Sylvie Cossette

Clinical Implications of a Reduction in Psychological Distress on Cardiac Prognosis in Patients Participating in a Psychosocial Intervention Program

Objective The objective of this secondary analysis was to examine the relationships between a reduction in psychological distress and long-term cardiac and psychological outcomes in post–myocardial infarction patients who participated in a randomized trial of home-based psychosocial nursing interventions (the Montreal Heart Attack Readjustment Trial [M-HART]). Gender differences were considered. Methods We studied 433 patients (36.0% women) from the M-HART treatment group who received two home visits after achieving a high psychological distress score (ie, ≥5) on the General Health Questionnaire (GHQ). Short-term GHQ success was determined by a return to a normal GHQ score (<5) or a reduction of ≥50% after the two visits. Patients with short-term successful and unsuccessful GHQ outcomes were compared for mid-term maintenance of success, 1-year death and readmission rates, and 1-year depression and anxiety symptoms. Results Patients with short-term GHQ success were more likely to show mid-term GHQ success (p < .001), marginally less likely to die of any causes (p = .087), less likely to die of cardiac causes (p = .043), less likely to be readmitted for any reason (p < .001) and for cardiac reasons (p < .001), and less likely to have high depression (p < .001) and anxiety (p < .001) at 1-year than patients with short-term unsuccessful GHQ outcomes. Results held for men and women and were not altered by controlling for potential confounders. However, the number of deaths prevented analysis with statistical controls. Conclusions Post–myocardial infarction interventions that reduce psychological distress have the potential to improve long-term prognosis and psychological status for both men and women.

The Impact of a Multidisciplinary Information Technology–Supported Program on Blood Pressure Control in Primary Care

Background—Hypertension is a leading mortality risk factor yet inadequately controlled in most affected subjects. Effective programs to address this problem are lacking. We hypothesized that an information technology–supported management program could help improve blood pressure (BP) control. Methods and Results—This randomized controlled trial included 223 primary care hypertensive subjects with mean 24-hour BP >130/80 and daytime BP >135/85 mm Hg measured with ambulatory monitoring (ABPM). Intervention subjects received a BP monitor and access to an information technology–supported adherence and BP monitoring system providing nurses, pharmacists, and physicians with monthly reports. Control subjects received usual care. The mean (±SD) follow-up was 348 (±78) and 349 (±84) days in the intervention and control group, respectively. The primary end point of the change in the mean 24-hour ambulatory BP was consistently greater in intervention subjects for both systolic (−11.9 versus −7.1 mm Hg; P<0.001) and diastolic BP (−6.6 versus −4.5 mm Hg; P=0.007). The proportion of subjects that achieved Canadian Guideline target BP (46.0% versus 28.6%) was also greater in the intervention group (P=0.006). We observed similar BP declines for ABPM and self-recorded home BP suggesting the latter could be an alternative for confirming BP control. The intervention was associated with more physician-driven antihypertensive dose adjustments or changes in agents (P=0.03), more antihypertensive classes at study end (P=0.007), and a trend toward improved adherence measured by prescription refills (P=0.07). Conclusions—This multidisciplinary information technology–supported program that provided feedback to patients and healthcare providers significantly improved blood pressure levels in a primary care setting.

Randomized Controlled Trial of Tailored Nursing Interventions to Improve Cardiac Rehabilitation Enrollment

Background:Short hospital stays for patients with acute coronary syndromes (ACSs) reduce the opportunity for risk factor intervention during admission. After discharge, cardiac rehabilitation can decrease the recurrence of coronary events by up to 25%. However, it remains underused. Objectives:The aim of this study was to determine whether a nursing intervention focused on individual ACS patients’ perceptions of their disease and treatment would increase rehabilitation enrollment after discharge. Method:A total of 242 ACS patients admitted to a specialized tertiary cardiac center were randomized to either the intervention or usual care (n = 121 in both groups). The intervention included one nurse–patient meeting before discharge with 2 additional contacts over the 10 days after discharge (mean duration = 40 minutes per contact). The primary outcome was enrollment in a free rehabilitation program offered to all participants 6 weeks after discharge. Secondary outcomes included illness perceptions; family support; anxiety level; medication adherence; and cardiac risk factors including lack of exercise, smoking, body mass index, and diet. Results:The sample was composed of a majority of male, married workers who experienced a myocardial infarction or unstable angina without severe complications. The mean hospital stay in both groups was 3.6 days. There was a significantly higher rate of rehabilitation enrollment in the intervention group (45%) than in the control group (24%; p = .001). For the secondary outcomes, only the personal control dimension of illness perceptions was improved significantly with the intervention. Discussion:Progressive, individualized interventions by nurses resulted in greater rehabilitation enrollment, thereby potentially improving long-term outcome.

