Factors associated with memory of informal caregivers: A scoping review protocol

The ability to retain and remember information (memory) is essential to caregiving tasks. There is evidence that caregivers are at greater risk for experiencing deteriorations in cognitive status than non-caregivers, especially memory; however, we have a limited understanding of factors that are related to changes in caregiver memory. This scoping review intends to comprehensively map factors related to caregiver memory reported in the literature within the chronic caregiving context. Specific aims include (1) identifying factors related to caregiver memory; (2) examining how caregiver memory has been measured; and (3) describing changes in caregiver memory during their caregiving period. This review will be conducted following Arksey and O'Malley's framework and reported using the PRISMA guidelines for Scoping Reviews (PRISMA-ScR). Studies will be included if (1) the studies focus on home-based unpaid long term family caregiving; (2) study participants (patients), of any age, have one (or more) chronic illness or disability and receive care from a caregiver for 6 months or more; (3) caregivers are adults (> = 18 years of age). Any chronic disease or condition will be included. The search will encompass gray literature and peer-reviewed literature in MEDLINE (via Ovid), CINAHL Plus with Full Text (via EBSCOhost), Embase (via Elsevier), APA PsycINFO (via EBSCOhost), Sociology Source Ultimate (via EBSCOhost), and ProQuest Dissertations and Theses Global. Data extraction will include specific details about the participants, concept, context, study methods, and key caregiver-related findings. The Caregiver Health Model will provide a framework to categorize factors that impact caregivers' memory including caregiver health promotion activities, caregiver attitudes and beliefs, caregiver task, and caregiver needs. Factors that do not fall into the Caregiver Health Model domains will be organized by emerging themes.

Group Coaching Among African-American Individuals with Prediabetes in a Faith-Based Setting

Roughly 88 million adults have prediabetes and over 84% are unaware that they even have prediabetes. African-Americans have an increased risk of being diagnosed with prediabetes. Faith-based organizations have a history of serving as a primary source of social support for African-Americans. Parishioners with prediabetes from four African-American churches participated in free, evidence-based group coaching to learn how to manage and control risk factors associated with type 2 diabetes. The weekly group coaching sessions took place at a local church and they were co-facilitated by two trained professionals: a lifestyle coach and a nurse practitioner. At the conclusion of the 16-week group coaching sessions, participants had a decrease in hemoglobin A1C levels, an increase in minutes of physical activity per week, and an improvement in knowledge and behavior.

Caregiver Characteristics Associated With Cognitive Complaints in Women With Breast Cancer

OBJECTIVES

To explore whether caregiver characteristics were associated with cognitive complaints reported by women with breast cancer undergoing chemotherapy.

SAMPLE & SETTING

61 dyads of women with breast cancer and their caregivers were recruited at Duke Women's Cancer Care Raleigh in North Carolina.

METHODS & VARIABLES

An exploratory, cross-sectional design was used. Data were obtained on patients and caregivers. Patient cognitive complaints were represented by cognitive impairment (CI) and cognitive ability (CA).

RESULTS

Two significant associations were found.

IMPLICATIONS FOR NURSING

Healthcare providers should consider caregivers when assessing and managing patients' cognitive symptoms. This study suggests the value of including caregivers when establishing interventions for patients who have cognitive complaints.

Exploring the challenges and needs of home caregivers of hemodialysis patients in the Philippines: A mixed methods study

OBJECTIVES

Although the importance of home caregivers of chronic kidney disease patients has been increasingly recognized, their perceived caregiving difficulties and requisites remain underexplored. This study investigated the challenges and needs of home caregivers of hemodialysis patients in the Philippines.

METHODS

We utilized a mixed-method (QUAN + qual), explanatory sequential design. Data were collected from July 2017 to May 2018 from 46 home caregivers of hemodialysis patients. A three-part researcher-made survey were developed from literature search, personal values and cultural context, while some items were generated from a standardized tool that measures caregiver infrastructure and needs of those caring from frail US veterans. The tool developed gathered the participants' profile, caregiving characteristics, and related needs. The tool was validated and pretested for reliability. Fifteen participants were also interviewed to explore caregiving challenges and needs. Descriptive and χ² statistics were used for quantitative outcomes, while thematic analysis was employed for qualitative data.

