Kay Currie

Determinants of effective heart failure self-care: a systematic review of patients’ and caregivers’ perceptions

Context Disease management interventions for heart failure (HF) are inconsistent and very seldom incorporate the views and needs of patients and their caregivers into intervention design. Objective and data To improve intervention effectiveness and consistency, a systematic review identified 49 studies which examined the views and needs of patients with HF and their caregivers about the nature and determinants of effective HF self-care. Results The findings identify key drivers of effective self-care, such as the capacity of patients to successfully integrate self-care practices with their preferred normal daily life patterns and recognise and respond to HF symptoms in a timely manner. Conclusions Future interventions for HF self-care must involve family members throughout the intervention and harness patients’ normal daily routines.

A systematic review of the main mechanisms of heart failure disease management interventions.

Objective To identify the main mechanisms of heart failure (HF) disease management programmes based in hospitals, homes or the community. Methods Systematic review of qualitative and quantitative studies using realist synthesis. The search strategy incorporated general and specific terms relevant to the research question: HF, self-care and programmes/interventions for HF patients. To be included, papers had to be published in English after 1995 (due to changes in HF care over recent years) to May 2014 and contain specific data related to mechanisms of effect of HF programmes. 10 databases were searched; grey literature was located via Proquest Dissertations and Theses, Google and publications from organisations focused on HF or self-care. Results 33 studies (n=3355 participants, mean age: 65 years, 35% women) were identified (18 randomised controlled trials, three mixed methods studies, six pre-test post-test studies and six qualitative studies). The main mechanisms identified in the studies were associated with increased patient understanding of HF and its links to self-care, greater involvement of other people in this self-care, increased psychosocial well-being and support from health professionals to use technology. Conclusion Future HF disease management programmes should seek to harness the main mechanisms through which programmes actually work to improve HF self-care and outcomes, rather than simply replicating components from other programmes. The most promising mechanisms to harness are associated with increased patient understanding and self-efficacy, involvement of other caregivers and health professionals and improving psychosocial well-being and technology use.

A systematic review of patient heart failure self-care strategies.

Background:Self-care is at the foundation for living with a chronic condition such as heart failure (HF). Patients with HF express difficulty with translating self-care knowledge into understanding “how” to engage in these activities and behaviors. Understanding the strategies that patients develop to engage in self-care will help healthcare providers (HCPs) improve support for unmet self-care needs of HF patients. The purpose of this systematic review was to highlight strategies that HF patients use to accommodate self-care recommendations into the reality of their daily lives. Methods:A systematic review using qualitative meta-synthesis was carried out. Included studies had to contain a qualitative component and data pertaining to self-care of HF from adults older than 18 years and be published as full papers/theses beginning 1995. Ten databases were searched until March 19, 2012. Results:Of 1421 papers identified by the search, 47 were included. Studies involved the following: 1377 patients, 45% women, mean age of 67 years (range, 25–98 years), 145 caregivers, and 15 HCPs. Approaches to self-care reflected both perception- and action-based strategies and were a means to effectively manage HF. Although HF patients often expressed difficulty on how to integrate self-care recommendations into their daily lives, they developed intentional, planned strategies that harnessed previous experiences. Conclusions:Healthcare providers must appreciate that patients view self-care as an “adaptation” that they undertake to maintain their independence and quality of life. In addition, HCPs must recognize that because self-care is a process of learning over time from experience, an individualized approach that emphasizes how to self-care must be adopted for patients to develop the necessary HF self-care skills.

The importance of interactions between patients and healthcare professionals for heart failure self-care: A systematic review of qualitative research into patient perspectives:

Background: Effective heart failure (HF) self-care can improve clinical outcomes but is dependent on patients’ undertaking a number of complex self-care behaviors. Research into the effectiveness of HF management programs demonstrates mixed results. There is a need to improve understanding of patient perspectives’ of self-care need in order to enhance supportive interventions. Aim: This paper reports selected findings from a systematic review of qualitative research related to HF self-care need from the patients’ perspective. The focus here is on those facets of patient-healthcare professional relationships perceived by patients to influence HF self-care. Method: We searched multiple healthcare databases to identify studies reporting qualitative findings with extractable data related to HF self-care need. Joanna Briggs Institute systematic review methods were employed and recognized meta-synthesis techniques were applied. Critical realist theory provided analytical direction to highlight how individual and contextual factors came together in complex ways to influence behavior and outcomes. Results: Altogether 24 studies (1999–2012) containing data on patient-healthcare professional relationships and HF self-care were included. Interaction with healthcare professionals influenced self-care strongly but was notably mixed in terms of reported quality. Effective HF self-care was more evident when patients perceived that their healthcare professional was responsive, interested in their individual needs, and shared information. Poor communication and lack of continuity presented common barriers to HF self-care. Conclusion: Interactions and relationships with clinicians play a substantial role in patients’ capacity for HF self-care. The way healthcare professionals interact with patients strongly influences patients’ understanding about their condition and self-care behaviors.

