Jason T. Slyer

The effectiveness of tight glycemic control on decreasing surgical site infections and readmission rates in adult patients with diabetes undergoing cardiac surgery: A systematic review

OBJECTIVE A systematic review of the effects of tight glycemic control with a continuous insulin infusion to achieve blood glucose levels ≤ 200 mg/dL on surgical site infections and readmission rates in adult patients with diabetes after cardiac surgery. METHODS A quantitative systematic review of the literature. Databases, including PubMed, CINAHL, EMBASE, and CENTRAL, were searched for relevant studies from database inception through August 2014. Randomized and quasi-experimental studies were included. RESULTS A meta-analysis of ten studies demonstrated that glycemic control with a continuous insulin infusion to achieve blood glucose levels ≤ 200 mg/dL significantly reduced surgical site infection rates (odds ratio 0.35, 95% confidence interval 0.25-0.49; Z = 6.0, P < 0.00001) compared with standard diabetes management. CONCLUSIONS Maintaining blood glucose levels ≤ 200 mg/dL with a continuous insulin infusion in all stages of the perioperative period in cardiac surgery patients with diabetes can reduce the incidence of surgical site infections.

A qualitative systematic review of internal and external influences on shared decision-making in all health care settings

Review question/objective The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared‐decision making for adult patients and health care providers in all health care settings. The specific questions to be answered are: What are the internal and external influences on shared decision making from the perspective of adult patients in all health care settings? What are the internal and external influences on shared decision making from the perspective of health care providers caring for adult patients in all health care settings? Background Patient‐centered care is emphasized in todays healthcare arena. This emphasis is seen in the works of the International Alliance of Patients’ Organizations (IAOP) who describe patient‐centered healthcare as care that is aimed at addressing the needs and preferences of patients.1 The IAOP presents five principles which are foundational to the achievement of patient‐centered healthcare: respect, choice, policy, access and support, as well as information.1 These five principles are further described as: respect for the patients needs, preferences, values, autonomy, and independence; the right of the patient to have a choice to participate as a partner in making healthcare decisions based on their individual abilities and preferences; meaningful and active involvement in healthcare policy‐making through sharing in decision‐making to ensure that patients are at the center of the policy design; support of a patients access to safe, quality and appropriate services; and the development and offering of age appropriate, linguistically, educationally, and culturally designed information that will enable the individual patient to make decisions about their healthcare needs. Within the description of these five principles the idea of shared decision‐making is clearly evident. The concept of shared decision‐making began to appear in the literature in the 1990s.2 It is defined as a “process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient‐centered care.”3(p.23) The details of the shared decision‐making process are complex and consist of a series of steps including: the recognition that a decision can or must be made; identifying the possible courses of action; listing the pros, cons, and other characteristics of each possibility; comparing the options and identifying one as probably better than the rest; accepting or rejecting options resulting in the final choice; authorization of the final choice; and implementation of that choice.4 Three overall representative decision‐making models are noted in contemporary literature. These three models include: paternalistic, informed decision‐making, and shared decision‐making.5 The paternalistic model is an autocratic style of decision‐making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision‐making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement.5 Finally, the shared decision‐making model is representative of a sharing and a negotiation towards treatment decisions. 5 Thus, these models represent a range with patient non‐participation at one end of the continuum to informed decision making or a high level of patient power at the other end.5 Several shared decision‐making models focus on the process of shared decision‐making previously noted. A discussion of several process models follows below. Charles et al.5 depicts a process model of shared decision‐making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included: the participation of at least two parties, both parties take steps to participate in the process of treatment decision‐making, information sharing occurs as a prerequisite to share in decision‐making, an ultimate decision is made, and both parties agree to the decision. This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker.5,6 This model also depicts the need to take steps to participate in the shared decision‐making process. To take steps means that there is an agreement between and among all involved that shared decision‐making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision‐making and the actuality of shared decision‐making in practice is not strong.5 Research concerning patients and patient preferences on shared decision‐making points to variations depending on age, education, socio‐economic status, culture, and diagnosis. 7‐12 Healthcare providers may also hold preferences for shared decision‐making; however, research in this area is not as comprehensive as is patient focused research.13 Elwyn et al.14 explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision‐making process.14 An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patients preference is different from clinical practice guidelines.15 This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.12 The notion of information sharing as a prerequisite to shared decision‐making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision‐making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision‐making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patients ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.16 Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al.5 portrays shared decision‐making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the “test of a shared decision (as distinct from the decision‐making process) is if both parties agree on the treatment option.”5(p.688) Towle and Godolphin17 developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision‐making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision‐making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include: Develop a partnership with the patient. Establish or review the patients preferences for information. Establish or review the patients preferred role in decision‐making. Ascertain and respond to the patients ideas, concerns, and expectations. Identify choices and evaluate the research evidence. Present evidence, taking into account competencies 2 and 3, in a way that helps the patient to reflect on and assess the impact of alternative decisions with regard to his or her values and lifestyle. Negotiate a decision in partnership with the patient and resolve conflict. Agree on an action plan and complete arrangements for follow‐up.17 Patient competencies include: Define the preferred health care provider‐patient relationship. Find a healthcare provider and establish, develop, and adapt a partnership. Articulate health problems, feelings, beliefs, and expectations in an objective and systematic manner. Communicate in order to understand and share relevant information. Access information. Evaluate information. Negotiate decisions, give feedback, resolve conflict, and agree on an action plan.17 This model illustrates the shared decision‐making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model.5 This model, however, gives greater emphasis to the process of the co‐participation of the healthcare provider and the patient. The co‐participation depicts a mutual partnership

