Donald E. Bailey

Active surveillance for early-stage prostate cancer: Review of the current literature

The natural history of prostate cancer is remarkably heterogeneous and, at this time, not completely understood. The widespread adoption and application of prostate‐specific antigen (PSA) screening has led to a dramatic shift toward the diagnosis of low‐volume, nonpalpable, early‐stage tumors. Autopsy and early observational studies have shown that approximately 1 in 3 men aged >50 years has histologic evidence of prostate cancer, with a significant portion of tumors being small and possibly clinically insignificant. Utilizing the power of improved contemporary risk stratification schema to better identify patients with a low risk of cancer progression, several centers are gaining considerable experience with active surveillance and delayed, selective, and curative therapy. A literature review was performed to evaluate the rationale behind active surveillance for prostate cancer and to describe the early experiences from surveillance protocols. It appears that a limited number of men on active surveillance have required treatment, with the majority of such men having good outcomes after delayed selective intervention for progressive disease. The best candidates for active surveillance are being defined, as are predictors of active treatment. The psychosocial ramifications of surveillance for prostate cancer can be profound and future needs and unmet goals will be discussed. Cancer 2008.

Helping patients with localized prostate carcinoma manage uncertainty and treatment side effects: nurse-delivered psychoeducational intervention over the telephone.

The objective of this study was to test the efficacy of an individualized uncertainty management intervention delivered by telephone to Caucasian and African‐American men with localized prostate carcinoma and directed at managing the uncertainties of their disease and treatment.

Uncertainty intervention for watchful waiting in prostate cancer.

Watchful waiting is a reasonable alternative to treatment for some older men with localized prostate cancer, but it inevitably brings uncertainty. This study tested the effectiveness of the watchful waiting intervention (WWI) in helping men cognitively reframe and manage the uncertainty of watchful waiting. Based on Mishels Reconceptualized Uncertainty in Illness Theory (Image. 1990; 256–262), the WWI was tested with a convenience sample of 41 men. Experimental subjects received 5 weekly intervention calls from a nurse. Control subjects received usual care. Outcomes were new view of life, mood state, quality of life, and cognitive reframing. Repeated measures of analysis of variance were used to test the effectiveness of the WWI. The sample was 86% Caucasian and 14% African American, with an average age of 75.4 years. Intervention subjects were significantly more likely than controls to view their lives in a new light (P = .02) and experience a decrease in confusion (P = .04) following the intervention. Additionally, intervention subjects reported greater improvement in their quality of life than did controls (P = .01) and believed their quality of life in the future would be better than did controls (P = .01). This studys findings document the benefits of the WWI for patients living with uncertainty.

Nurse assistant mental models, sensemaking, care actions, and consequences for nursing home residents

In a nursing home case study using observation and interview data, the authors described two mental models that guided certified nurse assistants (CNAs) in resident care. The Golden Rule guided CNAs to respond to residents as they would want someone to do for them. Mother wit guided CNAs to treat residents as they would treat their own children. These mental models engendered self-control and affection but also led to actions such as infantilization and misinterpretations about potentially undiagnosed conditions such as depression or pain. Furthermore, the authors found that CNAs were isolated from clinicians; little resident information was exchanged. They suggest ways to alter CNA mental models to give them a better basis for action and strategies for connecting CNAs and clinical professionals to improve information flow about residents. Study results highlight a critical need for registered nurses (RNs) to be involved in frontline care.

Barriers to and Facilitators of Clinical Practice Guideline Use in Nursing Homes

OBJECTIVES: To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).

Patterns of Medical and Nursing Staff Communication in Nursing Homes: Implications and Insights From Complexity Science

Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical “chain of command” between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.

Moderators of an uncertainty management intervention: for men with localized prostate cancer.

BackgroundThe effectiveness of psycho-educational interventions for cancer patients is well documented, but less is known about moderating characteristics that determine which subgroups of patients are most likely to benefit. ObjectivesThe aim of this study was to determine whether certain individual characteristics of African-American and White men with localized prostate cancer moderated the effects of a psycho-educational Uncertainty Management Intervention on the outcomes of cancer knowledge and patient-provider communication. MethodsMen were blocked by ethnicity and randomly assigned to one of three conditions: Uncertainty Management Intervention provided to the patient only, Uncertainty Management Intervention supplemented by delivery to the patient and family member, or usual care. The individual characteristics explored were education, sources for information, and intrinsic and extrinsic religiosity. ResultsUsing repeated measures multivariate analysis of variance, findings indicated that there were no significant moderator effects for intrinsic religiosity on any of the outcomes. Lower level of education was a significant moderator for improvement in cancer knowledge. For the outcome of patient-provider communication, fewer sources for cancer information was a significant moderator for the amount told the patient by the nurse and other staff. Less extrinsic religiosity was a significant moderator for three areas of patient provider communication. The three areas are the amount (a) the physician tells the patient; (b) the patient helps with planning treatment; and (c) the patient tells the physician. ConclusionsTesting for moderator effects provides important information regarding beneficiaries of interventions. In the current study, men’s levels of education, amount of sources for information, and extrinsic religiosity influenced the efficacy of the Uncertainty Management Intervention on important outcomes.