RESULTS

Participants provided moderate assistance to patients, spending an average of 10.65 h/day and 5.08 days/week in caregiving. The most difficult caregiving circumstances were having costly expenses (78.26%); missing work (50.00%); and experiencing negative feelings (47.83%), stress (43.48%), and physical difficulties (34.78%). They also had the lowest confidence in deciding when to contact health providers (x̅ = 3.31, SD = 0.94) and finding patient care services (x̅ = 2.93, SD = 1.08). Qualitative findings further revealed caregiving needs and challenges in cost management, physical and psychological health, assumption of multiple roles, lifestyle adjustment, and reinforcement of carer knowledge, skills, and attitudes.

CONCLUSION

Supportive strategies are needed to address the challenges encountered by home caregivers of hemodialysis patients. Findings can be utilized in developing appropriate interventions for home caregivers in low-resource settings where home caregiving and healthcare system issues, such as lack of access to resources and social support, are prevalent.

Psychological distress among medically complex veterans with a recent emergency department visit

Medical complexity and psychological distress are associated with frequent emergency department (ED) use. Despite this known association, our understanding is limited about which patients are at risk for persistent psychological distress and what patterns of distress emerge over time. A secondary data analysis was used to examine self-reported psychological distress (defined as ≥14 unhealthy days due to poor mental health in the past month) at 30 and 180 days following enrollment in a randomized control trial of 513 medically complex Veterans after a nonpsychiatric ED visit. We used a multivariable ordered logistic regression model to examine the association of a priori factors [baseline psychological distress, age, race, income, health literacy, deficits in activities of daily living (ADL), and deficits in instrumental activities of daily living] with three psychological distress classifications (no/low, intermittent, and persistent). Among 513 Veterans, 40% reported at baseline that they had experienced high psychological distress in the previous month. Older age was associated with lower odds of high psychological distress (OR = 0.95; 95% CI: 0.94-0.97). Baseline factors associated with significantly higher odds of persistent psychological distress at 30 and 180 days assessments, included having the inadequate income (OR = 1.61; 95% CI: 1.02-2.55), having low health literacy (OR = 1.63; 95% CI: 1.01-2.62), and reporting at least one ADL deficit (OR = 1.94; 95% CI: 1.13-3.33). Psychological distress at follow-up was common among medically complex Veterans with a recent ED visit. Future research should explore interventions that integrate distress information into treatment plans and/or link to mental health referral services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Academic-Practice Partnership for Caregiver Training and Support: The Duke Elder Family/Caregiver Training (DEFT) Center

BACKGROUND After a hospital stay, many older adults rely on their caregivers for assistance at home. Empirical evidence demonstrates that caregiver support programs in hospital-to-home transitions are associated with favorable caregiver and patient outcomes. We tested the feasibility of implementing the Duke Elder Family/Caregiver Training (DEFT) program in an academic medical center.METHODS: We recruited adult caregivers of homebound patients who were aged 55 years or older from Duke University Hospital in Durham, North Carolina. Caregivers attended a face-to-face caregiver training and received two telephone checks after hospital discharge with DEFT services ending at 14 days of hospital discharge. We used a one-item survey to measure overall DEFT satisfaction. We also monitored 30-day readmissions of patients whose caregivers completed the DEFT program.RESULTS: The DEFT Center received 104 consult orders in six months. Of these, 61 agreed to participate but nine caregivers were unable to schedule the DEFT training and three decided to eventually withdraw from participation. Forty-nine caregivers received the DEFT training, 12 of whom were ineligible to continue because of change in patients' disposition plan. Of the remaining 37 caregivers, 15 completed the full program and reported high satisfaction; one patient was readmitted within 30 days of discharge.LIMITATIONS: The DEFT implementation was based on academic-medical partnership and relied on electronic medical records for consult and documentation. Replicability and generalizability of findings are limited to settings with similar capabilities and resources.CONCLUSION: The implementation of a caregiver training and support program in an academic medical center was feasible and was associated with favorable preliminary outcomes.

Understanding the Associations between Caregiver Characteristics and Cognitive Function of Adults with Cancer: A Scoping Review

Cognitive impairment (CI) is one of symptoms that adults with cancer frequently report. Although there are known factors that contribute to a patient's CI, these factors did not sufficiently explain its variability. Several studies conducted in patients with neurocognitive disorders have reported relationships between patients' cognitive function and caregiver characteristics, which are poorly understood in the context of cancer. This scoping review aims to map the literature on caregiver characteristics associated with CI in adults with cancer. We used the framework proposed by Arksey and O'Malley and PRISMA-Sc. Studies published in English by 2019 were searched through seven electronic databases. All retrieved citations were independently screened and eligibility for inclusion was determined by two independent authors. Ten studies met inclusion for this review with all of them showing significant associations between a patient's cognitive function and caregiver characteristics. Caregiver's mental health was the most commonly associated with a patient's cognitive function followed by family functioning, adaptation to illness, attitude toward disclosure of the illness, burden, coping and resilience, and demographic characteristics. These review findings suggest that enhanced information about CI in relation to caregiver characteristics will eventually provide the foundation for multifocal interventions for patients with impaired cognitive function. This scoping review identified caregiver characteristics that are associated with patients CI. These characteristics should be also assessed when health providers assess and treat CI of adults with cancer.

Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial

BACKGROUND

Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit.

OBJECTIVE

To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED.

DESIGN

Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976).

SETTING

Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC.

PARTICIPANTS

Five hundred thirteen Veterans who were at high risk for repeat ED visits.

INTERVENTION

The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services.

MAIN MEASURES

The primary outcome was repeat ED use within 30 days.

KEY RESULTS

Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care.

CONCLUSIONS

A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants' increased engagement with primary care and some chronic disease management services.

TRIALS REGISTRATION

ClinicalTrials.gov NCT01717976.

HEALTH CARE PRIORITIES OF OLDER KOREAN IMMIGRANTS: THROUGH THE LENS OF LIFE COURSE THEORY

More than half of Korean Americans living in the US are immigrants, these immigrants hold unique cultural perspectives, including collectivism and filial piety that originates from Korean culture. Every older adult has life experiences and background that build and shape their own wishes and values for their health care goals. Thus, a qualitative descriptive study was conducted using the Life Course Theory as a guiding framework to examine older Korean immigrants’ health care goals and the influence of their life courses. Twenty six interviews from 13 participants were analyzed using content thematic analysis. Study rigor was ensured by audit trail, peer debriefing, and prolonged engagement. Data were organized under five overarching themes: health care priorities, time, location, linked lives, and turning point. Older Korean immigrants valued painlessness and being independent as health care goals (Health care priorities). They experienced a dynamic historical period in Korea before immigrating to the US (Time). Once they reached the US, they were disconnected from their social support and traditional values (Location). Children and Korean churches constitute older Korean immigrants’ primary support system once in the US (Linked lives). Their tumultuous life experiences contributed to their current perspectives on health care goals and priorities (Turning point). In studies of older immigrant populations, it is important to acknowledge individual differences while simultaneously understanding the general life history and cultural background behind individuals’ values and perspectives. Life course approach provides both a contextual understanding of older adults’ backgrounds and the trajectories of their individual life courses.

Caregiver Burden as a Mediator Between Emotional Distress and Concentration Problems in Patients With Cancer

OBJECTIVES

To examine the longitudinal mediation effect of caregiver burden on the relationship between emotional distress and concentration among individuals with cancer.

SAMPLE & SETTING

96 patients with cancer and their caregivers (96 dyads) were selected from a study conducted at Duke University.

METHODS & VARIABLES

A secondary analysis from a longitudinal study was used. Caregiver burden, as well as patients' emotional distress and concentration problems, were selected as variables and analyzed.

RESULTS

Caregiver burden acts as a mediator between emotional distress and concentration problems among patients with cancer. More severe caregiver burden is associated with more severe concentration problems for the patient. Dyads with higher patient emotional distress at one week (T1) also had higher caregiver burden at T1, which increased the concentration problems of patients at T1. When caregiver burden became more severe over time, patient concentration problems also increased.

IMPLICATIONS FOR NURSING

Healthcare providers should assess caregiver burden and identify factors that contribute to increased caregiver burden. Providing support for managing caregiver burden and patients' emotional distress will help improve patients' concentration capacity.

Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants: A Cohort Study

BACKGROUND

Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages.

OBJECTIVE

To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs).

DESIGN

Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record.

SETTING

568 VA primary care facilities.

PATIENTS

368 481 adult patients with diabetes treated pharmaceutically.

MEASUREMENTS

The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively.

RESULTS

The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant.

LIMITATION

Most VA patients are men who receive treatment in a staff-model health care system.

CONCLUSION

No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs.

PRIMARY FUNDING SOURCE

VA Health Services Research and Development.

Interpersonal continuity of primary care of veterans with diabetes: a cohort study using electronic health record data

Background

Continuity of care is a cornerstone of primary care and is important for patients with chronic diseases such as diabetes. The study objective was to examine patient, provider and contextual factors associated with interpersonal continuity of care (ICoC) among Veteran’s Health Administration (VHA) primary care patients with diabetes.

