Integrative review of the needs and challenges of indigenous palliative care in rural and remote settings.

AIMS: To appraise and synthesize the empirical literature on the needs and challenges of Indigenous peoples' accessibility to palliative care in rural and remote settings. DESIGN: Whittemore and Knafl's updated approach to integrative reviews, PRISMA guidelines and CASP (2020) checklists for narrative analysis were followed. DATA SOURCES: A systematic search of the published empirical literature from 1 January 2015 to 31 December 2021 was undertaken in five databases. REVIEW METHODS: Twenty-four studies met the research question and the inclusion criteria. RESULTS: Four themes describe the findings: Respect of Indigenous cultural beliefs on death and dying, connection to the land, needs for culturally responsive care and presence of institutional and systemic barriers. These themes indicate a pressing need to increase the accessibility and utilization of palliative care. Most of the studies were qualitative and conducted by teams of Indigenous and non-Indigenous researchers. CONCLUSION: Integrating Indigenous knowledge and providing culturally responsive palliative care are steps towards achieving the decolonization of palliative care and responding to Indigenous people's needs of palliative care services. Institutional and systemic racism affect Indigenous peoples' access and delivery of palliative services in Canada and globally. IMPACT: The review highlights the need for establishing partnerships and building local capacity with Indigenous communities to develop and implement culturally responsive palliative care programmes in remote locations.

Hidden Tales of Ebola: Airing the Forgotten Voices of Ugandan "Ebola Nurses".

INTRODUCTION: According to the Centers for Disease Control and Prevention, Ebola has affected the lives of thousands, including health care workers. With few studies describing the experience of nurses who survived Ebola, the study aimed to describe Ugandan nurses' experiences. METHOD: Using a phenomenological design, in-depth interviews were conducted among five Ugandan nurses who contracted Ebola and survived. RESULT: Thematic analysis revealed themes of expectations of dying, hopelessness, loneliness, and betrayal by family, community, and the health system. DISCUSSION: Results support the need for policies targeting holistic practice protocols to protect all health care professionals during future outbreaks. Last, nursing survivors should have access to government-guaranteed support programs, including free health care and financial stipends. These results and recommendations transcend to the current reality of living with COVID-19 (coronavirus disease 2019). Efficient practice protocols could protect all rights and privileges and contribute to access to treatment and stigma removal.

Examination of Breast Cancer Screening Knowledge, Attitudes, and Beliefs among Syrian Refugee Women in a Western Canadian Province.

BACKGROUND: Women living in the Arab world present low breast cancer screening rates, delayed diagnosis, and higher mortality rates. PURPOSE: To further explore the Muslim Syrian refugee women's breast self-examination (BSE), utilization of clinical breast examination (CBE) and mammography. METHODS: A cross-sectional descriptive exploratory study design was used. The sample consisted of 75 refugee women. Data were collected using Champion's Health Belief Model Scale, the Cancer Stigma Scale, and the Arab Culture-Specific Barriers to Breast Cancer Questionnaire. Descriptive, Pearson correlation and logistic regression analyses were used to analyze the data. RESULTS: A minority of women had BSE (32%), CBE (12%) and mammograms (6.7%) anytime during their lifetime. Women's breast cancer screening (BCS) knowledge ranked at a medium level (M = 10.57, SD = 0.40). Low knowledge score, BSE information, policy opposition, responsibility, barriers to BSE, and seriousness were found to be statistically significant in women's BSE practice. BSE benefits and religious beliefs significantly predict CBE Age, education, knowledge, responsibility, susceptibility, social barriers, and religious beliefs were statistically significant in women's mammography use (p < .01). CONCLUSIONS: Participants' breast cancer screening practices were low. Health beliefs, Arab culture and stigma about cancer affected women's BCS practices. Faith-based interventions may improve knowledge and practices.

An integrative review of Indigenous informal caregiving in the context of dementia care.

