Adaptive web-based stress management programs among adults with a cardiovascular disease: A pilot Sequential Multiple Assignment Randomized Trial (SMART).

OBJECTIVE: To assess the feasibility and acceptability of using a Sequential Multiple Assignment Randomized Trial (SMART) to optimize the delivery of a web-based, stress management intervention for patients with a cardiovascular disease (CVD). METHODS: 59 patients with a CVD and moderate stress were randomized to a self-directed web-based stress management program (n = 30) or the same intervention plus lay telephone coaching (n = 29). After 6 weeks, non-responders were re-randomized to continue with their initial intervention or switched to motivational interviewing (MI). Feasibility, acceptability, and clinical significance were assessed. RESULTS: SMART procedures were feasible. Attrition rates were almost twice as high in the web-only group than the lay coach group. This might be because of the low satisfaction (47%) in the web-only group. On average, 1.7/5 modules were completed. Effect sizes for stress and quality of life generally exceeded 0.2 (clinical benchmark), except for the group that initially received lay coaching and then switched to MI. CONCLUSIONS: Results suggest that a larger trial would be feasible. Issues pertaining to attrition and satisfaction for non-responders need to be addressed. PRACTICE IMPLICATIONS: Findings contribute to the evidence on how best to develop and deliver e-Health interventions to maximize their efficacy while remaining cost-effective.

Chronic Illness Management in Culturally and Linguistically Diverse Patients: Exploring the Needs, Access, and Understanding of Information.

In Canada, people from culturally and linguistically diverse (CALD) backgrounds are at a greater risk of developing a chronic illness, and are more likely to experience adverse health effects and challenges in accessing high-quality care compared with Canadian-born individuals. This, in part, has been attributed to having inadequate access to information and resources needed to manage their illness(es). A qualitative descriptive design and inductive content analysis were used to explore the information needs of 24 CALD patients with chronic illnesses. Participants identified medical, lifestyle, and psychosocial information needs. How much information was needed depended on such antecedents as illness trajectory, severity, and perception. Most information needs remained unmet. A number of communication strategies were identified to bridge language barriers that go beyond translation and are based on effective health education strategies. Findings can help health care professionals better identify CALD patients' information needs and provide strategies that go beyond translation.

Exploring the Necessity of Routine Daily Chest X-rays for Mechanically Ventilated Patients in the Pediatric Intensive Care Unit: An Integrative Review.

PROBLEM: In the PICU of a university teaching hospital, daily chest X-rays (CXR) are performed on all intubated and non-invasive ventilation-assisted patients, even when the patient is stable with no changes in clinical status. Inconsistent practice was identified with PICUs globally. This review aims to address the risk-benefit balance of clinical value, outcomes, cost, and radiation exposure when performing routine daily CXRs in the PICU. ELIGIBILITY CRITERIA: CINAHL, Medline, and Embase (Ovid) were searched for relevant articles within the last ten years (2009 to 2019). Articles involving routine daily CXR on adult patients were included due to limited pediatric research. SAMPLE: 18 articles were included in this review which evaluated the necessity of routine daily CXR protocol in the ICU setting and the risks of radiation exposure (pediatric n = 5, adult n = 10, both n = 3). RESULTS: When comparing the routine daily to on-demand CXR ordering protocols, there was no difference noted in clinical outcomes including mortality, complications, length of stay in hospital or ICU, and number of ventilator days. The on-demand CXR protocol decreased the number of CXRs per patient, which thereby decreased radiation exposure for patients, decreasing their risk of potential toxicity and malignancy. CONCLUSION: Routine daily CXR protocols are no longer recommended due to lack of clinical value, similar outcomes, increased cost, and since it places patients at risk for undue radiation exposure. IMPLICATIONS: Further studies should evaluate clinical and physical exam findings that would trigger ordering a CXR in order to optimize their diagnostic value in the pediatric setting.

The effect of culturally-adapted health education interventions among culturally and linguistically diverse (CALD) patients with a chronic illness: A meta-analysis and descriptive systematic review.

