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ABSTRACT: CONTEXT: Encouraging use of hospice and minimizing the use of cure-oriented aggressive interventions that detract from quality of life in the last month of life are specific targets for improvement in cancer care. OBJECTIVES: To evaluate the effect of an interdisciplinary cancer support team (CST) on quality of care and quality of life in patients with advanced cancers. METHODS: A nonrandomized clinical trial was conducted, comparing outcomes before and after the integration of an interdisciplinary CST in routine care of adults with Stage III or IV lung, gastrointestinal, or gynecologic cancer. In the control arm, patients (n = 332) received usual care; after the initiation of the intervention arm, eligible patients (n = 278) received the CST intervention. The intervention consisted of individualized care coordination, symptom management, education, psychosocial and spiritual supports, and advance care planning throughout the 15-month study period. Quality of end-of-life care was measured through an "aggressiveness of care" index. Health-related quality of life (HRQOL) was measured with the Functional Assessment of Cancer Therapy-General. RESULTS: There were no statistically significant differences between groups on specific indicators of quality of care. Surviving subjects with higher survival expectancy (who also reported better baseline quality of life) in the intervention arm had the greatest improvement in HRQOL scores, compared with the other three groupings of survival expectancy by treatment group (high vs. low by intervention vs. control) (P = 0.044). CONCLUSION: Individually tailored supportive services from an interdisciplinary team are associated with improved HRQOL in some patients. This has implications for the potential benefits that can be accrued from providing intensive support to all patients, even those who may appear to be at less risk for distress. There also are important methodological considerations in using aggressiveness of care indices as a measure of quality of care.
Journal of pain and symptom management 03/2013; · 2.42 Impact Factor
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ABSTRACT: Over a decade of research on the relationship between nurse staffing and patient outcomes has demonstrated the important role of nurses in the provision of high-quality, safe care, yet currently, no evidence-based nurse staffing guidelines exist. A systematic review of reviews was conducted to explore reasons why this is the case and recommend directions for future research to improve upon this gap. Authors of the 29 included reviews reported variability in methods and measurement approaches, lack of incorporation of nurse processes and system factors that potentially affect relationships among variables, and overall inconsistencies in results across primary studies. We propose use of an Integrated Framework for a Systems Approach to Nurse Staffing Research to inform the development of applicable conceptual models. Future studies that use a systems approach and focus on establishing causal relationships among variables will potentially strengthen the evidence and advance the science in this area.
Western Journal of Nursing Research 02/2013; · 1.19 Impact Factor
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ABSTRACT: Objective: Little is known about relationships between patient spiritual well-being and caregiver outcomes for those with advanced cancer. We were interested in examining the relationship between patient physical quality of life (QOL) and caregiver depression and to also evaluate whether patient spiritual well-being (SWB) played a mediating role in this relationship. Method: This is a prospective longitudinal study that was conducted in the outpatient clinics at a university-affiliated comprehensive cancer center. 226 patients with Stage III or IV cancer (lung, GI, GYN) and their primary caregivers were interviewed upon enrollment into the study and three months later. Measures of spirituality, health-related quality of life, and physical functioning were included in the interviews. Results: Key findings were that the relationship between patient physical QOL and caregiver depression was inverse and moderate (β = -0.24, p = 0.004) and that patient SWB (meaning/peace) played a significant (p = 0.02) and medium-size role (β = -0.31) in mediating the relationship between patient physical QOL and caregiver depression. The nature of these relationships was stable over time. Significance of results: Patients' spirituality is central to their coping and adjusting to cancer. It is this aspect of patient overall quality of life that mediates the relationship to caregiver well-being. The most potent intervention for caregiver depression may be attending to patient spiritual distress.
Palliative and Supportive Care 11/2012;
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ABSTRACT: Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments.
Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events.
Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls.
The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.
Journal of Nursing Measurement 01/2012; 20(3):155-85.