the effectiveness of patient-centered self-care education for adults with heart failure on knowledge, self-care behaviors, quality of life, and readmissions: a systematic review

Background Patient‐centered self‐care education is an educational approach that employs meaningful, targeted education tailored to an individual patients needs, preferences, and values. Patient‐centered educational approaches may empower patients with heart failure to be successful in self‐care management and improve outcomes. Objective To evaluate the effectiveness of patient‐centered self‐care education for adults with heart failure on knowledge, self‐care behaviors, quality of life, and readmissions. Inclusion criteria Types of participants Adult patients, 18 years and older, with a diagnosis of heart failure. Types of interventions All types of patient‐centered, self‐care education interventions for adult patients with heart failure provided by any health care provider. Types of outcomes Heart failure knowledge, heart failure self‐care behaviors, heart failure‐related quality of life, heart failure admissions or readmissions within one‐year post intervention. Types of studies Randomized controlled trials. Search strategy The search strategy aimed to find relevant published and unpublished studies in the English language between January 1990 and July 2013. Several electronic databases were searched: CINAHL, Pubmed, PsychINFO, EMBASE, CENTRAL, ERIC, Scopus, and DynaMed. A search for gray literature was also performed. Methodological quality Two reviewers evaluated the included studies for methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute. Data collection Data were extracted using a standardized data extraction instrument from the Joanna Briggs Institute. Data synthesis Due to clinical heterogeneity between included studies, statistical meta‐analysis was not possible. Results are presented in a narrative form. Results A total of seven articles describing five randomized controlled trials and one pseudo‐randomized trial were included. Four studies demonstrated reduced readmissions with only one reaching statistical significance at six months follow‐up (11.4% intervention, 44.2% control, P=0.01). Five studies demonstrated an improvement in quality of life with only one reaching statistical significance between baseline and 12 months follow‐up (P=0.002). One study measured knowledge and demonstrated a statistically significant improvement at the 12 months follow‐up (P=0.05). One study measured self‐care and demonstrated a statistical significant improvement among the intervention group at one month (P<0.001) and three months (P=0.005) compared with the control. These statistical significant findings indicate the positive effects of the intervention by demonstrating an improvement in outcomes as measured by patients experiencing a more productive quality of life, an increase in heart failure‐related knowledge, improved self‐care behaviors, and decreased readmission rates post intervention. Conclusions Patient‐centered self‐care education for adult patients with heart failure may have a positive benefit in reducing heart failure readmissions and improving heart failure‐related knowledge, self‐care behaviors, and quality of life. Factors that may influence outcomes include a multidisciplinary team approach and reinforcement of individualized advice with emphasis during care transitions. Implications for practice Utilization of a multidisciplinary team in a variety of settings with ongoing reinforcement of individualized goals and objectives, while continually assessing patient‐specific needs, may be necessary in effecting care delivery. Implication for research Future studies may consider interventions inclusive of more diverse ethnic populations of varying literacy and socio‐economic levels, promoting generalizability of findings. Greater details specific to the patient‐centered aspect of the intervention, including optimal time‐frames for duration should be determined.

