clinical effectiveness of CKD programs designed for Indigenous people, two provided evidence of cost and cost-effectiveness of a CKD program, and two provided qualitative evidence of barriers and enablers of implementation of effective and/or acceptable CKD management programs. Common features of effective and acceptable programs were integration within existing services, nurse-led care, intensive follow-up, provision of culturally-appropriate education, governance structures supporting community ownership, robust clinical systems supporting communication and a central role for Indigenous Health Workers. Conclusions Given the human cost of dialysis and the growing population of people living with CKD, there is an urgent need to draw lessons from the available evidence from this and other sources, including studies in the broader population, to better serve this population with programs that address the barriers to receiving high-quality care and improve quality of life.
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Affiliation(s)
- Rachel Reilly
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia. .,Johanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia. .,Onemda VicHealth Koori Health Group, School of Population and Global Heath, the University of Melbourne, Carlton, Victoria, Australia.
| | | | - Judith Gomersall
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia.,Johanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia.,School of Public Health, University of Adelaide, Adelaide, Australia
| | | | - Micah D J Peters
- Johanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Steven Warren
- Baker IDI Heart and Diabetes Institute, Alice Springs, Australia
| | - Rebekah O'Shea
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Alan Cass
- Menzies School of Health Research, Darwin, Australia
| | - Alex Brown
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia
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Nihat A, de Lusignan S, Thomas N, Tahir MA, Gallagher H. What drives quality improvement in chronic kidney disease (CKD) in primary care: process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) trial. BMJ Open 2016; 6:e008480. [PMID: 27053264 PMCID: PMC4823455 DOI: 10.1136/bmjopen-2015-008480] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES This study is a process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) study, comparing audit-based education (ABE) and sending clinical guidelines and prompts (G&P) with usual practice, in improving systolic blood pressure control in primary care. This evaluation aimed to explore how far clinical staff in participating practices were aware of the intervention, and why change in practice might have taken place. SETTING 4 primary care practices in England: 2 received ABE, and 2 G&P. We purposively selected 1 northern/southern/city and rural practice from each study arm (from a larger pool of 132 practices as part of the QICKD trial). PARTICIPANTS The 4 study practices were purposively sampled, and focus groups conducted with staff from each. All staff members were invited to attend. INTERVENTIONS Focus groups in each of 4 practices, at the mid-study point and at the end. 4 additional trial practices not originally selected for in-depth process evaluation took part in end of trial focus groups, to a total of 12 focus groups. These were recorded, transcribed and analysed using the framework approach. RESULTS 5 themes emerged: (1) involvement in the study made participants more positive about the CKD register; (2) clinicians did not always explain to patients that they had CKD; (3) while practitioners improved their monitoring of CKD, many were sceptical that it improved care and were more motivated by pay-for-performance measures; (4) the impact of study interventions on practice was generally positive, particularly the interaction with specialists, included in ABE; (5) the study stimulated ideas for future clinical practice. CONCLUSIONS Improving quality in CKD is complex. Lack of awareness of clinical guidelines and scepticism about their validity are barriers to change. While pay-for-performance incentives are the main driver for change, quality improvement interventions can have a complementary influence.