Methods

This patient-level cohort study (N = 656,368) used electronic health record data of adult, pharmaceutically treated patients (96.5% male) with diabetes at national VHA primary care clinics in 2012 and 2013. Each patient was assigned a “home” VHA facility as the primary care clinic most frequently visited, and a primary care provider (PCP) within that home clinic who was most often seen. Patient demographic, medical and social complexity variables, provider type, and clinic contextual variables were utilized. We examined the association of ICoC, measured as maintaining the same PCP across both years, with all variables simultaneously using logistic regression fit with generalized estimating equations.

Results

Among VHA patients with diabetes, 22.3% switched providers between 2012 and 2013. Twelve patient, two provider and two contextual factors were associated with ICoC. Patient characteristics associated with disruptions in ICoC included demographic factors, medical complexity, and social challenges (example: homeless at any time during the year OR = 0.79, CI = 0.75–0.83). However, disruption in ICoC was most likely experienced by patients whose providers left the clinic (OR = 0.09, CI = 0.07–0.11). One contextual factor impacting ICoC included NP regulation (most restrictive NP regulation (OR = 0.79 CI = 0.69–0.97; reference least restrictive regulation).

Conclusions

ICoC is an important mechanism for the delivery of quality primary care to patients with diabetes. By identifying patient, provider, and contextual factors that impact ICoC, this project can inform the development of interventions to improve continuity of chronic illness care.

The experiences of older caregivers of cancer patients following hospital discharge

PURPOSE

This study addressed the experiences of older caregivers of cancer patients in the 2 weeks following a hospital discharge. It sought to understand the challenges they face in providing supportive care to patients at home.

METHODS

Qualitative descriptive interviews with a narrative approach were conducted with each caregiver at 1 and 2 weeks following the patient's discharge from the hospital. A thematic analysis approach was used to identify the themes that emerged from the caregiver interviews.

RESULTS

Caregivers were primarily Caucasian (77%), were mostly 68 years of age or older (62%), and were primarily caring for a spouse (69%). Three key themes emerged from the qualitative analysis: caregiver and patient wellness are connected, caregivers' struggle with control issues, and challenges in communication with health professionals.

CONCLUSIONS

These findings highlight psychosocial changes that caregivers experience over the 2-week time period following hospital discharge. Implications include the need to identify interventions to better prepare caregivers for the post-discharge period.

Cancer-Related Cognitive Impairment in Breast Cancer Patients: Influences of Psychological Variables

Approximately 3.1 million women in the US are living with breast cancer and up to 75% of these women experience cancer-related cognitive impairment (CRCI). CRCI is described as impairments in memory, verbal fluency, thought processes, and attention span. Despite the high prevalence of breast cancer, only a few studies have been published on CRCI and most of these studies primarily focused on its pathophysiological mechanism. However, recent evidence has demonstrated that breast cancer patients with CRCI are more likely to have high level of psychologic distress, suggesting a possible relationship between CRCI and psychologic distress. This review aims to examine existing literature that describes CRCI in relation to psychological distress among breast cancer patients. One thousand four hundred and ninety-eight articles were searched using PubMed, CINAHL, and PsycINFO. Thirteen studies met inclusion criteria, and one article was additionally pulled from article reference lists. Of these19 studies, psychologic distress has been operationalized in varied ways such as anxiety (n = 3), depression (n = 2), both anxiety and depression (n = 4), stress (n = 4), worry (n = 2), mental fatigue (n = 1), and undefined psychological distress (n = 2). Except for six studies designed as a longitudinal study, the rest of studies used a cross-sectional design. Twelve studies used both subjective and objective measures to assess cognitive function. We found that the patients with high psychological distress displayed lower performance on cognitive function tests. Our finding indicates that psychological variables contributed to CRCI that breast cancer patients experienced. Areas for further investigation are proposed that will advance the care of breast cancer patients with CRCI.

Risk stratification for return emergency department visits among high-risk patients

OBJECTIVES

To compare 2 methods of identifying patients at high-risk of repeat emergency department (ED) use: high Care Assessment Need (CAN) score (≥90), derived from a model using Veterans Health Administration (VHA) data, and "Super User" status, defined as more than 3 ED visits within 6 months of the index ED visit.

STUDY DESIGN

Retrospective cohort study.

METHODS

Using McNemar's test, we compared rates of high-risk classification between CAN score and Super User status. We examined differences in patient characteristics and healthcare utilization across 4 levels of risk classification: high CAN and Super User status (n = 198), CAN <90 and non-Super User (n = 622), high CAN and non-Super User (n = 616), or Super User and CAN score <90 (n = 106). We used logistic regression to identify associations between risk classification and any ED visit within 90 days.