The effectiveness of group visits for patients with heart failure on knowledge, quality of life, self-care, and readmissions: a systematic review

Background Heart failure is a major health burden worldwide. Patient education is the primary process used to increase knowledge of self‐care practices for patients with heart failure. Most education occurs during one‐on‐one visits between a patient and a health care provider. Group visits with a health care provider and a small group of patients provide an alternative method for providing patient education. The goal of group visits for patients with heart failure would be to increase patient knowledge and self‐care abilities, while improving self‐efficacy. Objective The objective of this review is to identify the effectiveness of group visits for patients with heart failure on knowledge, quality of life, self‐care behaviors, and hospital readmissions. Inclusion criteria Types of participants Community‐living adult patients (18 years and above) of all races and ethnicities with a diagnosis of heart failure. Types of interventions Group visits for adult patients with heart failure compared to one‐on‐one provider visits. Types of outcomes Patient knowledge about heart failure, quality of life, self‐care behaviors, unplanned readmissions, and emergency room visits. Types of studies Randomized controlled trials, non‐randomized controlled trials, and quasi‐experimental trials were considered for inclusion. In their absence other qualitative studied designs were considered. Search strategy Published and unpublished studies in the English language were sought from the inception of the included databases through September 2012. The databases searched included: PubMed, CINAHL. Embase, and Health Source: Nursing/Academic edition. A search for gray literature and hand searching of reference lists were also performed. Methodological quality Two reviewers evaluated the included studies for methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute. Data collection and synthesis Data were extracted using standardized data extraction instruments from the Joanna Briggs Institute. Due to heterogeneity between included studies, statistical pooling was not possible. Results are presented in a narrative form. Results Two pilot studies were included in this review. One study demonstrated an improvement in heart failure knowledge and a trend toward improvement in self‐care behaviors. The other study showed improvements in self‐care behaviors and depression while reducing the number of hospitalizations. Conclusions The group visit model has the potential for improving knowledge and self‐care behaviors, while increasing quality of life and decreasing hospitalizations for patients with heart failure. Implications for practice Clinicians should consider group visits as an alternative method of providing patient‐centered care that allows the clinician to see a large number of patients in a short time period while providing education and health management. Implications for research Randomized control trials should be conducted to determine the most effective format and the most effective health care provider team for the group visit model on larger samples of culturally diverse populations across multiple settings. Future research should also seek to determine the most appropriate duration for the group visit appointment.

Effectiveness of structured multidisciplinary rounding in acute care units on length of stay and satisfaction of patients and staff: a quantitative systematic review.

BackgroundConsistent, concise and timely communication between a multidisciplinary team of healthcare providers, patients and families is necessary for the delivery of quality care. Structured multidisciplinary rounding (MDR) using a structured communication tool may positively impact length of stay (LOS) and satisfaction of patients and staff by improving communication, coordination and collaboration among the healthcare team. ObjectivesTo evaluate the effectiveness of structured MDR using a structured communication tool in acute care units on LOS and satisfaction of patients and staff. Inclusion criteria Types of participantsAdult patients admitted to acute care units and healthcare providers who provide direct care for adult patients hospitalized in in-patient acute care units. Type of interventionThe implementation of structured MDR utilizing a structured communication tool to enhance and/or guide communication. Types of studiesQuasi-experimental studies and descriptive studies. OutcomesLength of stay, patient satisfaction and staff satisfaction. Search strategyThe comprehensive search strategy aimed to find relevant published and unpublished quantitative English language studies from the inception of each database searched through June 30, 2015. Databases searched include Cumulative Index to Nursing and Allied Health Literature, PubMed, Excerpta Medica Database, Health Source, Cochrane Central Register of Controlled Trials and Scopus. A search of gray literature was also performed. Methodological qualityAll reviewers independently evaluated the included studies for methodological quality using critical appraisal tools from the Joanna Briggs Institute (JBI). Data extractionData related to the methods, participants, interventions and findings were extracted using a standardized data extraction tool from the JBI. Data synthesisDue to clinical and methodological heterogeneity in the interventions and outcome measures of the included studies, statistical meta-analysis was not possible. Results are presented in narrative form. ResultsEight studies were included, three quasi-experimental studies and five descriptive studies of quality improvement projects. In the three quasi-experimental studies, one had a statistically significant decrease (p = 0.01), one no change (p = 0.1) and one had an increase (p = 0.03) in LOS; in the two descriptive studies, one had a statistically significant decrease (p = 0.02) and the other reported a trend toward reduced LOS. Two studies evaluated patient satisfaction, one showed no change (p = 0.76) and one showed a trend toward increased patient satisfaction at 12 months. Six studies demonstrated an improvement in staff satisfaction (p < 0.05) after implementation of structured MDR. ConclusionThe evidence suggests that MDR utilizing a structured communication tool may have contributed to an improvement in staff satisfaction. There was inconclusive evidence to support the use of structured MDR to improve LOS or patient satisfaction. The use of a structured communication tool during MDR is one means to facilitate communication and collaboration, thus improving satisfaction among the multidisciplinary team. More rigorous research using higher level study designs on larger samples of diverse patient populations is needed to further evaluate the effectiveness of structured MDR on patient care outcomes and satisfaction of patients and providers.