The Association Between Mild Cognitive Impairment and Self-care in Adults With Chronic Heart Failure: A Systematic Review and Narrative Synthesis.

Background:Emerging evidence suggests that heart failure (HF) patients who have mild cognitive impairment (MCI) may experience greater difficulty with self-care. Objective:This article reports a systematic review that addressed the objective “What is the evidence for an association between MCI and self-care, measured in 1 or more of the self-care domains related to HF, in adults who have a diagnosis of chronic HF?” Method:We adopted Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the review and synthesis of quantitative research studies that formally measured both cognitive function and self-care in HF patients and sought to describe the relationship between these factors. Results:Ninety-one potentially relevant studies were located; 10 studies (2006–2014) were included. Because of heterogeneity in the retrieved studies, meta-analysis was not possible. Narrative synthesis found growing evidence regarding the association between MCI and adverse effects on self-care in HF. Nine studies reported significant positive associations between MCI and self-care in HF, either specifically in relation to medication adherence or more generic measures of self-care activity. One study reported a significant, negative correlation between cognitive function and self-care, suggesting that worse cognitive function was associated with better self-care; however, this is partially explained by a small sample size and mixed methodology. Conclusions:These findings have implications for clinical practice. It is known that HF patients have difficulty with self-care, and the influence of cognitive function needs to be considered when providing professional support. Further research to determine the feasibility and acceptability of cognitive assessment in routine clinical care is recommended.

A grounded theory of taking control after fall-induced hip fracture

Purpose: We applied the grounded theory method to explore the post discharge concerns of older people after fall-induced hip fracture repair. It was anticipated that this understanding would increase awareness of issues that may impact on recovery and rehabilitation. Method: Semi-structured interviews were carried out with 19 older people after discharge home. Initially, purposive sampling guided data collection and thereafter theoretical sampling was employed. Interviews were analysed using the constant comparative method. Results: We generated a theory of how older people ‘take control’ after hip fracture. Conceptually, taking control was about ‘balancing’ and was both a process and a range of strategies. The three stages of the process that people moved through were: ‘going under’, ‘keeping afloat’ and ‘gaining ground’. Nautical metaphors conceptualise the precarious and unstable conditions that older people faced as they struggled to regain their independence. Older people struggled to balance help and risk, in their attempt to manage their concerns relating to losing control of their future independence. Conclusion: Older people are vulnerable to losing a sense of control after a health trauma. This theory adds a new dimension to our understanding of recovery from hip fracture and highlights that older people and their families need tailored information and support to enable them to take control safely and appropriately. Implications for Rehabilitation Older people are vulnerable to losing a sense of control after traumatic injury such as hip fracture. Our research suggests that older people engage in a precarious process of balancing as they strive to take control after fall induced hip fracture. Successful balancing entails the provision of tailored information and support. This theoretical explanation aims to help practitioners understand the older person’s perspective of recovery from traumatic injury in a new light.

The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review

Executive summary Background Older adults with dementia may have feeding difficulties for several reasons: they may experience deterioration in motor and cognitive skills making eating difficult, they may forget to eat, fail to recognise food or they may suffer from dysphagia. Food intake is often poor and malnutrition is common, leading to adverse health outcomes. This review specifically focussed on how best to promote and achieve ‘normal’ eating and feeding in older adults with dementia, in order that undernutrition and its consequences could be avoided. Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia. Types of Participants Adults over the age of sixty with dementia in any care setting (who were not living independently). People receiving enteral tube feeding were excluded. Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers, family or volunteers, educational interventions, changes in food service. Types of Outcomes The primary outcomes were improvement in dietary intake and/or nutritional status. Measurements included: dietary intake, anthropometry, clinical outcomes, functional indicators. Types of Studies Randomised controlled trials, controlled trials and quasi‐experimental studies with a ‘before and after’ design. Search Strategy The search strategy aimed to find both published and unpublished studies using a three‐step approach. Papers were limited to the English language and a date restriction of 1999 to 2009 was set. Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion. Data Extraction For quantitative studies, data was extracted using a data extraction form developed to include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. This was based on the JBI data extraction tool from MAStARI and 2 reviewers extracted data independently. Data synthesis Heterogeneity in study designs, interventions and outcomes meant meta‐analysis was not possible. Findings were discussed in a narrative summary. Results The review included 11 studies. This included one RCT, 1 randomised crossover study, 3 controlled non‐randomised trials, 6 quasi‐experimental studies. None of the studies provided robust evidence, however there was moderate evidence (Level 3) to support a Grade B recommendation for improvements in dietary intake and/or nutritional status with the following interventions: education of healthcare staff, simple environmental manipulations such as the use of high contrast tableware or small dining rooms, the introduction of something of interest such as an aquarium or background music, or the provision of feeding assistance, provision of enhanced menus, use of a decentralised food service, enhanced nutritional screening combined with increased dietetic time. Conclusion There is moderate (Level 3) evidence to support each of the interventions appraised in this review. Implications for Practice There is moderate support that warrants consideration of the interventions listed above. Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care. Implications for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following: inclusion of reliable outcome measures, full details of interventions, randomisation of participants, inclusion of control groups, adequate sample sizes, longitudinal follow up, consideration of baseline demographics of intervention groups, and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care.