AIMS: To appraise the empirical literature on the needs of Indigenous informal caregivers caring for people living with dementia in Indigenous communities. DESIGN: Whittemore and Knafl's updated approach to integrative reviews, PRISMA guidelines, and CASP checklists for narrative analysis were followed. DATA SOURCES: A systematic search of published empirical literature from January 2010 to August 2020 was undertaken in six databases. REVIEW METHODS: Fifty-one studies met the research question and the inclusion criteria. RESULTS: Five themes describe the findings: Decolonizing Western perspectives on dementia, the centrality of cultural safety, caregivers' experiences, pre-dementia community education and family and community-centred care emerged from the thematic analysis. Most of the studies used quantitative methodologies, and few studies were conducted using community-based approaches. CONCLUSION: This review shows that Indigenous caregiving represents an emerging field in nursing and health sciences in a context of a global crisis. Researchers need to focus on Indigenous values and voices to adapt care and support informal caregivers. Our review emphasizes that working with Indigenous communities will likely translate into new care delivery models, policies and practices to support Indigenous informal caregivers and address the specific social determinants impacting caregivers' roles and tasks. IMPACT: This review highlights the necessity of having community and family-based discussions on enhancing the delivery of dementia care for Indigenous peoples in Canada and worldwide. Decolonizing Western perspectives of dementia translate into culturally safe approaches that aim to integrate Indigenous cultural perspectives of holism, reciprocity, wisdom, respect of older people and relationality into nursing practice. The support of Indigenous informal caregivers requires future studies to address the stigmatizing Western views of dementia.

A qualitative examination of othering processes within international nursing placements.

BACKGROUND: International placements represent a popular choice to develop cultural competency and safety in nursing. The question as to whether study abroad programs enable the development of cultural competency and safety skills or provide exotic travel experiences needs further clarifications. OBJECTIVE: The study explores the usefulness of international placements in developing cultural safety among undergraduate nursing students. DESIGN: An exploratory qualitative design was used to answer these research questions: 1) How do undergraduate students make sense of their study abroad experiences? And 2) How international placements facilitate the acquisition of cultural safety and consciousness-raising about racial and social privileges? PARTICIPANTS: A sample of 7 participants who completed a 4th-year community and acute care stages in Global South countries were recruited. METHODS: A postcolonial feminist theoretical approach was used to guide the study. DATA COLLECTION: Semi-structured interviews explored participants' perceptions of cultural differences, ways of adapting to cultural diversity, and the benefits and challenges of their global experiences. Thematic content analysis was used to analyze the data. RESULTS: Thematic analysis revealed three themes: 1) Self-knowledge, 2) othering, and 3) consciousness of neocolonialism. DISCUSSION: Results raise some concerns about the usefulness of international stages in developing cultural competency and cultural safety in undergraduate nursing students. Results indicate that international placements can be useful to raise consciousness about racial and social privileges. Yet, international placements involve some risks to the receiving Global South countries. This study unmasks Othering's processes, where participants reproduce harmful neocolonial relations. CONCLUSIONS: International placements involve cultural risks that translate into Othering processes where Global South nurses and students are represented as powerless. Postcolonial feminist theories are relevant to study international placements as they enable the critical examination of race, gender, and social class and how they play out in international placements in Global South countries.

An integrative review of empirical literature on indigenous cognitive impairment and dementia.

AIMS: To synthesize research findings about Indigenous perspectives on cognitive impairment and dementia. DESIGN: Whittemore and Knafl's updated approach to integrative review and PRISMA guidelines for narrative analysis was followed. DATA SOURCES: A systematic search of the published literature from 2010-June 2020 was undertaken in four databases and complemented by supplementary searches. REVIEW METHODS: Thirty-four studies met the research question and inclusion criteria. RESULTS: Four themes describe the findings. Most of the studies were conducted by non-Indigenous researchers and may reflect Western perspectives on dementia rather than Indigenous views. A majority of the studies report epidemiological data or the testing of clinical tools. CONCLUSION: The review indicates a dearth of knowledge about Indigenous perspectives on ageing and understanding of cognitive impairment and dementia. Researchers need to draw on Indigenous traditional knowledge, culture, and traditions through a meaningful engagement with Indigenous communities and Elders to indigenize and decolonize dementia care. IMPACT: This integrative review highlights the need for community-led discussions and community engagement around Indigenous perspectives, needs, and understandings of ageing, cognitive impairment, and dementia care.

Exploring healthcare providers' perspectives of the paediatric discharge process in Uganda: a qualitative exploratory study.