The multidimensionality of caring: a confirmatory factor analysis of the Caring Nurse–Patient Interaction Short Scale

AIM This paper is a report of a study to evaluate the construct validity of the four-dimensional Caring Nurse-Patient Interaction-Short Scale using confirmatory factor analysis. BACKGROUND Validating theoretical structures of caring is an ongoing challenge in the discipline of nursing. Our previous work has contributed to this literature by the exploration of the dimensionality of the Caring Nurse-Patient Interaction Short Scale via an exploratory factor analysis. The Caring Nurse-Patient Interaction Short Scale comprises 23 items reflecting four caring domains: humanistic care, relational care, clinical care and comforting care. METHOD A methodological study was conducted involving a convenience sample of 531 nursing students in a baccalaureate nursing programme (20% were already Registered Nurses). Data were collected in 2002 and 2004. Confirmatory factor analysis of the Caring Nurse-Patient Interaction Short Scale was performed. FINDINGS As expected with large samples and models, the chi-squared-associated P-value was statistically significant (chi2 = 811.43, d.f. = 224, P < 0.01). However, the other indices reached acceptable levels with 0.054 for the standardized root mean-squared residuals, 0.070 for the root mean-square error of approximation, 0.88 for the goodness of fit index, 0.98 for the comparative fit index and 0.97 for the normal fit index. The factor loadings for all items with their hypothesized factor were > or = 0.48 and statistically significant at the 0.01 level. CONCLUSION The Caring Nurse-Patient Interaction Short Scale model was judged to fit the data adequately. Although further testing of the scale with different samples of patients is warranted, our model emerged as a middle-range theory during the construct validity process and still reflects Watsons theory while offering a structure that is testable in clinical research.

Predictors of the Psychological Well-Being of Primary Caregivers Living With a Demented Relative: A 1-Year Follow-Up Study

This 1-year follow-up study aimed to examine the predictors of change in psychological well-being, using two negative indicators (psychological distress and negative feelings about the caregiver role) and two positive indicators (positive feelings about the caregiver role and positive affect) of well-being. The sample consisted of primary caregivers (n = 180) cohabiting with a demented relative. Four variables were involved in predictive relationships with psycho logical well-being The first variable, appraisal of the disturbance from dysfunctional behaviors at Time 1, was selectively predictive of an increase in the two negative indicators over a year. The second and third variables, increased conflicts in the exchange of informal support and less frequent informal support at Time 1, were predictive of an increase in psychological distress. The fourth variable, frequent use of affective-stimulative dementia management strategies at Time 1, appeared to predict an increase in the two positive indicators of well-being. Knowledge of these four predictors can be useful in designing interventions that target the improvement of well-being.

Cerebral oximetry as a biomarker of postoperative delirium in cardiac surgery patients

PURPOSE A promising monitoring strategy for delirium is the use of cerebral oximetry, but its validity during delirium is unknown. We assessed the relationship between oximetry and delirium. We hypothesized that as cerebral oximetry values increased, delirium would resorb. MATERIALS AND METHODS An observational study was conducted with 30 consecutive adults with delirium after cardiac surgery. Oximetry, delirium assessments, and clinical data were collected for 3 consecutive days after delirium onset. Oximetry was obtained using near-infrared spectroscopy. Delirium was assessed using diagnosis, occurrence (Confusion Assessment Method-ICU), and severity scales (Delirium Index). RESULTS All patients presented delirium at entry. The mean oximetry value decreased from 66.4±6.7 (mean±SD) to 50.8±6.8 on the first day after delirium onset and increased in patients whose delirium resorbed over the 3 days. The relationship between oximetry, delirium diagnosis, and severity was analyzed with a marginal model and linear mixed models. Cerebral oximetry was related to delirium diagnosis (P≤.0001) and severity (P≤.0001). CONCLUSION This study highlighted the links between increased cerebral oximetry values and delirium resorption. Oximetry values may be useful in monitoring delirium progression, thus assisting in the management of this complicated condition.

Researching Complex Interventions in Health : The State of the Art

Table of contentsKEYNOTE PRESENTATIONSK1 Researching complex interventions: the need for robust approachesPeter CraigK2 Complex intervention studies: an important step in developing knowledge for practiceIngalill Rahm-HallbergK3 Public and patient involvement in research: what, why and how?Nicky BrittenK4 Mixed methods in health service research – where do we go from here?Gunilla BorglinSPEAKER PRESENTATIONSS1 Exploring complexity in systematic reviews of complex interventionsGabriele Meyer, Sascha Köpke, Jane Noyes, Jackie ChandlerS2 Can complex health interventions be optimised before moving to a definitive RCT? Strategies and methods currently in useSara LevatiS3 A systematic approach to develop theory based implementation interventionsAnne SalesS4 Pilot studies and feasibility studies for complex interventions: an introductionLehana Thabane, Lora GiangregorioS5 What can be done to pilot complex interventions?Nancy Feeley, Sylvie CossetteS6 Using feasibility and pilot trials to test alternative methodologies and methodological procedures prior to full scale trialsRod TaylorS7 A mixed methods feasibility study in practiceJacqueline Hill, David A Richards, Willem KuykenS8 Non-standard experimental designs and preference designsLouise von EssenS9 Evaluation gone wild: using natural experimental approaches to evaluate complex interventionsAndrew WilliamsS10 The stepped wedge cluster randomised trial: an opportunity to increase the quality of evaluations of service delivery and public policy interventionsKarla Hemming, Richard Lilford, Alan Girling, Monica TaljaardS11 Adaptive designs in confirmatory clinical trials: opportunities in investigating complex interventionsMunyaradzi DimairoS12 Processes, contexts and outcomes in complex interventions, and the implications for evaluationMark PetticrewS13 Processes, contexts and outcomes in complex interventions, and the implications for evaluationJanis Baird, Graham MooreS14 Qualitative evaluation alongside RCTs: what to consider to get relevant and valuable resultsWillem Odendaal, Salla Atkins, Elizabeth Lutge, Natalie Leon, Simon LewinS15 Using economic evaluations to understand the value of complex interventions: when maximising health status is not sufficientKatherine PayneS16 How to arrive at an implementation planTheo van AchterbergS17 Modelling process and outcomes in complex interventionsWalter SermeusS18 Systems modelling for improving health careMartin Pitt, Thomas Monks