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ABSTRACT: The decision regret scale (DRS) is a five-item instrument that captures an individual's regret associated with a healthcare decision. Cross-sectional data were collected from 109 cardiac patients who decided to receive an internal cardioverter defibrillator (ICD). Exploratory and confirmatory factor analyses, assessments of the internal reliability consistency (alpha = .86), and discriminant validity established the DRS as a reliable and valid measure of decision regret in ICD recipients. The DRS, a psychometrically sound instrument, has relevance for clinicians and researchers vested in optimizing the decisional outcomes of ICD recipients. Future research is needed to examine the reliability and validity of the DRS in a larger and more diverse sample of ICD recipients.
Journal of Nursing Measurement 01/2012; 20(1):21-34.
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Barbara J Daly
AACN Advanced Critical Care 10/2011; 22(4):321-2.
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ABSTRACT: To examine the frequency with which quality of life and treatment limitation were discussed in formal family meetings for long-stay intensive care unit patients with high risk for mortality and morbidity.
Descriptive observational study.
Five intensive care units.
One hundred sixteen family surrogate decisionmakers of long-stay intensive care unit patients who participated in an intensive communication system that aimed to provide weekly meetings with family decisionmakers. The structure of each meeting was to address medical update, patient preferences, treatment plan, and milestones for evaluating the treatment plan.
None.
We audiotaped initial family meetings for 116 family decisionmakers for a total of 180 meetings. On average, meetings were 24 mins long with a majority of time being devoted to nonemotional speech and little (12%) spent discussing patient preferences. Quality of life was discussed in 45% and treatment limitation in 23% of all meetings. Quality-of-life discussions were more likely to occur when patients were admitted to a medical intensive care unit (odds ratio [OR] 5.9; p = .005), have a family decisionmaker who is a spouse (OR 9.4; p = .0001), were older (OR 1.04; p = 01), have a shorter length of stay (OR 0.93; p = .001), and have a family decisionmaker who was a spouse (OR 5.1; p = .002). For those with a treatment limitation discussion, 67% had a do-not-resuscitate order, 40% were admitted to a medical intensive care unit, 56% had a family decisionmaker who had been their caregiver, and 48% of their family decisionmakers were their children.
To guide discussion with families of the subset of intensive care unit patients with high risk of mortality and long-term morbidity, quality of life was not consistently addressed. Continued efforts to assist clinicians in routinely including discussions of quality-of-life outcomes is needed.
Critical care medicine 09/2011; 40(2):461-7. · 6.37 Impact Factor
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ABSTRACT: The purpose of this study was to describe health promotion behaviors and work productivity loss in informal caregivers of individuals with advanced stage cancer. Using a cross-sectional, correlational design, 70 caregivers completed measures of health behaviors, mood, social support, and burden. Absenteeism and presenteeism were evaluated in employed caregivers (n = 40). Caregivers reported low levels of physical activity. The mean percentage of work productivity loss due to caregiving was 22.9%. Greater work productivity loss was associated with greater number of caregiving hours, higher cancer stage, married status, and greater anxiety, depression, and burden related to financial problems, disrupted schedule, and health. Nurses should assess caregivers and provide health promotion interventions, which may ultimately reduce the economic impact of caregiving.
Research in Nursing & Health 09/2011; 34(6):483-95. · 1.71 Impact Factor
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ABSTRACT: Decisional conflict may predispose surrogate decision makers (SDMs) of the chronically critically ill (CCI) to making health care decisions that are not aligned with the patient's health care preferences and increase the SDM's likelihood of experiencing decision regret. This study establishes the relationship between decisional conflict and decision regret and offers insight on tailoring decision support interventions to the preferences of SDMs of CCI patients.
