Emily Ang

Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital A randomized controlled trial

AIM This article is a report of a randomized controlled trial to examine the effectiveness of a targeted multiple intervention strategy in reducing the number of patient falls in an acute care hospital. BACKGROUND Prevention of patient falls remains a challenge that has eluded healthcare institutions. The effectiveness of targeted multiple fall prevention interventions in reducing the incidences of falling has not been established. METHODS Patients who scored 5 and above on the Hendrich II Fall Risk Model, a fall assessment tool, were recruited in 2006. Patients who were randomized to the intervention group received targeted multiple interventions. Both the research groups received the standard fall prevention interventions from the ward nurses. The rates of fall incidences for both groups were reported with 95% CI, calculated using Wilson method and compared using the Chi-square test. The relative risk was estimated and 95% CI was calculated using the methods described by Armitage and Berry. The times to first fall events were constructed using the Kaplan-Meier method. The hazard ratio was reported at 95% CI and the comparison was made using the log-rank test. RESULTS There were 912 and 910 participants in the control and intervention groups, respectively. The fall incidence rates were 1·5% (95% CI: 0·9-2·6) and 0·4% (95% CI: 0·2-1·1) in the control and intervention groups, respectively. The relative risk estimate of 0·29 (95% CI: 0·1-0·87) favours the intervention group. CONCLUSION This study showed that targeted multiple interventions were effective in reducing the incidences of falls in patients in the acute care setting.

Anxiety in patients with breast cancer undergoing treatment: a systematic review

BACKGROUND Breast cancer is one of the most common cancers worldwide, and anxiety is a psychological morbidity that is inevitable. Many researchers have investigated the prevalence and detrimental effects of anxiety in breast cancer treatment, but little is known about differences in anxiety level among women receiving different breast cancer treatments. A systematic review of all available literature was needed to attain better understanding of anxiety in patients undergoing treatment for breast cancer. AIM This review aimed to determine the best available evidence on the level of anxiety among women with breast cancer who were undergoing cancer treatment(s), and the factor(s) contributing to anxiety in various treatment modalities. METHODS The search sought to gather data from published and unpublished studies conducted between 1990 and 2010. An initial search on CINAHL and Medline was done to identify relevant search terms. A search strategy was then developed, using MeSH headings and key words. The following databases were searched: CINAHL, PubMed, ScienceDirect, PsycINFO, Cochrane Database of Systematic Review, Scopus, Wiley InterScience and PsycARTICLES. All papers are quantitative papers (randomised controlled trials and descriptive studies) that examined anxiety level in women with breast cancer of stage 0 to stage IIIA, over and equal to 21 and below 65 years of age, who were undergoing/had undergone treatment restricted to chemotherapy, radiotherapy and/or surgery, and these quantitative papers have made correlations between womens anxiety levels and contributing factors. The Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory were the two tools most frequently used by these papers to quantify the anxiety level. Two reviewers independently assessed the eligibility of the papers for inclusion. Eighteen papers were selected based on relevance, and assessed for methodological quality using MAStARI. Ten research papers that met our methodological standard were included in the review. Both reviewers agreed on the papers to be included and excluded. Due to the methodological heterogeneity of the included papers, a meta-analysis was not possible. The studies were hence presented in narrative summary. RESULTS Anxiety seems to be ubiquitous, presenting itself in all treatment types for breast cancer. Anxiety level in women who underwent chemotherapy was highest before the first chemotherapy infusion, mediated by age and trait anxiety. Radiotherapy regimes did not affect anxiety level in radiotherapy-treated patients, and most research concluded that anxiety level was higher among women who underwent mastectomy than those who underwent breast conservation therapy. CONCLUSIONS The prevalence and intensity of anxiety have been shown to be pronounced among breast cancer women who were undergoing/had undergone one or more of the three treatments. Chemotherapy, as compared to other treatments, is shown to be associated with a higher anxiety level. With the prevalence, intensity and correlated factors of anxiety identified through this review, future research may investigate the interventions that could help alleviate anxiety among these patients. Anxiety is prevalent in women with breast cancer undergoing treatment, especially those undergoing chemotherapy. Healthcare professionals should pay greater attention to identify signs of anxiety in patients and design interventions to help alleviate it earlier.