Evaluation of a nurse mentoring intervention to family caregivers in the management of delirium after cardiac surgery (MENTOR_D): a study protocol for a randomized controlled pilot trial

BackgroundDespite the use of evidence-based preventive measures, delirium affects about 40% of patients following cardiac surgery with the potential for serious clinical complications and anxiety for caregivers. There is some evidence that family involvement as a core component of delirium management may be beneficial since familiarity helps patients stay in contact with reality, however, this merits further investigation. There is also currently a gap in the scientific literature regarding objective indicators that could enhance early detection and monitoring of delirium. Therefore, this randomized pilot trial examines the acceptability, feasibility, and preliminary efficacy of an experimental nursing intervention to help family caregivers manage post-cardiac surgery delirium in their relatives. It also explores the validity of a new and innovative measure that has potential as an indicator for delirium.Methods/DesignIn this two-group randomized pilot study (n = 30), the control group will receive usual care and the intervention group will receive the experimental intervention aimed at reducing delirium severity. The intervention nurse’s objective will be to foster the family caregiver’s self-efficacy in behaving in a supportive manner during delirium episodes. Data will be collected from standard delirium assessment scales and a novel measure of delirium, i.e., cerebral oximetry obtained using near infrared spectroscopy, as well as medical records and participants’ responses to questionnaires.DiscussionNew strategies for early detection, monitoring, and management of delirium are needed in order to improve outcomes for both patients and families. The present article exposes feasibility issues based on the first few months of the empirical phase of the study that may be useful to the scientific community interested in improving the care of patients with delirium. Another potentially important contribution is in the exploration of cerebral oximetry, a promising measure as an objective indicator for early detection and continuous monitoring of delirium. The proposed pilot study will build towards a larger trial with the potential to improve knowledge about delirium management and monitoring.Trial registrationThis pilot study was registered at Controlled Trials on March 27th 2013 and was assigned #ISRCTN95736036.

The Systematic Development of a Nursing Intervention Aimed at Increasing Enrollment in Cardiac Rehabilitation for Acute Coronary Syndrome Patients

Acute coronary syndrome (ACS) is a leading cause of morbidity worldwide. Although cardiac rehabilitation (CR) programs can decrease recurrence of coronary events by as much as 25%, few patients engage in CR after a cardiac event. Current therapeutic procedures for ACS are provided quickly after the onset of symptoms, resulting in briefer hospital stays. Therefore, within this shorter time frame, the education of patients about ACS risk factors and their reduction presents a new nursing challenge. The purpose of this paper is to describe the systematic pathway in the development of a nursing intervention which addresses these new challenges in ACS risk factor reduction. The intervention aims to increase enrollment in CR, and enhance illness perceptions and medication adherence, while decreasing anxiety, risk factors, and emergency revisits.

Randomized controlled trial of a nursing intervention to reduce emergency department revisits.

OBJECTIVE To determine whether a nursing intervention delivered at emergency department (ED) discharge would reduce ED revisits. METHOD A randomized study was conducted in the ED of a tertiary cardiac hospital in Montreal, Quebec. Between November 2006 and March 2010, 3,795 patients were assessed for eligibility based on two risk factors for ED revisits (≥1 ED visit in the past year and ≥6 medications); 132 were randomized to the experimental group (EG) and 133 to the control group (CG). The intervention included one nurse-patient meeting before leaving the ED, with two additional telephone contacts over the next 2 weeks. The primary outcome was time to ED revisits within 30 days after discharge. Secondary outcomes included time to ED revisits over 90, 180, and 365 days and hospitalizations over 30, 90, 180, and 365 days. RESULTS A planned interim analysis that stopped the study with half of the planned sample showed that the time to ED revisits was similar in both groups at 30 days (p=0.81; revisits: 18.2% in EG, 19.6% in CG), 90 days (p=0.44), 180 days (p=0.98), and 365 days (p=0.75). The only difference identified was a lower hospitalization proportion at 180 days in the EG group (13.6% v. 24.1%; p=0.038). CONCLUSIONS These findings are consistent with previous research showing that few ED-based interventions are successful in reducing ED returns. Factors other than those targeted by the intervention, including an improvement in usual care, may explain the findings.