Shared Decision-Making for Nursing Practice: An Integrative Review

Background: Shared decision-making has received national and international interest by providers, educators, researchers, and policy makers. The literature on shared decision-making is extensive, dealing with the individual components of shared decision-making rather than a comprehensive process. This view of shared decision-making leaves healthcare providers to wonder how to integrate shared decision-making into practice. Objective: To understand shared decision-making as a comprehensive process from the perspective of the patient and provider in all healthcare settings. Methods: An integrative review was conducted applying a systematic approach involving a literature search, data evaluation, and data analysis. The search included articles from PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and PsycINFO from 1970 through 2016. Articles included quantitative experimental and non-experimental designs, qualitative, and theoretical articles about shared decision-making between all healthcare providers and patients in all healthcare settings. Results: Fifty-two papers were included in this integrative review. Three categories emerged from the synthesis: (a) communication/ relationship building; (b) working towards a shared decision; and (c) action for shared decision-making. Each major theme contained sub-themes represented in the proposed visual representation for shared decision-making. Conclusion: A comprehensive understanding of shared decision-making between the nurse and the patient was identified. A visual representation offers a guide that depicts shared decision-making as a process taking place during a healthcare encounter with implications for the continuation of shared decisions over time offering patients an opportunity to return to the nurse for reconsiderations of past shared decisions.

A systematic review of the effectiveness of web-based programs on the reduction of childhood obesity in school-aged children

Background There has been a rapid rise in obesity among school‐aged children despite efforts made in promoting weight management and physical activity. Overweight and obese children are likely to stay obese into adulthood and are more likely to develop diabetes and cardiovascular diseases at a younger age. Using web‐based technology is one avenue to reach this population. Web‐based technology is fast and interactive which makes it appealing to this population; therefore, it may increase participation and adherence. To date, the evidence has not been systematically evaluated to determine if web‐based interventions have a positive impact on reducing childhood obesity. Objective To identify the best available evidence on the effectiveness of web‐based programs on the reduction of childhood obesity in school‐aged children. Inclusion criteria Types of participants School‐age children, four to 18 years of age, regardless of gender, ethnicity, or national origin. Types of interventions Web‐based programs including, but not limited to, the Internet, social networking media, mobile applications, and email aimed at the reduction of obesity among school‐age children. Types of outcomes Weight measures such as body mass index, body weight, and/or waist circumference. Types of studies Randomized and pseudo‐randomized control trials. Search strategy To find both published and unpublished studies in the English Language from 1991 through August 2012. A search of MEDLINE, CINAHL, EMBASE, PubMed, PsychINFO, Healthsource Nursing/Academic Edition, ERIC and Academic Search Premier was conducted. A search for gray literature was also performed. Methodological quality Two reviewers evaluated the included studies for methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute. Data collection and synthesis Data were extracted using standardized data extraction instruments from the Joanna Briggs Institute. Due to clinical heterogeneity between included studies, statistical meta‐analysis was not possible. Results are presented in a narrative form. Results A total of 12 articles describing eight interventions were included in this review. All of the included studies were randomized controlled trials. Four of the eight interventions showed improvements in weight measurements. One study demonstrated a reduction in body mass index z‐score at 16‐weeks post intervention (F[5,60]=5.11, p=0.027). One study demonstrated a reduction in waist‐hip ratio at eight‐months post intervention (effect size = ‐0.01, p=0.02). One study demonstrated a greater loss in mean body fat in the intervention group compared to the control group (‐1.12 ± 0.47 vs. 0.42 ± 0.47, p<0.05). One study demonstrated a reduction in body mass index (t87 = ‐2.7, p<0.01) and body mass index z‐score (T87 = ‐3.1, p<0.01) at nine‐months follow‐up. Two interventions showed no difference in weight measures post intervention; two interventions showed an increase in body mass index post intervention. Conclusions A reduction in overweight and obesity in school‐aged children may be seen with the implementation of web‐based weight reduction interventions as part of a multi‐component intervention. The studies included in this review suggest that other components, such as parental involvement, face‐to‐face mentoring, and feedback and reminders, when coupled with web‐based weight management interventions, may improve patient outcomes. Implications for practice The evidence suggests that using web‐based technology as part of multicomponent intervention for the implementation of weight reduction programs in school‐aged children is promising. Implications for research Future studies should evaluate the effects of web‐based technology as a single intervention on a larger sample over longer periods of time to establish the full effect of web‐based interventions on reducing childhood obesity.