Designing and Evaluating an Interactive Multimedia Web-Based Simulation for Developing Nurses’ Competencies in Acute Nursing Care: Randomized Controlled Trial

Background Web-based learning is becoming an increasingly important instructional tool in nursing education. Multimedia advancements offer the potential for creating authentic nursing activities for developing nursing competency in clinical practice. Objective This study aims to describe the design, development, and evaluation of an interactive multimedia Web-based simulation for developing nurses’ competencies in acute nursing care. Methods Authentic nursing activities were developed in a Web-based simulation using a variety of instructional strategies including animation video, multimedia instructional material, virtual patients, and online quizzes. A randomized controlled study was conducted on 67 registered nurses who were recruited from the general ward units of an acute care tertiary hospital. Following a baseline evaluation of all participants’ clinical performance in a simulated clinical setting, the experimental group received 3 hours of Web-based simulation and completed a survey to evaluate their perceptions of the program. All participants were re-tested for their clinical performances using a validated tool. Results The clinical performance posttest scores of the experimental group improved significantly (P<.001) from the pretest scores after the Web-based simulation. In addition, compared to the control group, the experimental group had significantly higher clinical performance posttest scores (P<.001) after controlling the pretest scores. The participants from the experimental group were satisfied with their learning experience and gave positive ratings for the quality of the Web-based simulation. Themes emerging from the comments about the most valuable aspects of the Web-based simulation include relevance to practice, instructional strategies, and fostering problem solving. Conclusions Engaging in authentic nursing activities using interactive multimedia Web-based simulation can enhance nurses’ competencies in acute care. Web-based simulations provide a promising educational tool in institutions where large groups of nurses need to be trained in acute nursing care and accessibility to repetitive training is essential for achieving long-term retention of clinical competency.

Strengthening the afferent limb of rapid response systems: an educational intervention using web-based learning for early recognition and responding to deteriorating patients

Background The timely recognition and response to patients with clinical deteriorations constitute the afferent limb failure of a rapid response system (RRS). This area is a persistent problem in acute healthcare settings worldwide. In this study, we evaluated the effect of an educational programme on improving the nurses’ knowledge and performances in recognising and responding to clinical deterioration. Method The interactive web-based programme addressed three areas: (1) early detection of changes in vital signs; (2) performance of nursing assessment and interventions using airway, breathing, circulation, disability and expose/examine and (3) reporting clinical deterioration using identity, situation, background, assessment and recommendation. Sixty-seven registered nurses participated in the randomised control study. The experimental group underwent a 3 h programme while the control group received no intervention. Pretests and post-tests, a mannequin-based assessment and a multiple-choice knowledge questionnaire were conducted. We evaluated the participants’ performances in assessing, managing and reporting the deterioration of a patient using a validated performance tool. Results A significantly higher number of nurses from the experimental group than the control group monitored respiratory rates (48.2% vs 25%, p<0.05) and pulse rates (74.3% vs 37.5%, p<0.01) in the simulated environment, after the intervention. The post-test mean scores of the experimental group was significantly higher than the control group for knowledge (21.29 vs 18.28, p<0.001), performance in assessing and managing clinical deterioration (25.83 vs 19.50, p<0.001) and reporting clinical deterioration (12.83 vs 10.97, p<0.001). Conclusions A web-based educational programme developed for hospital nurses to strengthen the afferent limb of the RRS significantly increased their knowledge and performances in assessing, managing and reporting clinical deterioration.

The effectiveness of patient navigation programs for adult cancer patients undergoing treatment: a systematic review