INTRODUCTION: The burden of childhood mortality continues to be born largely by low-income and middle-income countries. The critical postdischarge period has been largely neglected despite evidence that mortality rates during this period can exceed inpatient mortality rates. However, there is a paucity of data on the paediatric discharge process from the perspective of the healthcare provider. Provider perspectives may be important in the development of an improved understanding of the barriers and facilitators to improving the transition from hospital to home. OBJECTIVES: To explore healthcare providers' and facility administrators' perspectives of the paediatric discharge process with respect to: (1) current procedures, (2) barriers and challenges, (3) ideas for change, (4) facilitators for change and (5) the importance of discharge planning. DESIGN: A qualitative exploratory approach using focus groups (14) and in-depth interviews (7). SETTING: This study was conducted at seven hospitals providing paediatric care in Uganda. RESULTS: Current discharge procedures are largely based on hospital-specific protocols or clinician opinion, as opposed to national guidelines. Some key barriers to an improved discharge process included caregiver resources and education, critical communication gaps, traditional practices, and a lack of human and physical resources. Teamwork and motivation to see improved paediatric transitions to home were identified as facilitators to implementing the ideas for change proposed by participants. The need for a standardised national policy guiding paediatric discharges, implemented through education at many levels and coupled with appropriate community referral and follow-up, was broadly perceived as essential to improving outcomes for children. CONCLUSIONS: Although significant challenges and gaps were identified within the current health system, participants' ideas and the identified facilitators provide a significant basis from which change may occur. This work can facilitate the development of sustainable and effective interventions to improve postdischarge outcomes in Uganda and other similar settings.

Paediatric postdischarge mortality in developing countries: a systematic review.

OBJECTIVES: To update the current evidence base on paediatric postdischarge mortality (PDM) in developing countries. Secondary objectives included an evaluation of risk factors, timing and location of PDM. DESIGN: Systematic literature review without meta-analysis. DATA SOURCES: Searches of Medline and EMBASE were conducted from October 2012 to July 2017. ELIGIBILITY CRITERIA: Studies were included if they were conducted in developing countries and examined paediatric PDM. 1238 articles were screened, yielding 11 eligible studies. These were added to 13 studies identified in a previous systematic review including studies prior to October 2012. In total, 24 studies were included for analysis. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted and synthesised data using Microsoft Excel. RESULTS: Studies were conducted mostly within African countries (19 of 24) and looked at all admissions or specific subsets of admissions. The primary subpopulations included malnutrition, respiratory infections, diarrhoeal diseases, malaria and anaemia. The anaemia and malaria subpopulations had the lowest PDM rates (typically 1%-2%), while those with malnutrition and respiratory infections had the highest (typically 3%-20%). Although there was significant heterogeneity between study populations and follow-up periods, studies consistently found rates of PDM to be similar, or to exceed, in-hospital mortality. Furthermore, over two-thirds of deaths after discharge occurred at home. Highly significant risk factors for PDM across all infectious admissions included HIV status, young age, pneumonia, malnutrition, anthropometric variables, hypoxia, anaemia, leaving hospital against medical advice and previous hospitalisations. CONCLUSIONS: Postdischarge mortality rates are often as high as in-hospital mortality, yet remain largely unaddressed. Most children who die following discharge do so at home, suggesting that interventions applied prior to discharge are ideal to addressing this neglected cause of mortality. The development, therefore, of evidence-based, risk-guided, interventions must be a focus to achieve the sustainable development goals.

Predictor variables for post-discharge mortality modelling in infants: a protocol development project.

BACKGROUND: Over two-thirds of the five million annual deaths in children under five occur in infants, mostly in developing countries and many after hospital discharge. However, there is a lack of understanding of which children are at higher risk based on early clinical predictors. Early identification of vulnerable infants at high-risk for death post-discharge is important in order to craft interventional programs. OBJECTIVES: To determine potential predictor variables for post-discharge mortality in infants less than one year of age who are likely to die after discharge from health facilities in the developing world. METHODS: A two-round modified Delphi process was conducted, wherein a panel of experts evaluated variables selected from a systematic literature review. Variables were evaluated based on (1) predictive value, (2) measurement reliability, (3) availability, and (4) applicability in low-resource settings. RESULTS: In the first round, 18 experts evaluated 37 candidate variables and suggested 26 additional variables. Twenty-seven variables derived from those suggested in the first round were evaluated by 17 experts during the second round. A final total of 55 candidate variables were retained. CONCLUSION: A systematic approach yielded 55 candidate predictor variables to use in devising predictive models for post-discharge mortality in infants in a low-resource setting.