The effectiveness of group visits for patients with heart failure on knowledge, quality of life, self-care, and readmissions: a systematic review protocol

Review question/objective The objective of this review is to identify the effectiveness of group visits for patients with heart failure (HF) on knowledge, quality of life, self‐care behaviors, and hospital readmissions. Research Questions: What is the impact of group visits for patients with HF on knowledge related to HF compared to standard one‐on‐one medical care? What is the impact of group visits for patients with HF on quality of life compared to standard one‐on‐one medical care? What is the impact of group visits for patients with HF on self‐care behaviors compared to standard one‐on‐one medical care? What is the impact of group visits for patients with HF on emergency room visits and unplanned hospital readmissions compared to standard one‐on‐one medical care? Background Heart failure (HF) continues to be a major health burden throughout the world. There are currently over 5.7 million Americans,1 15 million Europeans,2 and 277,800 Australians3 living with HF. These numbers are expected to double by 2040.4 Patients and caregivers perform the majority of HF care in the home.5 Patients with HF need to learn to be successful in self‐managing their condition to lessen the burden of symptoms such as fatigue, dyspnea, and edema. Patient education is the primary process used to increase knowledge of self‐care practices for patients with HF. Patients with HF need to follow a complex medical regimen while adhering to a low sodium diet and prescribed fluid restrictions. In addition patients monitor their physical condition daily for exacerbation of symptoms or signs of fluid overload. Education, behavior modification, and skill development are necessary for a patient with HF to be successful in self‐managing their condition. Most HF education occurs during one‐on‐one visits between the patient and the health care provider in an examination room during a regular clinic visit. However, there is usually limited time to address all of the needed education topics in an in‐depth, meaningful manner with information the patient can take home and utilize in their daily routines. Group visits provide an alternative venue to provide care for this complex patient population. A group visit is an interactive process between a health care provider and a small group of patients and their caregivers who usually share a common medical concern. The participants of group visits can benefit from the knowledge and experiences of the other participants while providing support and encouragement to each other as they learn to cope with living with a chronic condition. The process of the group visit was first developed in 1991 by Dr. John C. Scott at the Kaiser Permanente system in Colorado, United States.6 Dr. Scott and a nurse held monthly group visits lasting 60 minutes with a group of 15 to 20 patients to manage their complex medical conditions. The group visit model can vary across settings, including from 6‐20 patients over a 1‐2 hour period with varying times devoted to education and discussion of health concerns. The group visit typically incorporates a one‐on‐one physical examination with a physician or nurse practitioner in conjunction with a group discussion and medical management. Group visits have shown to be beneficial in improving patient outcomes for conditions such as diabetes, hypertension, and other chronic illness.7,8,9,10 The goal of group visits for patients with HF is to increase patient knowledge and self‐care abilities, while improving self‐efficacy. Self‐care incorporates the decision making process a patient undergoes when deciding on a course of action to maintain stability as a result of a change in symptoms. 11 Improved self‐care can improve symptoms, which will likely result in an increase in quality of life and a reduction in hospitalizations related to decompensation. Quality of life (QOL) refers to a patients perception of the impact of a health condition and treatment on the patients health status13 and can be measured with valid and reliable tools such as the Minnesota Living with Heart Failure Questionnaire (MLHFQ) 14or the Kansas City Cardiomyopathy Questionnaire (KCCQ).15 Self‐care abilities can be measured using an instrument such as the Self‐Care Heart Failure Index (SCHFI).11 HF knowledge can be measured using an instrument such as the Atlanta Heart Failure Knowledge Test.12 Group visits can be used to continue to optimize medication therapy while providing a forum for knowledge acquisition and fostering support. A search of the Cochrane Library of Systematic Reviews, the Joanna Briggs Library of Systematic Reviews, MEDLINE, and CINAHL did not identify any previously conducted systematic reviews on the effectiveness of group visits on outcomes for patients with heart failure. Therefore, this review seeks to identify studies evaluating the effectiveness of group visits for patients with heart failure on patient knowledge, quality of life, self‐care behaviors, and hospital readmissions.