RESULTS

Of 1542 veterans, 52.8% (n = 814) had a CAN score ≥90 and 19.7% (n = 304) were Super Users (P <.0001), indicating discrepant rates of high-risk classification. However, we found no differences in patient characteristics. Rates of subsequent ED use were high: 63.1% of patients had 1 or more ED visits. No levels of risk classification were associated with subsequent ED use within 90 days (P = .25).

CONCLUSIONS

Among the VHA users with multimorbidity and 3 or more prior ED visits or hospitalizations, subsequent ED use was high. Although CAN scores have demonstrated utility for predicting hospitalizations and deaths, prior utilization and multimorbidity without further risk classification identified a high-risk group for repeat ED use.

Factors Associated With Having a Physician, Nurse Practitioner, or Physician Assistant as Primary Care Provider for Veterans With Diabetes Mellitus

Expanded use of nurse practitioners (NPs) and physician assistants (PAs) is a potential solution to workforce issues, but little is known about how NPs and PAs can best be used. Our study examines whether medical and social complexity of patients is associated with whether their primary care provider (PCP) type is a physician, NP, or PA. In this national retrospective cohort study, we use 2012-2013 national Veterans Administration (VA) electronic health record data from 374 223 veterans to examine whether PCP type is associated with patient, clinic, and state-level factors representing medical and social complexity, adjusting for all variables simultaneously using a generalized logit model. Results indicate that patients with physician PCPs are modestly more medically complex than those with NP or PA PCPs. For the group having a Diagnostic Cost Group (DCG) score >2.0 compared with the group having DCG <0.5, odds of having an NP or a PA were lower than for having a physician PCP (NP odds ratio [OR] = 0.83, 95% confidence interval [CI]: 0.79-0.88; PA OR = 0.85, CI: 0.80-0.89). Social complexity is not consistently associated with PCP type. Overall, we found minor differences in provider type assignment. This study improves on previous work by using a large national dataset that accurately ascribes the work of NPs and PAs, analyzing at the patient level, analyzing NPs and PAs separately, and addressing social as well as medical complexity. This is a requisite step toward studies that compare patient outcomes by provider type.

Randomized trial of an uncertainty self-management telephone intervention for patients awaiting liver transplant

OBJECTIVE

We tested an uncertainty self-management telephone intervention (SMI) with patients awaiting liver transplant and their caregivers.

METHODS

Participants were recruited from four transplant centers and completed questionnaires at baseline, 10, and 12 weeks from baseline (generally two and four weeks after intervention delivery, respectively). Dyads were randomized to either SMI (n=56) or liver disease education (LDE; n=59), both of which involved six weekly telephone sessions. SMI participants were taught coping skills and uncertainty management strategies while LDE participants learned about liver function and how to stay healthy. Outcomes included illness uncertainty, uncertainty management, depression, anxiety, self-efficacy, and quality of life. General linear models were used to test for group differences.

RESULTS

No differences were found between the SMI and LDE groups for study outcomes.

CONCLUSION

This trial offers insight regarding design for future interventions that may allow greater flexibility in length of delivery beyond our study's 12-week timeframe.

PRACTICE IMPLICATIONS

Our study was designed for the time constraints of today's clinical practice setting. This trial is a beginning point to address the unmet needs of these patients and their caregivers as they wait for transplants that could save their lives.

Assessment of Research Capacity Among Nursing Faculty in a Clinical Intensive University in The Philippines

BACKGROUND

Many nursing studies are conducted in the United States, Europe, and Australia, where only a fourth of the world's population resides. There is a need to promote nursing research in Asia to enhance the contextual relevance of their evidence-based nursing interventions. A first step toward this goal is to determine the perceived research capacity among nursing faculty in academic settings in the Philippines.

METHODS

This study described the perceived research capacity among nursing faculty of the University of Santo Tomas - College of Nursing, Manila, Philippines. The study used a survey that contained four sections: subject demographics; knowledge and skill on research designs and research process; research involvement, services, and incentives; and factors affecting research involvement. Chi-square test of homogeneity and MANOVA analyzed the gathered data.

RESULTS

Findings showed that the faculty perceived themselves as knowledgeable and skillful in conducting research. However, current teaching assignments hindered their capacity to conduct research. University-sponsored incentives and college-based research services had also remained underutilized despite their availability. Overall, heavy teaching load was the greatest hindrance to research endeavors.