OBJECTIVE: To review the effectiveness of health education interventions adapted for culturally and linguistically diverse (CALD) populations with a chronic illness. METHODS: A systematic review and meta-analysis were conducted. Eligible studies were identified across six databases. Data were extracted and intervention effect was summarized using standardized mean difference. If there were insufficient data for meta-analysis, a descriptive summary was included. Modifying effects of intervention format, length, intensity, provider, self-management skills taught, and behavioral change techniques (BCTs) utilized were examined. RESULTS: 58 studies were reviewed and data were extracted for 36 outcomes. Most interventions used multiple modes of delivery and were facilitated by bilingual health care professionals (HCPs). On average, interventions included 5.19 self-management skills and 4.82 BCTs. Interventions were effective in reducing BMI, cholesterol, triglycerides, blood glucose, HbA1C, and depression, and in increasing knowledge. Effectiveness was influenced partly by provider, with HCPs favored over lay providers or paraprofessionals in increasing knowledge; however, the opposite was noted for HbA1c. CONCLUSIONS: Health education interventions are effective among CALD populations, particularly at improving objective, distal outcomes (e.g., anthropometric measures). These interventions may be equally effective in improving proximal patient-reported outcomes (PROs); however, diversity in PROs limited analyses. PRACTICE IMPLICATIONS: Core outcome sets (COS) are needed to further investigate and compare health education intervention effectiveness on PROs.

Does Hand Massage Have Sustained Effects on Pain Intensity and Pain-Related Interference in the Cardiac Surgery Critically Ill? A Randomized Controlled Trial.

BACKGROUND: Despite the promising short-term pain relief effect of massage, little is known regarding its sustained effects on pain intensity and pain-related interference with functioning. AIMS: To evaluate the sustained effect of hand massage on the pain intensity and pain-related interference with functioning of cardiac surgery patients. DESIGN: A randomized controlled trial. SETTINGS: A medical-surgical intensive care unit in Canada. PARTICIPANTS/SUBJECTS: Adult patients undergoing cardiac surgery and at low risk for postoperative complications were eligible. METHODS: In the intensive care unit, patients were randomly assigned to either 20-minute hand massage, hand holding, or rest. Pain intensity and pain-related interference with functioning were assessed on the second postoperative day. RESULTS: A total of 60 patients were randomly allocated and 46 completed data collection on the second postoperative day. Although no significant differences were identified across groups, the hand massage group reported a maximum pain intensity (median 5.75, range: 2-10) that was lower than the hand-holding (median 6.50, range: 1-10) and standard care groups (median 6.25, range: 0-10). The hand massage group could reach 0 pain intensity throughout a 24-hour period (median 0, range: 0-7), contrary to the hand-holding (median 2, range: 0-5) and standard care groups (median 2, range: 0-4.5). A trend for statistical significance was noted for dichotomized ratings on pain interference with walking (p = .176) and sleep (p = .050). CONCLUSIONS: Hand massage could help patients experience longer periods without pain and lower levels of maximum pain intensity. When coupled with recovery activities, hand massage could reduce pain-related interference with functioning.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial.

Objective: To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill. Design: A three-arm randomized controlled trial. Setting: This study was conducted in a medical-surgical intensive care unit in Canada. Subjects: Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible. Methods: Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention. Results: From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups. Conclusions: Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Experiences of Older Adult Trauma Patients Discharged Home From a Level I Trauma Center.

The number of patients 65 years and older has been rising steadily every year at our Level I trauma center. Our clinical experience demonstrated that once discharged, some of these patients were not managing well. Postdischarge portrait is difficult to ascertain because this information is not captured in the trauma registry database. The purpose of this study was to describe the experiences of hospitalized trauma patients 65 years and older who are discharged home. A descriptive cross-sectional study of hospitalized trauma patients was conducted 1 month postdischarge using PREPARED Patient and 36-item Short Form Health Survey questionnaires. Data were analyzed with SPSS and NVivo. A convenience sample of 33 participants was recruited from four surgical inpatient trauma units of an urban, downtown hospital in Eastern Canada. Participants scored below 50% on most categories related to discharge preparedness and reported not having received enough information about their medication, available community resources, and permitted activities. They had worries about managing at home and 40% experienced unexpected problems. Participants reported feeling confident (80%) to be discharged home mostly because of support or previous experience with illness and 53% felt very prepared to return home. Health status scores were lowest for the domain "role limitation due to physical health" at 16% and highest around 70% for "emotional well-being" and "general health." Patients did not receive enough information; some experienced unexpected problems once home but having support and previous experience with illness seems to help participants be confident with discharge home. There is room for improvement on specific aspects of discharge planning and preparedness.