Background Advancements in technology and medical treatment have made cancer care treatment more complex. With the current trend of sub‐specialization in health care, cancer patients commonly receive care from multiple specialists and have wider treatment options. In view of this, there is a need to coordinate care and integrate information to enhance care and quality of outcomes for patients. Since the successful implementation of programs for increasing the survival rate of breast cancer patients at Harlem Hospital Center, New York, USA, patient navigation programs have been widely introduced in healthcare settings. Some literature has identified nurses as a primary candidate in assuming the role of a navigator. However, there is a need to further explore the effectiveness of patient navigation programs for their effectiveness in improving quality of life, and patient satisfaction and outcomes during the commencement of cancer treatment. Objectives The objective of this review was to synthesize the best available evidence on the effectiveness of patient navigation programs in adult cancer patients undergoing treatments such as radiotherapy and/or chemotherapy. Inclusion criteria Types of participants This review considered studies that included adults aged 18 years and over, diagnosed with any type of cancer and undergoing treatment in an acute care hospital setting, including inpatient and outpatient/ambulatory care. Types of intervention(s) and comparator(s) This review considered studies that evaluated nurse‐led patient navigation programs versus no patient navigation program or non‐structured care coordination. A patient navigation program includes patient education, psychosocial support, and care coordination. Types of studies This review considered randomized controlled trials and quasi‐experimental studies. Types of outcomes The review focused on the effects of patient navigator program clinical/patient outcomes. The review included studies on patient wellbeing and clinical outcomes, but excluded studies that had examined the impact of these programs on efficiency‐related outcomes, such as length of hospital stay and resource use. Search strategy A three‐step search strategy was utilized to find both published and unpublished studies in the databases: CINAHL, MEDLINE, Academic Search Complete, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Science Direct, Google Scholar (SCIRUS), MEDNAR (first 200 hits) and ProQuest Dissertations and Theses published between 1990 to 2013. Only studies published in English were included in this review. Methodological quality Two reviewers independently evaluated the methodological quality of studies that met the inclusion criteria for the review, using a standardized critical appraisal instrument from the Joanna Briggs Institute. Data extraction Data was extracted from the included papers using the standardized data extraction tool from the Joanna Briggs Institute Meta‐Analysis of Statistics Assessment and Review Instrument. Data synthesis Quantitative data was pooled in a statistical meta‐analysis using Review Manager 5.3. Effect sizes expressed as weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed statistically using the standard Chi‐square test. Where statistical pooling was not possible, the findings are presented in narrative form. Results After the process of study selection, four studies (two randomized controlled trials and two quasi‐experimental studies) with a total of 667 participants were included in the review. The results demonstrated no statistically significant difference in the quality of life of patients with cancer who had undergone patient navigation programs (pooled weighted difference = 0.41 [95% CI = ‐2.89 to 3.71], P=0.81). However, the two included studies that assessed patient satisfaction as an outcome measure both showed statistically significant improvements (p‐values = 0.03 and 0.001, respectively). In the study that assessed patient distress level, there was no statistically significant difference found between the: nurse‐led navigation and non‐navigation groups (P = 0.675). Conclusions Nurse‐led patient navigation programs were not effective in addressing outcomes such as quality of life and distress levels, the systematic review did not find any significant difference between the two groups. However, there was a statistically significance difference in increasing patient satisfaction. Implications for practice There is limited evidence that patient navigation programs improve the outcomes of quality of life and reduce distress (for adult patients with cancer undergoing treatment). However, there is good evidence that patient navigation programs improve patients’ satisfaction. Therefore it is recommended that patient navigation programs are used for adult cancer patients in the acute care setting to improve patients’ satisfaction. Implications for research There may be a need to explore a more rigorous evaluation of nurse‐led navigation programs to determine their effectiveness. Researchers should consider multi‐site studies and larger sample sizes for better generalization.

Reliability, validity and feasibility of quality of life instruments for adult patients with cancer undergoing chemotherapy: result from a systematic review

AIM The aim of this review was to analyse the literature critically and present the best available evidence related to quality of life (QoL) instruments that consists of all four subscales of physical, psychological, social and spiritual, which can be used in the clinical setting to assess adult patients with cancer on chemotherapy. INCLUSION CRITERIA This review included randomised control trials and observational studies without control group related to QoL instruments used for cancer chemotherapy. The types of participants for this review included all adults with cancer over the age of 18 years who have undergone chemotherapy. The QoL instruments for this review included instruments that consist of all subscales of physical, psychological, social and spiritual. In order to retrieve QoL instruments that were current and not outdated, this review included studies reported in the recent 10 years. SEARCH STRATEGY A three-step search strategy was utilised to search for primary research articles published in the English language from January 1998 to December 2009. An initial search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and the text terms used to describe the article. A second search strategy using all the identified keywords and the index terms was used for the 20 databases. The third search strategy was to search for additional studies from the relevant list of all identified articles. METHODOLOGICAL QUALITY The two independent reviewers appraised the included articles for methodological quality using the modified Elliot tool for reliability and validity. RESULTS A total of 3149 references was retrieved during the initial search. Only 13 articles with validation of the QoL instruments that contained all the four subscales of physical, psychological, social and spiritual were included in this review. Four QoL instruments were identified. These include the City of Hope QOL - Ovarian Cancer Tool (QOL-OVCA), QOL-Breast cancer version (QOL-BC), New India QoL tool and QoL Index-Cancer version (QLI-CV). Among the four identified QoL instruments, the frequency of assessment was more than once for QLI-CV, with intervals of 2 weeks to 6 months. Regarding the number of items, the QOL-BC instrument has the most number of items. All identified QoL instruments have content validity done. For reliability examination, all the identified QoL instruments have Cronbachs alpha of 0.7 and above for subscales. The correlation between subscales scores and overall QoL score was 0.53-0.93, 0.39-0.95 and 0.65-0.83 for QOL-OVCA, QOL-BC and QLI-CV, respectively. CONCLUSION In this review, there was one article on development of new QoL instrument, the New India QoL tool, which has comprehensive validity examinations - the least number of items that may be useful in the clinical setting but need further psychometric testing in different settings or languages. The QLI-CV instrument has had comprehensive intra- and inter-method validation on different languages, different cultural settings and various types of cancer. However, the instrument may not be feasible because the method to calculate the QoL score is not straightforward.