Diagnostic accuracy of calculated serum osmolarity to predict dehydration in older people: adding value to pathology laboratory reports.

OBJECTIVES: To assess which osmolarity equation best predicts directly measured serum/plasma osmolality and whether its use could add value to routine blood test results through screening for dehydration in older people. DESIGN: Diagnostic accuracy study. PARTICIPANTS: Older people (≥65 years) in 5 cohorts: Dietary Strategies for Healthy Ageing in Europe (NU-AGE, living in the community), Dehydration Recognition In our Elders (DRIE, living in residential care), Fortes (admitted to acute medical care), Sjöstrand (emergency room) or Pfortmueller cohorts (hospitalised with liver cirrhosis). REFERENCE STANDARD FOR HYDRATION STATUS: Directly measured serum/plasma osmolality: current dehydration (serum osmolality>300 mOsm/kg), impending/current dehydration (≥295 mOsm/kg). INDEX TESTS: 39 osmolarity equations calculated using serum indices from the same blood draw as directly measured osmolality. RESULTS: Across 5 cohorts 595 older people were included, of whom 19% were dehydrated (directly measured osmolality>300 mOsm/kg). Of 39 osmolarity equations, 5 showed reasonable agreement with directly measured osmolality and 3 had good predictive accuracy in subgroups with diabetes and poor renal function. Two equations were characterised by narrower limits of agreement, low levels of differential bias and good diagnostic accuracy in receiver operating characteristic plots (areas under the curve>0.8). The best equation was osmolarity=1.86×(Na++K+)+1.15×glucose+urea+14 (all measured in mmol/L). It appeared useful in people aged ≥65 years with and without diabetes, poor renal function, dehydration, in men and women, with a range of ages, health, cognitive and functional status. CONCLUSIONS: Some commonly used osmolarity equations work poorly, and should not be used. Given costs and prevalence of dehydration in older people we suggest use of the best formula by pathology laboratories using a cutpoint of 295 mOsm/L (sensitivity 85%, specificity 59%), to report dehydration risk opportunistically when serum glucose, urea and electrolytes are measured for other reasons in older adults. TRIAL REGISTRATION NUMBERS: DRIE: Research Register for Social Care, 122273; NU-AGE: ClinicalTrials.gov NCT01754012.

Priorities for global research into children's palliative care: results of an International Delphi Study.

BACKGROUND: There is an urgent need to develop an evidence base for children's palliative care (CPC) globally, and in particular in resource-limited settings. Whilst the volume of CPC research has increased in the last decade, it has not been focused on countries where the burden of disease is highest. For example, a review of CPC literature in sub Saharan Africa (SSA) found only five peer-reviewed papers on CPC. This lack of evidence is not confined to SSA, but can be seen globally in specific areas, such as an insufficient research and evidence base on the treatment of pain and other symptoms in children. This need for an evidence base for CPC has been recognised for some time, however without understanding the priorities for research in CPC organisations, many struggle with how to allocate scarce resources to research. METHOD: The International Children's Palliative Care Network (ICPCN) undertook a Delphi study between October 2012 and February 2013 in order to identify the global research priorities for CPC. Members of the ICPCN Scientific Committee formed a project working group and were asked to suggest areas of research that they considered to be important. The list of 70 areas for research was put through two rounds of the Delphi process via a web-based questionnaire. ICPCN members and affiliated stakeholders (n = 153 from round 1 and n = 95 from round 2) completed the survey. Participants from SSA were the second largest group of respondents (28.1 % round 1, 24.2 % round 2) followed by Europe. RESULTS: A list of 26 research areas reached consensus. The top five priorities were: Children's understanding of death and dying; Managing pain in children where there is no morphine; Funding; Training; and Assessment of the WHO two-step analgesic ladder for pain management in children. CONCLUSIONS: Information from this study is important for policy makers, educators, advocates, funding agencies, and governments. Priorities for research pertinent to CPC throughout the world have been identified. This provides a much needed starting place for the allocation of funds and building research infrastructure. Researchers working in CPC are in a unique position to collaborate and produce the evidence that is needed.