The Effectiveness of Hand Massage on Pain in Critically Ill Patients After Cardiac Surgery: A Randomized Controlled Trial Protocol.

BACKGROUND: Postoperative pain is common in the intensive care unit despite the administration of analgesia. Some trials suggest that massage can be effective at reducing postoperative pain in acute care units; however, its effects on pain relief in the intensive care unit and when pain severity is highest remain unknown. OBJECTIVE: The objective is to evaluate the effectiveness of hand massage on the pain intensity (primary outcome), unpleasantness and interference, muscle tension, anxiety, and vital signs of critically ill patients after cardiac surgery. METHODS: A 3-arm randomized controlled trial will be conducted. A total of 79 patients who are 18 years or older, able to speak French or English and self-report symptoms, have undergone elective cardiac surgery, and do not have a high risk of postoperative complications and contraindications to hand massage will be recruited. They will be randomly allocated (1:1:1) to standard care plus either 3 20-minute hand massages (experimental), 3 20-minute hand holdings (active control), or 3 20-minute rest periods (passive control). Pain intensity, unpleasantness, anxiety, muscle tension, and vital signs will be evaluated before, immediately after, and 30 minutes later for each intervention administered within 24 hours postoperatively. Peer-reviewed competitive funding was received from the Quebec Nursing Intervention Research Network and McGill University in December 2015, and research ethics approval was obtained February 2016. RESULTS: Recruitment started in April 2016, and data collection is expected to be complete by January 2017. To date, 24 patients were randomized and had data collection done. CONCLUSIONS: This study will be one of the first randomized controlled trials to examine the effect of hand massage on the pain levels of critically ill patients after cardiac surgery and to provide empirical evidence for the use of massage among this population. CLINICALTRIAL: ClinicalTrials.gov NCT02679534; https://clinicaltrials.gov/ct2/show/NCT02679534 (Archived by WebCite at http://www.webcitation.org/6l8Ly5eHS).

A psychosocial oncology program: perceptions of the telephone-triage assessment.

PURPOSE: Cancer can be a significant source of distress for patients and family members, which led to the creation of psychosocial oncology (PSO) programs across Canada. To access the PSO program at this institution, individuals are first triaged over the telephone by a clinical nurse specialist (CNS) who also provides psychosocial support during the call. In our study, we explored the perceptions of cancer patients or family members about their psychosocial telephone-triage assessment conducted by a CNS for a PSO program. METHODS: A qualitative descriptive design was used to explore the perceptions of nine cancer patients and family members triaged by the CNS for the PSO program. Audiotaped in-person interviews were transcribed verbatim and analyzed for themes and categories using a constant comparative method. RESULTS: Three major themes emerged: (1) Triage as a bridge to care, referred to the structure of telephone-triage and link to psychosocial services; (2) feeling a supportive presence, referred to the CNS' actions to foster a therapeutic relationship; and (3) different paths to tailored care, referred to the individualized strategies targeted to the participant's unique needs. As most participants described trusting the CNS, these three themes were found to emerge through a lens of trust. CONCLUSION: Overall, the telephone triage was able to address the concerns of many participants and provide individualized coping strategies and support. This study further demonstrates that psychosocial support can be provided during triage over the telephone.

Reasons for returning to the emergency department following discharge from an internal medicine unit: perspectives of patients and the liaison nurse clinician.