Losing the breast: A meta‐synthesis of the impact in women breast cancer survivors

To summarise qualitative studies exploring the impact of losing the breast in women breast cancer survivors.

Development and Validation of a Simplified Falls Assessment Tool in an Acute Care Setting.

An easy-to-use assessment tool, which contains reversible risk factors, might influence the success of a falls prevention program. A 2-phase study was undertaken to develop and validate a simplified falls assessment tool. Risk factors of confusion, dizziness, altered elimination, and difficulty with mobility were found to be significantly associated with fall status. The simplified falls assessment tool that contains these 4 risk factors yielded a comparable predictive value to Hendrich II Falls Risk Model.

The impact of negative childbirth experience on future reproductive decisions: A quantitative systematic review

AIM The aim of this study was to systematically retrieve, critique and synthesize available evidence regarding the association between negative childbirth experiences and future reproductive decisions. BACKGROUND A childs birth is often a joyous event; however, there is a proportion of women who undergo negative childbirth experiences that have long-term implications on their reproductive decisions. DESIGN A systematic review of quantitative studies was undertaken using Joanna Briggs Institutes methods. REVIEW METHODS A search was carried out in CINAHL Plus with Full Text, Embase, PsycINFO, PubMed, Scopus and Web of Science from January 1996 - July 2016. Studies that fulfilled the inclusion criteria were assessed by two independent reviewers using the Joanna Briggs Institutes Critical Appraisal Tools. Data were extracted under subheadings adapted from the institutes data extraction forms. RESULTS Twelve studies, which examined either one or more influences of negative childbirth experiences, were identified. The included studies were either cohort or cross-sectional designs. Five studies observed positive associations between prior negative childbirth experiences and decisions to not have another child, three studies found positive associations between negative childbirth experiences and decisions to delay a subsequent birth and six studies concluded positive associations between negative childbirth experiences and maternal requests for caesarean section in subsequent pregnancies. CONCLUSION To receive a holistic understanding on negative childbirth experiences, a suitable definition and validated measuring tools should be used to understand this phenomenon. Future studies or reviews should include a qualitative component and/or the exploration of specific factors such as cultural and regional differences that influence childbirth experiences.

Association between demographics and resilience - a cross-sectional study among nurses in Singapore

AIM To give an overview of the level of resilience among nurses in Singapore and to examine associations between various demographics variables and resilience level. BACKGROUND The World Health Organization reported a global needs-based shortage of over 9 million nurses and midwives in 2013. Building resilience among nurses has been postulated as one of the ways to support and retain nurses in the profession. METHOD A self-reported questionnaire consisting of questions on demographics and the Connor-Davidson Resilience Scale CD-RISC 10 was used. RESULTS Univariate analysis identified marital status, age group, years of experience in nursing, highest education qualification and job grade to have significant associations with resilience. During multivariate analysis, only marital status, age group, highest educational qualification and job grade remained significant. A strong association was found between highest educational qualification and resilience level; nurses with bachelors or postgraduate degree were about three times more likely than nurses with only a general nursing certificate to be of moderate/high resilience. CONCLUSION The experience of life events (as exemplified by marital status, age and working experience) was associated with higher resilience levels. IMPLICATIONS FOR NURSING POLICY There is a need for healthcare organizations and nurse leaders to develop programmes focusing on building resilience among younger and less experienced nurses. Nurses should also be supported in their pursuits for higher education, which will in turn lead to higher resilience, and consequently, retention of nurses within the profession and institution.