Knowledge of the professional role of others: a key interprofessional competency.

In this paper, the authors present the results of a study which delineated six key competencies of interprofessional collaborative practice for patient-centred care: communication; strength in one's professional role; knowledge of professional role of others; leadership; team function; and negotiation for conflict resolution. While all of these competencies are important and require special attention, this paper examines and discusses the competency knowledge of professional role of others and its associated behavioural indicators, especially as these relate to the interprofessional education of nursing students. The identification of these competencies and their behavioural indicators serve two purposes. It forms the basis for the preparation of students, preceptors, and faculty for interprofessional practice, and it develops a tool for assessing student performance in such practice. Consequently, we believe that the utilization of this key competency and its behavioural indicators will contribute to the development of programs that include specific knowledge and skills related to interprofessional nursing education. This will enable educators to support and evaluate students in interprofessional educational experiences more efficiently and effectively. Ultimately, as nursing students practice and become fully functioning practitioners, client care will be optimized.

Activity and barriers in girls (8-16 yr) based on grade and maturity status.

UNLABELLED: Minimal research has examined whether the decline in physical activity (PA) among adolescent girls is associated with chronological age (CA) or biological age (BA). PURPOSE: To describe the PA levels and perceived barriers to PA of adolescent girls grouped by school grade and maturity status (i.e., early or late maturing) within grades. METHODS: Two hundred and twenty-one girls (aged 8-16 yr, grades 4-10) wore an Actical accelerometer for 7 d and then completed a semistructured, open-ended questionnaire on perceived barriers to PA over the 7-d period. Predicted age at peak height velocity and recalled age at menarche were used to assess maturity among the elementary and high school girls, respectively. Maturity and grade group differences in PA were assessed using a MANCOVA and independent sample t-test and barriers to PA using chi-squared statistics. RESULTS: Daily minutes spent in moderate to vigorous PA decreased by 40% between grades 4 and 10. Within grade groupings, no differences in PA were found between early and late maturing girls (P > 0.05). Grades 4 to 6 participants cited more interpersonal (i.e., social) barriers. Grades 9 to 10 participants cited more institutional barriers to PA, primarily revolving around the institution of school. No differences were found in types of barriers reported between early and late maturing girls. CONCLUSION: Because PA and types of perceived barriers to PA were dependent on grade, future research should work to identify the most salient (i.e., frequent and limiting) barriers to PA by CA in youth. Once reliably was identified, multipronged intervention strategies must be tested for effectiveness to help youth cope with their salient barriers.

TENS for children's procedural pain.

A 3 x 6 factorial design with a double blind and placebo control was employed to investigate the effect of TENS treatment on pain produced by venipuncture. The three treatment groups consisted of TENS, placebo-TENS and control. Subjects were blocked into six 2-year age groups (ages: 5-17 years). During the period of the study, 896 children attending the outpatient laboratory of a general hospital were screened and 514 children completed the study. The data which were collected before venipuncture included expected pain and state anxiety. Following venipuncture, pain intensity was measured with a vertical visual analogue scale (VAS) and pain affect was assessed with McGrath's faces scale. Significant main effects for treatment and age groups were obtained. Pain intensity and affect were lowest for the TENS group and highest for the control group. The pain scores were greatest for lower age groups and lowest for higher age groups. The results of this study support the use of TENS for children's pain and the need for interventions for children's procedural pain.

Management of injection pain in children.

Researchers have come to understand a great deal about pain mechanisms, especially in the past 30 years. This understanding has spawned the development of a number of psychological pain control strategies which have been extensively assessed for use with adults. Less is known about pain control strategies in children. The purpose of this study was to assess the value of 2 cognitive strategies (suggestion and music distraction) in reducing pain in children. Two hundred children, aged 4.5-6.5 years, receiving routine immunization injections were randomly assigned to one of the intervention groups in this factorial study. The groups were designated as: distraction, distraction with suggestion, suggestion and control. Subjects reported their pain using a 4-point pain scale. Distraction was found to significantly decrease pain whereas suggestion did not. Combining suggestion and distraction did not further enhance pain relief compared to use of distraction alone. Age was found to be an important determinant of the success of distraction. Furthermore, age was found to be related to amount of pain reported by children regardless of type of treatment. The results of this study support the use of music distraction in the reduction of injection pain in children.