AIMS AND OBJECTIVES: To understand the patients' reasons for returning to the emergency department soon after their discharge from an internal medicine unit and to compare these reasons with the liaison nurse clinician's risk assessment tools used for discharge planning. BACKGROUND: Returns to the emergency departments soon after discharge from the hospital are a recurrent problem. Factors precipitating readmission to hospital have been analysed through the lens of health care providers, but few studies have explored the patients' perspectives on their reasons for returning to the emergency departments. DESIGN: A qualitative, descriptive study. METHODS: Semi-structured interviews were conducted with a convenience sample of eight patients recruited from a major teaching hospital in Montreal, Canada. Three different data sources were triangulated: patients' perspectives obtained through interviews and data from the tools used by the liaison nurse clinician, the Bounceback Probability Legend and the LACE Index Scoring Tool. RESULTS: Most patients attributed their return to the emergency department on being discharged too soon, feeling weak at discharge, having limited help at home with managing chronic illnesses and insufficient discharge instructions. participants' reasons for returning differed from those predicted by the liaison nurse clinician's evaluation using the risk assessment tools of each participant's risk of return. CONCLUSIONS: This study highlights patients' frailty upon discharge from the hospital and their informational need on their health condition and their support need to rely on during convalescence at home. Patient's readiness and concerns were not integrated as part of the liaison nurse clinician's evaluation tools for discharge planning. This led to discrepancies between the perspectives of the patients and the liaison nurse clinician about discharge planning. RELEVANCE TO CLINICAL PRACTICE: Health care professionals should evaluate patients' understanding of their illness, their readiness for self-management and work collaboratively with patients to assess concerns before discharge, so that appropriate support can be mobilised to prevent readmission.

An exploration of knowledge, attitudes and beliefs toward organ and tissue donation among the adult Haitian population living in the Greater Montreal area.

BACKGROUND: The decision to donate organs and tissues has the potential to save and improve the quality of life of the transplant recipient. Previous studies suggest lack of information, fears, and prejudices have prevented some cultural minorities from participating in organ and tissue donation (OTD). There is scarce information about the views of those who might be approached for potential donation in the Haitian community. In fact, Haitians are the largest Black ethno-cultural community in Montreal and are at higher risk for needing a kidney transplant (Desilets & Sodjinou, 2006). PURPOSE: To learn what Haitians know and believe about OTD in order to enable registered nurses to develop culturally appropriate approaches and interventions. DESIGN: A qualitative descriptive design was used to explore the knowledge, beliefs, and attitudes toward OTD among the adult Haitian population in the Montreal area. Focus groups were held with 24 members of the Haitian community and moderated by Haitian registered nurses who spoke French and Creole. DATA ANALYSIS: Group interviews were transcribed verbatim and analyzed for themes. Adult participants represented younger and older members of the community. They were from different socioeconomic backgrounds. FINDINGS: Knowledge about donation was influenced by the media, personal beliefs and experience, and level of trust in the health care system. Participants' recommendations on how to address OTD issues within the Haitian community were shaped by beliefs about wholeness, perceived need for donation and key persons who could influence decision-making behaviour. CONCLUSION: The level of distrust with the health care system and the study consent process used with participants might have affected the degree of participation and disclosure in discussions.

The experience of uncertainty in young adults with cancer.

The purpose of this qualitative descriptive study was to describe the experience of uncertainty in young adults with cancer. A purposeful sample of 6 young adults between the ages of 19 and 30 years undergoing chemotherapy treatment was recruited. Participants were interviewed twice using semistructured interviews. The investigators used constant comparison to examine the content of the transcript for common words, phrases, statements, or units of text that related to uncertainty. Findings revealed 3 major emerging themes. The first one being "types of uncertainty," which includes uncertainty and efforts at the right place, uncertainty and aspects of treatment, uncertainty and personal abilities, and uncertainty and the feasibility of plans related to life goals. Uncertainty was also found to trigger the development of certainties, which led to the second theme, "certainties: helpful or not?" A third emerging theme, dealing with uncertainty, described a variety of strategies used by young adults that included living on a day-to-day basis, being selfish, believing, getting information, trusting the physician, concentrating on positive things, keeping energy by pacing oneself, choosing social support, and trying to live a normal life. A consequence of dealing with the uncertainty and the cancer journey is the "enlightened path." It emerged and revealed how the cancer journey changed their lives. A number of implications for nursing practice therefore warrant consideration, especially fostering a sense of normalcy by identifying common behaviors, feelings, or needs among these young adults with cancer. Sharing this information and facilitating interactions with other young adults with cancer has the potential to promote coping with uncertainty.