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Affiliation(s)
- Akin Nihat
- Kingston Hospital, Kingston upon Thames, London, UK
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, UK
| | - Nicola Thomas
- School of Health and Social Care, London South Bank University, London, UK
| | - Mohammad Aumran Tahir
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, UK
| | - Hugh Gallagher
- South West Thames Renal and Transplantation Unit, Epsom and St Helier University Hospitals NHS Trust, Wrythe Lanen, Carshalton, Surrey, UK
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Lopez-Vargas PA, Tong A, Howell M, Craig JC. Educational Interventions for Patients With CKD: A Systematic Review. Am J Kidney Dis 2016; 68:353-70. [PMID: 27020884 DOI: 10.1053/j.ajkd.2016.01.022] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 01/22/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Preventing progression from earlier stages of chronic kidney disease (CKD) to end-stage kidney disease and minimizing the risk for cardiovascular events and other complications is central to the management of CKD. Patients' active participation in their own care is critical, but may be limited by their lack of awareness and understanding of CKD. We aimed to evaluate educational interventions for primary and secondary prevention of CKD. STUDY DESIGN Systematic review. Electronic databases were searched to December 2015, with study quality assessed using the Cochrane Collaboration risk-of-bias tool. SETTING & POPULATION People with CKD stages 1 to 5 in community and hospital settings (studies with only patients with CKD stage 5, kidney transplant recipients irrespective of glomerular filtration rate, or patients receiving dialysis were excluded). SELECTION CRITERIA FOR STUDIES Randomized controlled trials and nonrandomized studies of educational interventions. INTERVENTIONS Educational strategies in people with CKD. OUTCOMES Knowledge, self-management, quality-of-life, and clinical end points. RESULTS 26 studies (12 trials, 14 observational studies) involving 5,403 participants were included. Risk of bias was high in most studies. Interventions were multifaceted, including face-to-face teaching (26 studies), written information (20 studies), and telephone follow-up (13 studies). 20 studies involved 1-on-1 patient/educator interaction and 14 incorporated group sessions. 9 studies showed improved outcomes for quality of life, knowledge, and self-management; 9 had improved clinical end points; and 2 studies showed improvements in both patient-reported and clinical outcomes. Characteristics of effective interventions included teaching sessions that were interactive and workshops/practical skills (13/15 studies); integrated negotiated goal setting (10/13 studies); involved groups of patients (12/14 studies), their families (4/4 studies), and a multidisciplinary team (6/6 studies); and had frequent (weekly [4/5 studies] or monthly [7/7 studies]) participant/educator encounters. LIMITATIONS A meta-analysis was not possible due to heterogeneity of the interventions and outcomes measured. CONCLUSIONS Well-designed, interactive, frequent, and multifaceted educational interventions that include both individual and group participation may improve knowledge, self-management, and patient outcomes.
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Affiliation(s)
- Pamela A Lopez-Vargas
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Petek Šter M, Šter B. Pomen izobraževanja diplomiranih medicinskih sester v referenčnih ambulantah: primer arterijske hipertenzije. OBZORNIK ZDRAVSTVENE NEGE 2015. [DOI: 10.14528/snr.2015.49.1.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Uvod: Diplomirane medicinske sestre se za delo v referenčnih ambulantah dodatno izobražujejo. Namen raziskave je bil preveriti potrebo in oceniti uspešnost izobraževanja za diplomirane medicinske sestre v referenčnih ambulantah za področje arterijske hipertenzije.
Metode: Vključene so bile diplomirane medicinske sestre (n = 143), ki so obiskovale petintrideseturno urno izobraževanje o arterijski hipertenziji v času od januarja 2012 do marca 2013. Ugotavljali smo spremembo v znanju o vodenju bolnika z arterijsko hipertenzijo, zadovoljstvo udeležencev s celotnim modulom in posameznimi vsebinami modulov ter izbranimi učnimi metodami. Uporabili smo kvantitativno (deskriptivna statistika, parni t-test, enovzorčni t-test) in kvalitativno analizo podatkov.
Rezultati: Z vstopnim testom so bile prepoznane velike razlike v znanju udeležencev (zbrali so med 15,0 % in 100,0 % točk). Z izobraževanjem se je njihovo znanje pomembno izboljšalo (vstopni test 56,6 % vs. končni test 89,1 %, p < 0,001). Zadovoljstvo s celotnim modulom in posameznimi deli modula je bilo visoko: povprečna vrednost za celoten modul na lestvici od 5 do 10 je znašala 8,6 (s = 1,3). Metode poučevanja so bile ocenjene kot ustrezne: povprečna vrednost na lestvici od 1 do 5 je bila 4,6 (s = 0,6). Udeleženci so najbolj pohvalili uporabnost in kakovost predavanj, dostopnost predavateljev in povezovanje teorije s prakso preko prikazov praktičnih primerov.
Diskusija in zaključek: Ugotovitve naše raziskave podpirajo potrebo po dodatnem izobraževanju diplomiranih medicinskih sester v referenčnih ambulantah s področja arterijske hipertenzije.
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