CONCLUSION

Actions must be taken to reconfigure effort allocations with careful consideration of existing university and institutional bylaws.

Integrating Mental Health Concepts in the Care of Adults With Chronic Illnesses: A Curricular Enhancement

BACKGROUND

In the United States, inadequate attention has been given to the mental health needs of chronically ill adults, and the attempts to integrate mental health in primary care have fallen short.

METHOD

This article describes the beginning efforts of the faculty at Duke University School of Nursing to integrate mental health concepts into its adult-gerontological nurse practitioner and family nurse practitioner curricula.

RESULTS

Competency and course content mapping activities revealed opportunities for mental health enhancement. Five mental health concepts were identified for module development: spectrum of emotions, validation skills, self-management, resilience, and diversity. Mental health modules will be integrated in the nurse practitioner Physical Assessment and Diagnostic Reasoning course, as well as in various clinical courses.

CONCLUSION

Challenges and lessons learned, including efforts to foster active interprofessional learning among medical, physician assistant, and nurse practitioner students, are described.

Effects of enhanced caregiver training program on cancer caregiver's self-efficacy, preparedness, and psychological well-being

PURPOSE

We examined the effects of an enhanced informal caregiver training (Enhanced-CT) protocol in cancer symptom and caregiver stress management to caregivers of hospitalized cancer patients.

METHODS

We recruited adult patients in oncology units and their informal caregivers. We utilized a two-armed, randomized controlled trial design with data collected at baseline, post-training, and at 2 and 4 weeks after hospital discharge. Primary outcomes were self-efficacy for managing patients' cancer symptoms and caregiver stress and preparedness for caregiving. Secondary outcomes were caregiver depression, anxiety, and burden. The education comparison (EDUC) group received information about community resources. We used general linear models to test for differences in the Enhanced-CT relative to the EDUC group.

RESULTS

We consented and randomized 138 dyads: Enhanced-CT = 68 and EDUC = 70. The Enhanced-CT group had a greater increase in caregiver self-efficacy for cancer symptom management and stress management and preparation for caregiving at the post-training assessment compared to the EDUC group but not at 2- and 4-week post-discharge assessments. There were no intervention group differences in depression, anxiety, and burden.

CONCLUSION

An Enhanced-CT protocol resulted in short-term improvements in self-efficacy for managing patients' cancer symptoms and caregiver stress and preparedness for caregiving but not in caregivers' psychological well-being. The lack of sustained effects may be related to the single-dose nature of our intervention and the changing needs of informal caregivers after hospital discharge.

Discharge information and support for veterans Receiving Outpatient Care in the Emergency Department: study design and methods

BACKGROUND

An explicit goal of Patient Aligned Care Teams (PACTs) within the Veterans Health Administration is to promote continuity of care in primary care clinics and thereby reduce Emergency Department (ED) utilization; however, there has been little research to guide PACTs on how to accomplish this.

OBJECTIVES

The overall goal of this study is to examine the impact of a primary care-based nurse telephone support program [DISPO ED] on Veterans treated and released from the ED who are at high risk for repeat visits.

METHODS

This study is a two group randomized, controlled trial to evaluate DISPO ED for Veterans treated and released from the ED who are at high risk for repeat visits. We define high risk as those who have had an ED visit or hospitalization during the 6 month period before the index ED visit and have ≥2 chronic conditions. Veterans are randomized to nurse telephone support or usual care. The primary outcome is repeat ED use within 30 days; secondary outcomes are patient satisfaction with care and total costs.

DISCUSSION

The results of this randomized, controlled trial with an Effectiveness-Implementation Type I Hybrid design will be directly relevant to the care of more than 500,000 high risk patients seen in Veterans' Affairs Medical Center (VAMC) EDs annually. Results will also be informative to health systems outside VA aiming to reduce ED use through accountable care organizations.

Effects of nurse-managed protocols in the outpatient management of adults with chronic conditions: a systematic review and meta-analysis

BACKGROUND

Changes in federal health policy are providing more access to medical care for persons with chronic disease. Providing quality care may require a team approach, which the American College of Physicians calls the "medical home." One new model may involve nurse-managed protocols.

PURPOSE

To determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from January 1980 through January 2014.

STUDY SELECTION

Two reviewers used eligibility criteria to assess all titles, abstracts, and full texts and resolved disagreements by discussion or by consulting a third reviewer.