Taking aim at fall injury adverse events: best practices and organizational change.

Fall injuries represent a huge healthcare, social and financial burden to the Canadian population. In 2004, the McGill University Health Centre (MUHC) was awarded recognition as a National Spotlight Organization for Implementation of the Registered Nurses Association of Ontario Best Practice Guidelines (BPGs). That same year, the author and co-leader of the Best Practice Guideline Program began the CHSRF Executive Training in Research Application (EXTRA) Program with the goal of reducing falls injuries, one of the most common adverse events in the MUHC and in acute care in Canada. This demonstration project used multiple strategies to strengthen a culture of safety and improve performance relating to adverse events, including: pilot testing several evidence-based falls prevention interventions (autumn 2005), training teams of champions to work across multiple sites, developing an infrastructure to support organizational change, modifying existing quality indicators to become benchmarkable, conducting a cost analysis of falls prevention, evaluating pre- and post-pilot surveys of organizational climate and obtaining initial baseline measures of the safety climate within the organization. Positive patient, practitioner and organizational outcomes suggest that falls safety prevention is feasible in large, complex healthcare organizations--and that safety is both a moral and a financial imperative. Next stages of the BPG program include full rollout, and measuring sustainability via a formal outcome evaluation study.

Nursing research committee makes plans for the coming year.

Evidence-based practice (EBP) enhances the care of patients and families by guiding nurses in their patient care. Nursing leaders, health care administrators and policy-makers are increasingly requiring that nursing practice be based on the best available evidence. Murdoch (2004) stated that a review and synthesis of existing research is essential to identify the best available evidence. Koop (2002) further reflected on the challenges faced by oncology nurses when there are clinical situations for which there is little or no empirical evidence on which to base nursing decisions. A need to learn skills and gain confidence in identifying the best available evidence frequently motivates staff nurses and clinicians to learn more about critical appraisal of the research literature. At the McGill University Health Centre (MUHC) these needs have prompted nurses to enrol in the research utilization (RU) course that the health centre offers. This column will outline the context and components of the RU course and summarize feedback from participants. Challenges and limitations of this strategy and its relationship to oncology nursing practice are highlighted.

A research course to promote evidence-based nursing practice.

Evidence-based practice (EBP) enhances the care of patients and families by guiding nurses in their patient care. Nursing leaders, health care administrators and policymakers are increasingly requiring that nursing practice be based on the best available evidence. Murdoch (2004) stated that a review and synthesis of existing research is essential to identify the best available evidence. Koop (2002) further reflected on the challenges faced by oncology nurses when there are clinical situations for which there is little or no empirical evidence on which to base nursing decisions. A need to learn skills and gain confidence in identifying the best available evidence frequently motivates staff nurses and clinicians to learn more about critical appraisal of the research literature. At the McGill University Health Centre (MUHC), these needs have prompted nurses to enrol in the research utilization (RU) course that the health centre offers. This column will outline the context and components of the RU course and summarize feedback from participants. Challenges and limitations of this strategy and its relationship to oncology nursing practice are highlighted.

Translation and validation of a French version of Brown's Support Behaviors Inventory in perinatal health.

This article describes the process used for translation, testing for reliability and validity, and establishing factor structure of a French version of Brown's Support Behaviors Inventory (SBI-Fr). The objective was to provide an adequate self-report measure of satisfaction with social support during the perinatal period for use with a Francophone population in Québec, Canada. When compared with the English version, the French version had similar qualities regarding reliability and validity, but principal component analysis (N = 271) revealed that the SBI-Fr measures two distinct subscales, perceived satisfaction with partner's and others' support. The availability of the SBI-Fr will facilitate the inclusion of Francophone respondents in studies of satisfaction with social support during the perinatal period and permit cross-cultural comparison between Francophone and other populations in not only Canada but also other French-speaking countries.