the Assessment of Discomfort in Elderly Confused Patients: A Preliminary Study

&NA; With the increasing numbers of older adults in our population, nurses are reexamining all aspects of nursing care in order to best meet the needs of these individuals. Normal age changes, the impact of decades of environmental challenges, successful adaptations, acute illnesses, trauma and chronic illnesses combine to create a challenge for accurate and effective assessment of elderly patients. The nurse finds her assessment skills challenged with increasing frequency by the elderly patient who is also acutely confused and experiencing discomfort. The purpose of this study was to explore the clinical utility, validity and reliability of four different approaches to nursing assessment of discomfort with this particularly vulnerable group of elders.

Uncertainty, symptoms, and quality of life in persons with chronic hepatitis C.

BACKGROUND Chronic hepatitis C (CHC) is the most common blood-borne infection in the United States, but little is known about illness uncertainty in these patients. OBJECTIVE The authors examined the constructs of illness uncertainty. METHOD In this cross-sectional study, Mishels Uncertainty in Illness Scale was used to examine these constructs (ambiguity, complexity, inconsistency, unpredictability) and their relationships with fatigue, pain, depressive symptoms, comorbidity, and quality of life (QOL) in 126 CHC patients undergoing a watchful-waiting protocol. RESULTS The Ambiguity subscale had the strongest relationships with depressive symptoms, QOL, and fatigue, and three of the four subscales were significantly correlated with pain. CONCLUSION The results suggest targets for patient self-management interventions.