DATA EXTRACTION

One reviewer did data abstractions and quality assessments, which were confirmed by a second reviewer.

DATA SYNTHESIS

From 2954 studies, 18 were included. All studies used a registered nurse or equivalent who titrated medications by following a protocol. In a meta-analysis, hemoglobin A1c level decreased by 0.4% (95% CI, 0.1% to 0.7%) (n = 8); systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31 mm Hg) and 1.56 mm Hg (CI, 0.36 to 2.76 mm Hg), respectively (n = 12); total cholesterol level decreased by 0.24 mmol/L (9.37 mg/dL) (CI, 0.54-mmol/L decrease to 0.05-mmol/L increase [20.77-mg/dL decrease to 2.02-mg/dL increase]) (n = 9); and low-density-lipoprotein cholesterol level decreased by 0.31 mmol/L (12.07 mg/dL) (CI, 0.73-mmol/L decrease to 0.11-mmol/L increase [28.27-mg/dL decrease to 4.13-mg/dL increase]) (n = 6).

LIMITATION

Studies had limited descriptions of the interventions and protocols used.

CONCLUSION

A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions, such as diabetes, hypertension, and hyperlipidemia.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs.

Pillars for the care of older persons in the Caribbean

Pillars for the Care of Older Persons in the Caribbean: A Comprehensive Community-Based Framework (Pillars) is a hybrid of multiple public health frameworks developed through community-based participatory research processes. Health and social service professionals, governmental organizations, elderly persons, and others from across the English-speaking Caribbean countries developed the Pillars framework to address the growing elderly population and with an aim to increase the number of healthy and active years of life. The Pillars framework consists of four interrelated pillars organized across multiple sectors of society: primary care with care management; integrated services coordination; population-based health promotion and disease prevention; and planning and accountability. Pillars is enabled by an envisioned integrated system of information technology that will increase community-based services delivery, interprofessional communication and coordination, and will aggregate data with all identifiers removed for surveillance, planning, forecasting, policy making, evaluation, and research.

Effects of an individualized caregiver training intervention on self-efficacy of cancer caregivers

Caring for older cancer patients after hospital discharge is challenging and many of their caregivers lack confidence to do so. This study investigated the effects of an individualized caregiver training program on self-efficacy in home care and symptom management. A total of 120 patient-caregiver dyads were randomly assigned to either the treatment (n = 60) or control group (n = 60). The training focused on prevention of infection, pain control, maintenance of nutrition and adequate elimination, and specific care issues identified by the caregiver. Control group received information about community-based resources. Results revealed a significant increase in self-efficacy after the training in the treatment group but not in the control group. No intervention effect was seen on caregiver's psychological well-being (depression, anxiety, and quality of life) and patient's physical symptoms.

Effects of an Individualized Caregiver Training Intervention on Self-Efficacy of Cancer Caregivers

Caring for older cancer patients after hospital discharge is challenging and many of their caregivers lack confidence to do so. This study investigated the effects of an individualized caregiver training program on self-efficacy in home care and symptom management. A total of 120 patient–caregiver dyads were randomly assigned to either the treatment ( n = 60) or control group ( n = 60). The training focused on prevention of infection, pain control, maintenance of nutrition and adequate elimination, and specific care issues identified by the caregiver. Control group received information about community-based resources. Results revealed a significant increase in self-efficacy after the training in the treatment group but not in the control group. No intervention effect was seen on caregiver’s psychological well-being (depression, anxiety, and quality of life) and patient’s physical symptoms.

Supportive approaches for Alzheimer disease

Alzheimer disease (AD) accounts for most dementia diagnoses. Acetylcholinesterase inhibitors and antipsychotics are first-line drug therapies for cognitive decline and to manage neuropsychiatric symptoms, respectively. Because AD is relentlessly progressive, NPs will need to provide long-term support to patients and their caregivers.

The Connected Learning Model for disseminating evidence-based care practices in clinical settings

Clinical practice guidelines have been developed to improve patient care and outcomes. Guideline implementation is often stymied by the complexity of patients' conditions, complex care environments, and limited advanced clinical training of nursing staff. To translate key elements of heart failure guidelines into practice in a nursing home, the Connected Learning Model was developed based on the diffusion of innovations framework. An advanced practice nurse in geriatrics fostered greater interaction and collaboration among key administrative, medical, and nursing staff to promote awareness of heart failure guidelines and to translate key practices from those guidelines into the nursing home setting. Direct care staff skills for early recognition and reporting of signs and symptoms of acute heart failure were enhanced through a learner-centered educational program which included classroom and unit-based instruction and bedside clinical teaching. The Connected Learning Model is a promising method to mobilize advanced nursing expertise to bridge research/practice gaps through implementation of clinical practice guidelines that are systematically adapted to accommodate diverse health care contexts.