Succession planning for advanced nursing practice; contingency or continuity? The Scottish experience

Aim: Succession planning involves identifying key posts within an organization and supporting the ongoing development of individuals ready to move into these roles, thus ensuring continuity of the service. This paper presents an analysis of the succession planning process and illustrates the ways in which key principles may by applied in the case of advanced nursing practice. Background: An array of national policy documents has sought to provide guiding frameworks for effective role development within the National Health Service in Scotland. The growing importance of advanced practice in the contemporary care context might support the assumption that succession planning for these roles would be an integral part of organizational strategy. Key issues: The introduction of advanced practice roles in Scotland has been fragmented and seems largely contingent upon a variety of financial, managerial, and workforce drivers with limited evidence of organizational planning to support role development. Consideration of the elements of the succession planning process, as described in the literature, may improve the sustainability of future initiatives. A variety of flexible educational solutions are available to support staff development for advanced practice, however, the appropriateness of these must be determined in context.

Cross-sectional survey of meticillin-resistant Staphylococcus aureus home-based decolonization practices in Scotland

BACKGROUND Despite limited evidence of meticillin-resistant Staphylococcus aureus (MRSA) decolonization efficacy, the practice of decolonization for both pre-admission and on-admission patients is growing. Recent research within National Health Service (NHS) Scotland revealed low rates of treatment and consequent low efficacy in home-based decolonization. As no national guidelines on home-based decolonization currently exist, practices within NHS Scotland may be variable. AIM To establish current pre-admission MRSA home-based decolonization protocols and patient advice within NHS Scotland. Similarities and differences were identified to determine possible sources of variability. METHODS Cross-sectional survey distributed electronically to MRSA Screening Project Managers within each NHS geographical region in Scotland (N = 15). FINDINGS Thirteen out of 15 NHS regions responded; one region reported no standard protocol. From the remaining 12 regions, 100% recommended use of mupirocin and antiseptic bodywash daily for five days; this was the only consistent aspect of practice across responding regions. Variation was noted in advice regarding method of mupirocin application, bodywash product and volume of bodywash recommended. Six regions (50%) specified bodywash skin contact time, yet these times varied across regions. Mouth care was advocated by three regions (25%). Daily change of facecloths and clothes was endorsed by five regions (41.7%); four regions (33.3%) promoted daily towel changes. Only one region (8.3%) suggested daily bedroom cleaning; three regions (25%) advised changing bed linen daily. CONCLUSIONS Variation in protocols and patient advice may influence efficacy of home-based decolonization and further research may inform the development of evidence-based clinical guidelines.

Expert consensus regarding drivers of antimicrobial stewardship in companion animal veterinary practice: a Delphi study

Antimicrobial resistance (AMR) is a global challenge facing both human and animal healthcare professionals; an effective response to this threat requires a ‘One-Health’ approach to antimicrobial stewardship (AMS) to preserve important antibiotics for urgent clinical need. However, understanding of barriers and enablers to effective AMS behaviour in companion animal veterinary practice is currently limited. We conducted a Delphi study of 16 nationally recognised experts from UK-based veterinary policymakers, university academics and leaders of professional bodies. This Delphi study sought to identify veterinary behaviours which experts believe contribute to AMR and form vital aspects of AMS. Analysis of Delphi findings indicated a perceived hierarchy of behaviours, the most influential being antibiotic prescribing behaviours and interactions with clients. Other veterinary behaviours perceived as being important related to interactions with veterinary colleagues; infection control practices; and the use of diagnostic tests to confirm infection. Key barriers and enablers to AMS within each of these behavioural domains were identified. Specific interventions to address important barriers and enablers are recommended. To the authors’ knowledge, this is the first study to establish expert consensus at a national level about which ‘behaviours’ (aspects of veterinarian practice) should be targeted in relation to AMR and AMS in companion animal veterinary practice.