Applied nursing research: ANR 06/2011; · 0.87 Impact Factor
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ABSTRACT: The aim of this study was to examine the role of cognitive appraisal in predicting psychosocial adjustment during the postradiation treatment transition. A predictive correlational design was used in a convenience sample of 80 patients with breast, lung, and prostate cancer who were receiving radiation therapy. Two weeks prior to completion of treatment, participants completed instruments to measure symptom distress, uncertainty, cognitive appraisal, social support, and self-efficacy for coping. The Psychosocial Adjustment to Illness Scale was administered 1 month after therapy. Adjustment was significantly correlated with all independent variables, age, and comorbidity. Young age and high amounts of threat appraisal, harm/loss appraisal, uncertainty, and symptom distress were significantly associated with poor adjustment. The model predicted 52% of the variability in adjustment. Cognitive appraisal was not a significant explanatory variable for adjustment when controlling for uncertainty, cancer stage, age, and symptom distress. Symptom distress was the only significant predictor of adjustment.
Western Journal of Nursing Research 06/2011; 33(4):540-59. · 1.19 Impact Factor
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ABSTRACT: To explore the new and complex phenomenon of distance caregiving in the advanced cancer population.
Qualitative.
A large comprehensive cancer center in the midwestern region of the United States.
14 distance caregivers of parents with advanced cancer.
Patients with advanced lung, gastrointestinal, and gynecologic malignancies consented to have their distance caregiving adult children contacted to participate in the study. Responses to three open-ended questions guided the tape-recorded telephone interviews with the distance caregivers. Following transcription, content analysis with inductive coding was performed.
Two major themes, communication and control, and five subthemes, benefits and burdens of distance caregiving, dealing with uncertainty, direct action through information seeking, protecting, and staying connected, emerged from the data.
Distance caregivers experience some of the same stressors that local caregivers of patients with cancer experience. In addition, they have unique psychosocial needs related to the burden of geographic distance.
Distance caregivers could benefit from nursing interventions targeted at their unique needs. Innovative interventions using Web-based computer technology for improved communication, as well as supportive care interventions, may be helpful.
Oncology Nursing Forum 05/2011; 38(3):307-13. · 1.91 Impact Factor
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ABSTRACT: Recognition of the family as a component of patient-centered critical care has shifted our attention to the assessment of family satisfaction in the intensive care unit (ICU). To date, there are no established measures of satisfaction with ICU care for family members of the chronically critically ill (CCI). This study evaluated psychometric properties of the Critical Care Family Satisfaction Survey (CCFSS) in 326 family members of the CCI using exploratory and confirmatory factor analysis (CFA). From the exploratory factor analysis, two unique structural models emerged, each with alpha coefficients of .72 to .91 and discriminant validity among factors (r < .70). The CFA confirmed the best-fitting structural model was a 14-item, three-factor solution (χ(2) = 354, df = 148, p < .001, Tucker Lewis Index = .88, Comparative Fit Index = .90, root mean square error of approximation = .06). Thus, the modified 14-item version of the CCFSS is reliable and valid in family members of CCI patients.
Western Journal of Nursing Research 03/2011; 34(3):377-95. · 1.19 Impact Factor
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Barbara J Daly,
Sara L Douglas,
Elizabeth O'Toole,
Nahida H Gordon,
Rana Hejal,
Joel Peerless,
James Rowbottom,
Allan Garland,
Craig Lilly,
Clareen Wiencek,
Ronald Hickman
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ABSTRACT: Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients.
One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment.
Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place.
The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. Trial registry: ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.
Chest 12/2010; 138(6):1340-8. · 5.25 Impact Factor
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ABSTRACT: Multiple, complex factors influence end-of-life (EOL) decisions for all persons. In the African American population, these factors include history of disparities and discrimination in health care, which may affect the individual and the family, family system beliefs, values, and practices, and health care system issues. Family dynamics have an especially important role in treatment decisions for loved ones with advanced disease. A family systems framework can guide the clinicians in appreciating care needs and preferences at EOL. Understanding why so many African Americans choose aggressive and often burdensome care, even at the expense of suffering, is important for communication about options at the EOL and the delivery of quality care at the EOL.
The American journal of hospice & palliative care 12/2010; 27(8):560-6.