The Power of Relationship for High Quality Long Term Care

In an effort to ensure quality, nursing homes are among the most highly regulated and rule-driven health care organizations. With such attention to quality, why do industry assessments1 continue to report poor quality? Traditional models for organizing care are derived from longstanding Newtonian beliefs about the world and have led to a reliance on regulation and rules as a primary means of control.2 Complexity science, however, offers a new way to understand organizational dynamics3 and thus provides insights about why nursing homes may struggle to provide high quality care and suggests new targets for improvement. In particular, complexity science reveals that the capacity of a human system to change and improve is shaped by the quality of relationships among its members.4 Consider the following scenario. A certified nurse assistant (Katie CNA) discusses her assignment with the nurse. Katie CNA learns that she should first get Mrs. Jones up because this resident must be upright to eat due to choking risk; second bathe and dress Mrs. Smith who is incontinent and at risk for decubitus; and last care for Mrs. Lee because she is not incontinent and doesn’t mind sleeping later. Before beginning her assignment, however, Katie CNA hears from Mary CNA that Mrs. Lee’s daughter is on her way into the building. The nurses and CNAs all know that this daughter complains and is demanding when she finds her mother in bed past 7:30 am; these complaints have been discussed in recent unit meetings. Using this new information, Katie CNA adjusts her plans and takes care of Mrs. Lee first instead of following the nurse’s instructions. Remembering what she learned from the nurse, however, Katie CNA asks Mary CNA to get Mrs. Jones and Mrs. Smith out of bed right away. Mary CNA agrees but only after she secures Katie CNA’s promise to help with her heavy care residents later in the day. Meanwhile the nurse notices the daughter’s arrival, observes the adjustments made by Katie CNA and delays the daughter at the nurse’s station to allow Katie CNA time to prepare Mrs. Lee. This scenario describes a process of self-organization.5 Each individual began with a set of plans for her work. However, each quickly adjusted her actions based on new information that came through interaction with each other and observation of events. The outcome was good and appropriate care for those involved. Self-organization is a property of all social systems—referred to in complexity science as complex adaptive systems.3 Self-organization occurs when people are free to interact, exchange information, and adjust behavior to meet the immediate demands of the environment.5 In this scenario, three critical system parameters6 for effective self-organization were apparent in this small complex adaptive system. These system parameters, which are imbedded in the relationships among the members of the system, are: Appropriate information flow. Katie CNA received a clear assignment from the nurse and was open to additional new information from Mary CNA that made her aware of the need to adjust her plans. In addition, a unit meeting provided information to all staff members and allowed for discussion of the daughter’s history of complaints. Good connections among its members. Mary CNA had open communication with Katie CNA such that Katie trusted the information received. A unit meeting about Mrs. Lee’s daughter and her complaints is more evidence of good connection. In addition, the nurse was connected to the care setting such that she observed emerging events and thus was able to adjust her own behavior in response. Finally, Mary CNA trusted that Katie CNA would reciprocate and assist Mary with the heavy care residents. This trust was another sign of good connections among staff. There was sufficient cognitive diversity. Cognitive diversity refers the variety of people in a system in terms of characteristics such as roles or positions, education levels and background, or cultural orientations. Cognitive diversity means that the system will have more “new” information available to it. For example, people holding similar education, roles, and positions, are not as likely to learn something new from each other as would people who hold different education, roles and positions. In this scenario, the nurse and CNA, being cognitively diverse, interacted in a way that ensured a better understanding of events. Specifically, the nurse, using clinical knowledge, discussed information with Katie CNA in such a way that Katie understood that the care instructions were not meaningless rules to be followed. Because she learned the clinical basis for the care assignment, Katie CNA did not delay the care of Mrs. Jones and Smith when other demands arose; instead, she asked Mary CNA to substitute for her. Even this simplistic scenario suggests that a fairly complex set of behaviors were required for effective care. One would need a fairly long list of rules to specify the behaviors necessary to achieve this outcome, which occurred spontaneously and relatively effortlessly through self-organization. Such self-organization was possible only because of the nature of the relationships among the people on this unit. Currently, the authors are conducting a series of case studies in nursing homes in part to examine relationship patterns necessary for self-organization. To date, we have completed three, six-month case studies and found that in general, the relationship patterns in these nursing homes do not create a level of interaction needed to support truly effective self-organization. Some dominant patterns appeared across these three cases that are likely to exist in many other nursing homes as well. These dominant patterns, described below, suggest a restriction in information flow, poor connections among staff, and lack of interaction among people with cognitive diversity. Thus, the system parameters described above were restricted rather than enhanced. In these nursing homes, RNs were in supervisory or administrative roles and interacted with other nursing staff mainly over staffing problems and staff conflict issues. RNs engaged in interdisciplinary care planning but had minimal interaction with front line, LPN and CNA, staff. Sometimes RNs asked LPNs and CNAs for information, but little information was returned to them. LPNs were tied to medication and treatment carts, covering up to 30 or more residents. Thus, they interacted little with anyone else in their rush to medicate and treat residents on time. CNAs mainly interacted with other CNAs. If teamwork existed, it was in small cliques with conflict and lack of cooperation between cliques. CNAs were rewarded for completing individual assignments not for teamwork. There was heavy reliance on rules and rule enforcement. This meant that managers frequently interacted with staff to correct them on what they were doing wrong. In one example, a manager was observed correcting a CNA for placing a shampoo bottle in a laundry basket but the manager never knew, and thus did not acknowledge, that the CNA used her own money to buy the shampoo for a resident who had none. Not surprisingly, staff members in these nursing homes felt unappreciated. In sum, little attention was paid to the nature and quality of staff relationships. Something better is possible however! By recognizing that self-organization is a naturally occurring characteristic of all work units, managers have some new tools for facilitating a higher quality of care. Key to this capacity is fostering relationship patterns that appropriately alter the system parameters of information flow, connection, and cognitive diversity. Prior research studies have demonstrated a link between better resident outcomes, lower staff turnover and specific management practices that facilitate the system parameters. Some evidence-based management practices are: Reduce reliance on rules and on rule enforcement.4 Facilitate open communication where staff say what they believe without fear.4 In combination with communication openness, create a climate of clear expectations, appropriate rewards and attention to staff concerns.7 Facilitate participation in decision making (PDM) by nurses.4, 8 Facilitate CNA PDM along with high interaction between RNs and CNAs.9 Facilitate leadership behaviors that are relationship-oriented.4 Encourage staff not to wait for managers but to take initiative to raise issues and take advantage of chance encounters with managers to problem solve.10 Use every means for connecting staff, including formal and informal meetings, planned and unplanned encounters in the hallways.10 Foster frequent conversations among RNs, LPNs, and CNAs.11 Understanding that relationships are truly the basis for high quality care, we need to quickly learn to do things differently in long-term care. Over-reliance on rules is not working. This article suggests some effective management practices that bring people together, improve information flow, and increase cognitive diversity. Importantly good teamwork must be accompanied by good information flow between teams and levels in the organization. Let’s talk more not less.