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REVIEW QUESTION: What are the experiences and perceptions of physical restraint policies and practices by health professionals, administrators and policy makers in the acute care sector?

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REVIEW QUESTION: The overarching question for this qualitative systematic review is: What meanings are attributed to the experience of physical restraint among adult patients or their significant others in acute care hospitals? Specifically the review will seek to answer two questions.

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BACKGROUND: "Watchful waiting" or "active surveillance" is an alternative approach in the medical management of certain diseases. Most often considered appropriate as an approach to treatment for low-risk prostate cancer, it is also found in the literature in breast cancer surveillance, urinary lithiasis, lymphocytic leukemia, depression and small renal tumors. OBJECTIVES: This systematic review sought to:Identify and synthesize the best available international evidence on the experience of adults who choose watchful waiting or active surveillance as an approach to medical treatment. To this end the questions addressed in this review were:1. How do patients who have chosen watchful waiting or active surveillance describe the process of coming to the decision?2. What were the factors that influenced their decision to choose?3. How do patients who have chosen watchful waiting or active surveillance describe the experience? INCLUSION CRITERIA: Male or female patients, 18 years or older, who experience the phenomenon of choosing or not choosing watchful waiting or active surveillance as a treatment approach.The phenomena of interest were accounts of the experiences of adult patients who choose watchful waiting or active surveillance as an approach to medical treatment.This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and critical theory. Mixed method studies with narrative description and patient voice were also considered. Grey literature such as research reports and dissertations were also included. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies through electronic databases, reference lists, and the World Wide Web. Extensive searches were undertaken of relevant databases to include CINAHL, PubMed, SCOPUS and PsycINFO. A three-step search strategy was used in each component of the review. Studies were limited to English language papers. The search considered papers from the year 2000 to January 2015. METHODOLOGICAL QUALITY: Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. DATA EXTRACTION: Qualitative data were extracted from papers included in the review using the standardized data extraction tool from. The data extracted included specific details about the phenomena of interest that described the experiences pertinent to the review questions DATA SYNTHESIS: The data were synthesized using the Joanna Briggs Institute approach to meta-synthesis by meta-aggregation using the JBI-QARI software and methods. RESULTS: A total of 16 studies, critically appraised by two independent reviewers and deemed to be of high quality, were included in the final review. One study was excluded after appraisal. One hundred and fifty-five findings from the 16 studies were extracted into 10 categories and then into three synthesized findings. The synthesized findings explicated: CONCLUSIONS: The synthesized findings of the review conclude that the process of making the decision to choose watchful waiting is complex. Through the process patients and their significant others experience an array of emotions that often lead to uncertainty and anxiety. Once the decision is made patients must cope with the knowledge that they have a troubling diagnosis and make the necessary adjustments. An empathic, reassuring relationship with a healthcare practitioner eases the burden of this process.Healthcare providers need to recognize that not all patients are "at peace" with the decision of choosing watchful waiting. Uncertainty and fear may intensify during this time as well as feelings of stress and anxiety. Patients and their significant others often attempt to adapt in the best way they know how but the effectiveness of their coping strategies needs to be assessed. In addition, healthcare providers need to also be aware that with the increased anxiety and stress associated with watchful waiting, patients' understanding of healthcare information and the ability to ask questions may be diminished. Both providers and patients benefit from open discussions related to the many aspects of uncertainty and fear related to making and living with the decision. Employing a shared decision making model with regard to the management of the array of issues that comes from both making the decision and living with it is recommended. It appears that patients are very sensitive to recognizing when the care they are receiving lacks empathy. Communication that is open, empathic, and non-judgmental is essential. A willingness to discuss sensitive issues such as sexual function needs to be conveyed. Lastly, providers and their staff need to remain attentive to the importance of articulating aspects of the situation that are hopeful and optimistic as many patients, during their visits, take their cues regarding their health status from non-verbal and verbal interactions.Future studies should investigate.

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The evidence-based health care movement has generated new opportunity for scholars to generate synthesized sources of evidence. Systematic reviews are rigorous forms of synthesized evidence that scholars can conduct if they have requisite skills, time, and access to excellent library resources. Systematic reviews play an important role in synthesizing what is known and unknown about a particular health issue. Thus, they have a synergistic relationship with primary research. They can both inform clinical decisions when the evidence is adequate and identify gaps in knowledge to inform research priorities. Systematic reviews can be conducted of quantitative and qualitative evidence to answer many types of questions. They all share characteristics of rigor that arise from a priori protocol development, transparency, exhaustive searching, dual independent reviewers who critically appraise studies using standardized tools, rigor in synthesis, and peer review at multiple stages in the conduct and reporting of the systematic review.