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ABSTRACT: Overwhelmed family decision makers of chronically critically ill patients must comprehend vital information to make complex treatment decisions that are consistent with patients' preferences. Exploration of informational coping styles of family decision makers may yield evidence for tailored communication practices supporting the psychological and informational needs of family decision makers.
To describe patterns in the demographic characteristics and informational coping styles of family decision makers; to assess differences in informational satisfaction, role stress, and depressive symptoms between family decision makers classified as monitors and as blunters; and to describe the predictive associations between informational coping styles, informational satisfaction, and role stress on depressive symptoms in family decision makers.
A secondary data analysis of 210 family decision makers of cognitively impaired patients who required 3 days or more of mechanical ventilation. On enrollment, decision makers completed the abbreviated Miller Behavioral Style Scale to assess informational coping styles, the Critical Care Family Satisfaction Survey's informational subscale to assess informational satisfaction, a single-item measure of role stress, and the Center for Epidemiological Studies Depression scale to assess depressive symptoms.
No associations emerged between demographic characteristics and informational coping styles of family decision makers. Monitors had higher depression scores than did blunters. Both information coping style and informational satisfaction influenced depressive symptoms; however, role stress was the most significant predictor.
Family decision makers classified as monitors were at higher risk for depression than were those who seem to avoid information. Targeting monitors with additional psychological and informational support may mitigate their psychological impairment.
American Journal of Critical Care 09/2010; 19(5):410-20. · 1.66 Impact Factor
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ABSTRACT: Understanding the relationships between social and psychological determinants of health-related quality of life (HRQOL) is a critical step in developing effective screening tools and targeted interventions for psychosocial care.
The purpose of this study was to examine the relationship between dispositional optimism and HRQOL in newly diagnosed adult cancer patients.
A cross-sectional, predictive correlational design was used. The sample consisted of 163 patients with mixed diagnoses and stages who were within 180 days since diagnosis and had completed a battery of psychosocial measures upon enrollment into a psychosocial data registry during their first outpatient visit or treatment. Hierarchical multiple regression analyses were conducted to determine predictors of HRQOL.
Optimism was significantly correlated with spiritual well-being, anxiety, depression, and HRQOL. Optimism was not a significant predictor of HRQOL at initial diagnosis and treatment when age, scores on functional status, spiritual well-being, depression, and anxiety were entered into the regression equation.
Dispositional optimism is not a primary factor in HRQOL at initial diagnosis and treatment. Further exploration is needed to determine if optimism exerts a greater influence on HRQOL at another point along the cancer trajectory and if there is overlap between the constructs of optimism and spirituality.
Although systematic screening for dispositional optimism is not recommended, patients who display characteristics associated with low optimism require further assessment. Also, patients with poor functional status, young age, low levels of spirituality, and high levels of depression may be vulnerable for poor HRQOL.
Cancer nursing 03/2010; 33(3):235-43. · 1.88 Impact Factor
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ABSTRACT: To determine whether age or stage of cancer can be used to identify caregivers at high risk for excessive burden or distress.
Descriptive data collected as part of a psychosocial research registry, comparing younger caregivers with older and caregivers of early-stage patients with those of later stage.
Caregivers of newly diagnosed adult cancer patients.
Caregiver Reaction Assessment (CRA), the Profile of Mood States (POMS), single-item indicators from the Patient Reported Outcome Measurement Information System set, and the Medical Outcomes Study Social Support (MOS-SS) Scale. Patient information was obtained from the medical record.
Younger caregivers and caregivers of patients with Stage I and II cancer identified a greater lack of family support than older caregivers and caregivers of patients with Stage III and IV cancer. Significant regression models were found for three CRA subscales (Disrupted Schedule, Lack of Family Support, and Health Problems), as well as for the POMS depression and fatigue scales. Caregiver social support (MOS-SS) made the only significant contribution to the models. There were significant differences between caregivers with high and low levels of social support on almost all measures of well-being.