A systematic review on the effectiveness of continuity of care and its role in patient satisfaction and decreased hospital readmissions in the adult patient receiving home care services.

Background Continuity of care, a concept that in its broadest terms describes patient and provider coordination across time and settings, has evidenced a positive correlation with patient satisfaction and hospital readmission rates. Home health care, where patients receive care from a variety of healthcare practitioners, is one area where these measures are being investigated to determine the effectiveness of continuity of care. Objective To examine and synthesize the best available evidence related to the effectiveness of continuity of care interventions and their impact on patient satisfaction and all‐cause hospital readmissions rates in the adult patient who is receiving home care services. Inclusion Criteria Types of participants Male and female aged 18 years or older receiving home care services, regardless of diagnosis, stage or severity of disease, co‐morbidities, or previous treatment received. Types of intervention All types and models of interventions for continuity of care delivered by nurses to patients receiving home care services were considered for inclusion in the review. Types of outcomes Patient satisfaction and hospital readmissions. Types of studies In this review randomised controlled trials were considered for inclusion. In their absence, other research designs, such as non‐randomised controlled trials, quasi‐experimental studies, and before and after studies were considered for inclusion. Search Strategy Published and unpublished literature in the English language was sought from the inception of the databases through November 1, 2011.The databases searched included: Academic Search Premier, CINAHL ERIC, Health Reference Center Academic, MEDLINE via PubMed, ProQuest Nursing and Allied Health Source, ProQuest Health Management, Cochrane Central Register of Controlled Trials, EMBASE, Health Source Nursing Academic, PsycINFO and Bio‐Med. A search of the grey literature and virtual hand searching of relevant journals was also performed. Methodological quality Two reviewers evaluated the included studies for methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute. Data Collection Data were extracted using standardised data extraction instruments from the Joanna Briggs Institute. Data synthesis Statistical pooling via meta‐analysis was not possible. The results are presented in narrative form. Results Two randomised controlled trails and two quasi‐experimental studies were included in this review. In one randomised controlled trial, 66% of patients rated their overall satisfaction with care as very good or excellent as compared with 63% of those receiving usual care at 24 months (p=0.31). Another randomised controlled trial reported no statistically significant difference between groups (p value not reported). In one quasi‐experimental study there was higher satisfaction rate amongst intervention patients with a mean difference of 16.88 (95%CI[16.32, 17.43] compared with 14.65 (95%CI[13.61, 15.68] in the control group (p=0.001). In one randomised controlled trial there was no statistically significant difference between intervention and control groups in hospital admission rates per 1000 at year two (700 vs. 740; p=0.66). Another randomised controlled trial showed no difference in readmissions at 90 days between groups (36% vs. 35%; no p value reported). In one quasi‐experimental study, the mean number of hospital readmissions per patient was higher in the intervention group compared to the control group (0.75; 95% CI[ 0.47, 1.03] vs. 0.66; 95% CI[ 0.40, 0.91]; p=0.599), In another quasi‐experimental study, a statistically significant higher number of intervention group patients in the intervention group were discharged and remained at home (34 or 82.9%), compared to the control group (20 or 51.3%) (p<0.05). Conclusions Home care interventions that include nurses and advanced practice nurses with specialised training in the care of the population served as the direct provider along with collaboration with an interdisciplinary team in a high‐risk patient populations contributed to reduced hospital readmission rates. The outcomes of the included studies suggest that consistently scheduled home care services promote patient satisfaction. Implications for practice This review concluded that the utilisation of an advanced practice nurse with specialised training in a specific disease process in collaboration with a multidisciplinary team can affect readmission rates and patient satisfaction. Implications for research Further research is needed that captures a diverse patient population in terms of age and illness and the role that an advanced practice nurse can play.