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Delirium is a frequent, yet often unrecognized, occurrence in elderly hospitalized patients. In patients with hip fracture, the incidence of delirium is reported to be as high as 62% and even greater if over 65 years of age. One approach to the prevention and management of postoperative delirium in elderly patients with hip fracture is the clinical audit. A clinical audit is a retrospective assessment of clinical care of patients and is guided by criteria that are evidence-based statements of best practice. The use of measurable, objective criterion, with an agreed standard of performance is the hallmark of an audit. The clinical audit criteria presented in this article for the prevention and management of delirium in hospitalized elderly with hip fracture were determined by a compilation of systematic reviews and existing evidence-based clinical guidelines. The following 5 audit criteria are discussed: (1) All elderly patients with a hip fracture are assessed for risk factors for developing delirium daily using a valid and reliable tool; (2) the environment of the patient with hip fracture is assessed daily for conduciveness to maintaining sensory orientation; (3) all patients with hip fracture receive essential nursing care; (4) appropriate clinical criteria are applied to confirm a diagnosis of delirium in patients with hip fracture; and (5) nonpharmacologic interventions are employed before pharmacologic interventions in patients with hip fracture with a diagnosis of delirium.

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High-dependency environments are complex both from the standpoint of diversity of patient types and the nature of their functioning. Nurses manage this complexity at many different levels. Being attuned not only to the physical status of the patient but also the emotional/psychological status is paramount in maintaining a safe environment. Staff training and education is paramount in reducing risk. Institutions have a responsibility to provide resources to develop violence prevention programs.

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The experience of moral distress for professional nurses working in hospital environments causes a myriad of biological, psychological, and stress-related reactions. There is an institutional culpability in producing an environment where moral distress is experienced. This is particularly true when nurses feel the need to advocate for patients' well-being while coping with institutional constraints. The perception of patient pain and suffering as a result of medical decisions, which the nurse has little power to influence, contributes to the experience. Unequal power structures, prevalent in institutions, exacerbate the problem. Critical care nurses need to recognize moral distress and its adverse impact on providing optimal patient care. Critical care nurses should make a personal commitment that moral distress will not impact their nursing care and take a leadership role in their units to address this issue with their employing institution and develop strategies to lessen the impact of moral distress. These strategies should be based on the best available evidence such as this systematic review and other relevant appraised works.

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BACKGROUND: The presence of family members during resuscitation and invasive procedures has been, and continues to be debated in the literature. OBJECTIVE: To synthesize the best available research evidence on how families and health care practitioners experience family presence during resuscitation and invasive procedures. INCLUSION CRITERIA: Studies about families and health care practitioners experiencing family presence during resuscitation and invasive procedures were considered.This review considered family members and health care practitioners who had experienced the phenomena of family presence during resuscitation or invasive procedures.Family members and health care practitioners experience of family presence during resuscitation or invasive procedures.Qualitative evidence consisting of, but not limited to, designs such as interpretive, descriptive-exploratory, observational, phenomenology, ethnography, grounded theory, hermeneutics, participatory action research, and critical theory were included in the review. SEARCH STRATEGY: The search strategy sought to find both published and unpublished research articles from 1985 to 2009. The review was limited to papers written in English. METHODOLOGICAL QUALITY: Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the standardised tools developed by the Joanna Briggs Institute. DATA COLLECTION: Data were using standardized data extraction tools developed by the Joanna Briggs Institute. DATA SYNTHESIS: The Joanna Briggs Institute' approach for meta-synthesis by meta-aggregation was used. RESULTS: 25 studies were included in the review. 154 findings were extracted and synthesized into 14 categories and 5 synthesized findings. CONCLUSIONS: A tension is created between the belief of most family members that being present is a right and health care practitioners who believe they should have control over the circumstances of the practice. Although healthcare practitioners express concern that the practice will cause the family to experience psychological trauma the data does not suggest that this is the case. Most family members describe their presence as an opportunity to comfort and to gain closure. IMPLICATIONS FOR PRACTICE: IMPLICATIONS FOR RESEARCH.