Incorporating formal assessment of social support may be useful in identifying at-risk caregivers. In addition, there is a need to further investigate which dimensions of social support are most strongly related to measures of well-being.
Journal of the American Geriatrics Society 11/2009; 57 Suppl 2:S293-5. · 3.74 Impact Factor
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ABSTRACT: Advances in oncology treatment have prompted the need for a new model of palliative care. The Cancer Support Team, formerly known as the Safe Conduct Team, of the Ireland Cancer Center practices under a new model that emphasizes the variable timing of palliative care needs of patients and families across the cancer disease trajectory. This new model assumes that palliative care is offered in conjunction and as a component of disease-oriented care, but unlike previous models, it does not follow a linear pattern of use. Care needs fluctuate throughout the course of life-limiting disease. In addition, this new model recognizes that as current cancer treatment options improve quantity and quality of life, patient goals of care often include appropriate disease-oriented treatment near the end of life, prohibiting enrollment in hospice based on Medicare regulations. This model of palliative care ensures that oncology patients and families will receive an interdisciplinary plan of care based on their goals and preferences, even if they do not choose hospice care or do not qualify for the hospice benefit.
Journal of Hospice and Palliative Nursing 10/2009; 11(6):324-331. · 0.38 Impact Factor
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ABSTRACT: Data on likely postdischarge outcomes are important for decision making about chronically critically ill patients. It seems reasonable to categorize outcomes into "better" or overall desirable states and "worse" or generally undesirable states. Survival, being at home, and being cognitively intact are commonly identified as important to quality of life and thus may be combined to describe composite outcome states.
To categorize postdischarge outcome states of chronically critically ill patients and identify predictors of better and worse states.
Reanalysis of data from a trial of a disease management program for chronically critically ill patients. Two composite outcomes were created: (1) the "better" outcome: no cognitive impairment at 2 months after discharge and alive and at home at 4 months (ie, met all 3 criteria), and (2) the "worse" outcome: cognitive impairment 2 months after discharge, or death after discharge, or not living at home 4 months after discharge (ie, met at least 1 of these criteria).
Of 218 patients not requiring ventilatory support at discharge, 111 (50.9%) had a better outcome. Of 159 patients who were cognitively intact at discharge, 111 (69.8%) had a better outcome. Of the 39 patients who required ventilatory support at discharge, only 1 (3%) achieved the better outcome. Of 98 patients who were cognitively impaired at discharge, only 29 (30%) had the better outcome.
Need for mechanical ventilatory support and persistent cognitive impairment at discharge were associated with worse outcomes 4 months after discharge.
American Journal of Critical Care 10/2009; 18(5):456-64; quiz 465. · 1.66 Impact Factor
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ABSTRACT: This paper is a report of a concept analysis of patient acuity.
Patient acuity is a widely-used term in the health sciences literature, but often without specification of its exact meaning. Concept clarification is therefore needed to delineate the meaning of patient acuity.
A review of the Pubmed, CINAHL, MEDLINE and PsychInfo databases for the keyword 'acuity' in the title or abstract of papers in English language journals, as well as searches for the term 'acuity' and 'acute' in the Merriam-Webster and Oxford English Dictionaries were the data sources for this concept analysis. Papers were excluded if 'acuity' was not present in the title or abstract. Publication dates of the literature included in the review ranged from 1974 to 2008.
The attributes of acuity are severity, intensity and the pairing of acuity measurements with another concept. These attributes were organized according to Holzemer's Outcomes Model for Health Care Research as patient-, provider- or system-related. The sub-categories of attributes identified were physical, psychological, nursing care needs, workload, complexity, case-mix, patient classification systems, urgency/triage scales and other uses.
Researchers are encouraged to specify which attribute of acuity they are studying and to develop measurement tools specific to that attribute, in order to move the science towards standardization of the concept of acuity and its measurement.
Journal of Advanced Nursing 03/2009; 65(5):1114-26. · 1.48 Impact Factor