The effectiveness of delegation interventions by the registered nurse to the unlicensed assistive personnel and their impact on quality of care, patient satisfaction, and RN staff satisfaction: a systematic review

Background Delegation by the registered nurse is a decision making process that includes assessment, planning, implementation, and evaluation. Due to an ever‐expanding global shortage of nurses, registered nurses are increasingly dependent on unlicensed assistive personnel to assist in the provision of safe patient care. Delegation is recognised as a fundamental nursing skill that can be utilised effectively to improve quality care. Objective To examine and synthesize the best available evidence regarding the impact of delegation interventions used by the registered nurse with the unlicensed assistive personnel and their impact on quality of care, patient satisfaction, and registered nurse staff satisfaction. Inclusion Criteria Types of participants Registered nurses and unlicensed assistive personnel in patient care settings where delegation occurs. Types of interventions This review considered studies that evaluated the effectiveness of delegation interventions by registered nurses to unlicensed assistive personnel. Types of Outcomes The outcomes examined were quality of care, patient satisfaction, and/or registered nurse staff satisfaction as measured by validated and reliable tools. Types of Studies The review first considered randomised controlled trials; in their absence other research designs, such as non‐randomised controlled trials, or other quasi‐experimental studies, observational studies and descriptive studies were considered for inclusion in the systematic review. Search Strategy The search strategy aimed to find both published and unpublished studies in the English language from the inception of the included databases through December 2011. The databases searched included the Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, CINAHL, Healthsource Nursing/Academic edition, and PsycINFO. A search of the grey literature and electronic hand searching of relevant journals was also performed. Methodological Quality The studies selected for retrieval were critically evaluated by two independent reviewers for methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute. Data Collection Data were extracted using standardised data extraction instruments from the Joanna Briggs Institute. Data Synthesis Studies were found to have significant heterogeneity between the populations and interventions of the included studies; therefore, pooled statistical meta‐analysis could not be completed. The findings are presented in narrative form. Results Two quasi‐experimental studies were identified. In one study, the women counselled by the lay nurse aides received 80% of recommended messages compared to 75% received by the women counselled by the nurse‐midwives (&bgr;= 4.7, 95%CI: ‐1.7, 11.0; Non‐inferiority). Non‐inferiority was demonstrated between the lay nurse aides and the nurse‐midwives with respect to communication techniques. The mean performance was high, 95% and 98% among nurse‐midwives and lay nurse aides respectively (&bgr; =2.4, 95%CI: ‐0.2, 5.0; Non‐inferiority). No difference was found between the nurse‐midwives and the lay nurse aides in providing antenatal counselling, education, and maternal‐newborn care when proper training and supervision was given. The other study examined six hypotheses that looked at quality of care outcomes in a care model where the registered nurse delegated tasks to unlicensed assistive personal. Five of these outcomes showed no significant improvement as a result of the intervention. Patient knowledge about intravenous therapy was the only quality of care outcome that showed improvement post‐intervention with scores increasing from 27% at baseline to 78% at 12 months. There was no improvement in the one hypotheses evaluating registered nurses job satisfaction. Conclusions There is a paucity of evidence on the effectiveness of delegation interventions and strategies by registered nurses to unlicensed assistive personnel. Delegation interventions require characteristics such as teamwork, training, support, supervision, communication, and evaluation to positively impact quality of care, patient satisfaction, and registered nurse staff satisfaction outcomes. Implications for practice Task shifting could have a positive impact on quality of care and staff satisfaction while providing the registered nurse with an opportunity to increase efficiency. Implications for research The areas of feedback and evaluation in the registered nurse / unlicensed assistive personnel relationship needs further study.