Chronic Care Management for the Elderly: An Opportunity for Gerontological Nurse Practitioners

PURPOSE

To discuss the role that gerontological nurse practitioners (GNPs) may play in providing chronic care management for the elderly.

DATA SOURCES

Review of recent literature on chronic care management, personal experience of the authors in caring for older adults under the chronic care management model, and a case study.

CONCLUSIONS

GNPs are the most appropriate practitioners to provide and coordinate chronic care management to the population that needs it most--the elderly.

IMPLICATIONS FOR PRACTICE

Demographic shifts in the United States have increased the number of people with chronic illnesses; however, the nation's healthcare delivery system has not significantly evolved to meet the changing needs of its population. As a result, many people, especially older adults, suffer needlessly, and healthcare costs continue to rise. Chronic care management may alleviate older adults' chronic health problems, reduce expenditures for their health care, and promote their satisfaction and quality of life.

The use of the Minimum Data Set to identify depression in the elderly

OBJECTIVE

To determine whether depression in the elderly in institutionalized settings could be identified using the mood indicators in the Minimum Data Set (MDS) 2.0 (Section E1, Items A-P).

DESIGN

Descriptive study.

SETTING

Three nursing homes in the southeastern part of the country.

PARTICIPANTS

Residents aged 65 and above.

MEASUREMENTS

The items in "Indicators of Depression, Anxiety and Sad Mood" on the MDS 2.0 were used to identify observable features of depression in the elderly. The Cornell Scale for Depression in Dementia (CSDD) was used to validate the MDS indicators. Consensus analysis, which controls raters' bias, raters' ability, and item difficulty, was used to analyze data.

RESULTS

No depressive patterns were detected using the MDS indicators. On the CSDD, distinct depressive features were identified: anxiety, sadness, lack of reaction to pleasant events, irritability, agitation, multiple physical complaints, loss of interest, appetite loss, and lack of energy.

CONCLUSION

The incongruent findings on the MDS indicators the CSDD may be reflective of the assessment process used with the MDS rather than its ability to identify features of elderly depression. The practice of allowing nondirect caregivers to complete the MDS may have serious implications for the accuracy of the data collected.

Computer use among elderly people

This study investigates the literature on the state of knowledge on computer use among elderly people. Results of this review suggest that benefits may ensue if computer use is advocated. Functional limitations secondary to visual, hearing, and mobility changes; financial inadequacy; and cognitive limitation related to memory use are identified as barriers that may inhibit this population from learning how to use the computer. Methods and techniques dealing with these barriers are presented. Finally, teaching strategies that may be implemented to facilitate the learning process among elderly population on computer use are discussed and elucidated.

Validation of the Impact of Event Scale on a sample of American Vietnam veterans

The goal of the present report is to validate the Impact of Event Scale for use as a measure of the enduring nature of reactions to combat stress by 60 American Vietnam veterans. Validity was supported through significant correlations with measures of abusive violence and combat exposure. From factor analysis a single factor (general level of distress) supported the validity of the scale and thereby further use with Vietnam veterans.

Validation of the Purdue Post-Traumatic Stress Scale on a sample of Vietnam veterans

The Purdue Post-traumatic Stress Disorder Scale is a 15-item self-report instrument based on the DSM-III diagnostic criteria for post-traumatic stress disorder. This scale is a quick, easily administered, measure of psychological reactions to a traumatic event. The goal of the present report is to validate this instrument for use as a measure of long-lasting combat stress reactions of American Vietnam veterans. The PPS demonstrated a high degree of internal consistency with a Cronbach's coefficient alpha of 0.94. The PPS demonstrated construct validity through significant correlations with other self-report measures of combat experience and residual psychological distress, and through a factor analysis yielding three factors, labeled as arousal, avoidance, and the global perception of distress. Results support further use of the Purdue Post-traumatic Stress Scale as a research instrument for assessing the long-term impact of a traumatic event.

The Stressors of Clergy Children Inventory: reliability and validity

The purpose of this study was to develop and evaluate the Stressors of Clergy Children Inventory. The initial self-report survey was tested for internal consistency reliability. Tests for construct validity, concurrent validity, and internal consistency reliability indicated the inventory could be used in research. Recommendations for refinement and use were presented.