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BACKGROUND: The placement of hospitalised patients in isolation is either done to protect the immunocompromised patient from others (reverse or protective isolation) or to protect others from the patient's infectious process (isolation). Both situations require limiting the contact between the patient and others to prevent the spread of pathogens or to protect the immunocompromised patient. Isolating patients remains a primary treatment in the hospital setting. There is no formal meta-aggregation of the qualitative research literature that describes the meaning of this experience. Explication of the meaning will provide valuable information for clinicians as they care for persons in isolation. OBJECTIVES: The aim of this review was to synthesise the best available qualitative evidence on the experience of hospitalised patients being placed in isolation. INCLUSION CRITERIA: The participants were adult (> 18 years old) hospitalised patients in isolation.The phenomenon of interest was the meaning of being in isolation from the hospitalised patient's perspective.The studies of interest were qualitative studies that focused on adult hospitalized patients and their experience with being cared for in isolation. SEARCH STRATEGY: The search strategy sought to find both published and unpublished research studies from 1971 to May 2010. This review was limited to papers written in English. A three step search strategy was utilised. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of text words contained in the title and abstract, and of index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. Lastly, a final hand search of the reference lists from included papers was employed. METHODOLOGICAL QUALITY: Each paper was assessed independently by two reviewers for methodological quality prior to inclusion in the review using the appropriate Joanna Briggs Institute critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information (SUMARI) package. DATA COLLECTION: Data was extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument. DATA SYNTHESIS: Categories were formed based on aggregation of similar findings with like meaning. The categories were analysed to identify synthesised findings that were presented as declamatory and generalisable statements to guide and inform practice. RESULTS: A total of 12 studies were reviewed and, of those, 4 were excluded for methodological concerns and 8 were included in the review. The qualitative studies examined the hospitalised patients' experiences of being in isolation. A total of 56 findings were extracted from included studies. Findings were then synthesised in 11 categories. Two synthesised findings were developed from these categories: (1) The isolation experience causes fractured human connectivity and nurses must provide care that mitigates the negative effects of this; and (2) nurses must attend to the reality that a variety of factors affect the patient's ability to adapt to an artificial environment. CONCLUSION: The patient in isolation temporarily resides in an artificial environment, removed from the normalcy of their life. The experience of being in isolation causes severe limitation in or loss of self-determination and autonomy, resulting in the patient being caught in a restrictive environment in which they have little control. The isolated patient must relinquish their autonomy and due to limited contact with others there is disjointed and fractured human connection. IMPLICATIONS FOR PRACTICE: In order to moderate the detrimental psychosocial effects of isolation, institutional policies need to reflect the higher acuity of care required, allow the patient to have choices, design rooms that consider the long-term patient, and support nursing care that is considerate of the unique needs of the isolated patient. IMPLICATIONS FOR RESEARCH: Further exploration of the effects of isolation on the achievement of desired patient outcomes is needed. In-depth comparative studies between nurses' perceptions of the care they provide versus the patients' perception of the care they receive would provide valuable insights. Additionally, studies that explore patients' perception of how helpful they find nursing interventions aimed at meeting their psychosocial care needs would also provide useful data. Lastly, studies that explore the barriers perceived by nursing staff to implementing patient-centered care in the isolation environment would be helpful in informing nursing practice.

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BACKGROUND: Jameton who first conceptualized moral distress, described it as arising when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. The phenomenon of moral distress is well documented in the nursing literature but no systematic review exists. The plethora of literature on moral distress would suggest that attention to this phenomenon is deemed noteworthy by the profession. A synthesized understanding of how nurses experience the phenomenon of moral distress is presented. OBJECTIVES: The overall objective of this review was to appraise and synthesize the best available evidence on how professional nurses working in hospital environments experience ethical/moral distress. INCLUSION CRITERIA: This review considered qualitative research including descriptive/exploratory studies whose participants were professional nurses working in hospital environments and experienced either moral or ethical distress as a result of their patient care responsibilities. Studies were included that described participant's own experience of moral distress. SEARCH STRATEGY: The search strategy sought to find both published and unpublished research studies. This review was limited to papers in English. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of text words contained in the title and abstract, and of index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. METHODOLOGICAL QUALITY: Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the Qualitative Assessment and Review Instrument (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third party reviewer. DATA COLLECTION: Information was extracted by two reviewers from each paper using the Qualitative Assessment and Review data extraction tool (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer. DATA SYNTHESIS: Data synthesis aimed to portray an accurate interpretation and synthesis of themes arising from the selected participant's experience of moral distress. RESULTS: A total of 50 studies were identified and of those 39 were included in the review. These qualitative studies examined how professional nurses working in hospital environments experienced moral/ethical distress. Findings were analyzed using the JBI-QARI tool. The process of meta-synthesis using this program involved categorizing findings and developing synthesized topics from the categories. Four syntheses were developed related to the experience of moral distress: human reactivity, institutional culpability, patient pain and suffering, and unequal power hierarchies. CONCLUSION: Nurses who experience moral distress respond with a myriad of biological, psychological and stress reactions. Moral distress is experienced when nurses feel the need to advocate for patients well-being, while coping with institutional constraints. The perception of patient pain and suffering as a result of medical decisions of which the nurse has little power to influence also contributed to the experience. Unequal power structure prevalent in institutions exacerbates the problem. IMPLICATIONS FOR PRACTICE: In order to mitigate the effects of moral distress institutions need to design structures of support for nurses that provide education on the effects of moral distress, give nurses authentic voice in expressing ethical concerns and allow them to practice nursing in a way that does not violate their core professional values. IMPLICATIONS FOR RESEARCH: Further research is needed on the effectiveness of interventions designed to decrease the effect of moral distress on the workplace environment. Additionally, measuring the effectiveness of strategies designed to provide nurses a platform to openly express their ethical concerns and provide them an authentic voice would inform the profession. Research on the hierarchical structures of the nurse-physician relationship within the hospital environment and its effect on patient care outcomes would enrich the literature.