The experience of adults who choose watchful waiting or active surveillance as an approach to medical treatment: a qualitative systematic review.

BACKGROUND: "Watchful waiting" or "active surveillance" is an alternative approach in the medical management of certain diseases. Most often considered appropriate as an approach to treatment for low-risk prostate cancer, it is also found in the literature in breast cancer surveillance, urinary lithiasis, lymphocytic leukemia, depression and small renal tumors. OBJECTIVES: This systematic review sought to:Identify and synthesize the best available international evidence on the experience of adults who choose watchful waiting or active surveillance as an approach to medical treatment. To this end the questions addressed in this review were:1. How do patients who have chosen watchful waiting or active surveillance describe the process of coming to the decision?2. What were the factors that influenced their decision to choose?3. How do patients who have chosen watchful waiting or active surveillance describe the experience? INCLUSION CRITERIA: Male or female patients, 18 years or older, who experience the phenomenon of choosing or not choosing watchful waiting or active surveillance as a treatment approach.The phenomena of interest were accounts of the experiences of adult patients who choose watchful waiting or active surveillance as an approach to medical treatment.This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and critical theory. Mixed method studies with narrative description and patient voice were also considered. Grey literature such as research reports and dissertations were also included. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies through electronic databases, reference lists, and the World Wide Web. Extensive searches were undertaken of relevant databases to include CINAHL, PubMed, SCOPUS and PsycINFO. A three-step search strategy was used in each component of the review. Studies were limited to English language papers. The search considered papers from the year 2000 to January 2015. METHODOLOGICAL QUALITY: Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. DATA EXTRACTION: Qualitative data were extracted from papers included in the review using the standardized data extraction tool from. The data extracted included specific details about the phenomena of interest that described the experiences pertinent to the review questions DATA SYNTHESIS: The data were synthesized using the Joanna Briggs Institute approach to meta-synthesis by meta-aggregation using the JBI-QARI software and methods. RESULTS: A total of 16 studies, critically appraised by two independent reviewers and deemed to be of high quality, were included in the final review. One study was excluded after appraisal. One hundred and fifty-five findings from the 16 studies were extracted into 10 categories and then into three synthesized findings. The synthesized findings explicated: CONCLUSIONS: The synthesized findings of the review conclude that the process of making the decision to choose watchful waiting is complex. Through the process patients and their significant others experience an array of emotions that often lead to uncertainty and anxiety. Once the decision is made patients must cope with the knowledge that they have a troubling diagnosis and make the necessary adjustments. An empathic, reassuring relationship with a healthcare practitioner eases the burden of this process.Healthcare providers need to recognize that not all patients are "at peace" with the decision of choosing watchful waiting. Uncertainty and fear may intensify during this time as well as feelings of stress and anxiety. Patients and their significant others often attempt to adapt in the best way they know how but the effectiveness of their coping strategies needs to be assessed. In addition, healthcare providers need to also be aware that with the increased anxiety and stress associated with watchful waiting, patients' understanding of healthcare information and the ability to ask questions may be diminished. Both providers and patients benefit from open discussions related to the many aspects of uncertainty and fear related to making and living with the decision. Employing a shared decision making model with regard to the management of the array of issues that comes from both making the decision and living with it is recommended. It appears that patients are very sensitive to recognizing when the care they are receiving lacks empathy. Communication that is open, empathic, and non-judgmental is essential. A willingness to discuss sensitive issues such as sexual function needs to be conveyed. Lastly, providers and their staff need to remain attentive to the importance of articulating aspects of the situation that are hopeful and optimistic as many patients, during their visits, take their cues regarding their health status from non-verbal and verbal interactions.Future studies should investigate.

How professional nurses working in hospital environments experience moral distress: a systematic review.

The experience of moral distress for professional nurses working in hospital environments causes a myriad of biological, psychological, and stress-related reactions. There is an institutional culpability in producing an environment where moral distress is experienced. This is particularly true when nurses feel the need to advocate for patients' well-being while coping with institutional constraints. The perception of patient pain and suffering as a result of medical decisions, which the nurse has little power to influence, contributes to the experience. Unequal power structures, prevalent in institutions, exacerbate the problem. Critical care nurses need to recognize moral distress and its adverse impact on providing optimal patient care. Critical care nurses should make a personal commitment that moral distress will not impact their nursing care and take a leadership role in their units to address this issue with their employing institution and develop strategies to lessen the impact of moral distress. These strategies should be based on the best available evidence such as this systematic review and other relevant appraised works.

Overweight and obese low-income women: restorative health behaviors under overwhelming conditions.

In this grounded theory study we used semistructured interviews to explore how 16 low-income uninsured Midwestern United States women who were overweight or obese felt about their condition. Using grounded theory, we identified a central problem-overwhelming conditions exemplified by numerous stressors in the lives of the participants. Despite these overwhelming conditions, the participants identified numerous restorative health behaviors in five dimensions: health, economics, environment, knowledge, and commitment. Health care providers should be cognizant of their patients' complex lives and support them in identifying, adopting, and maintaining health-restoring behaviors that work for them.

How Families and Health Care Practitioners Experience Family Presence during Resuscitation and Invasive Procedures.

BACKGROUND: The presence of family members during resuscitation and invasive procedures has been, and continues to be debated in the literature. OBJECTIVE: To synthesize the best available research evidence on how families and health care practitioners experience family presence during resuscitation and invasive procedures. INCLUSION CRITERIA: Studies about families and health care practitioners experiencing family presence during resuscitation and invasive procedures were considered.This review considered family members and health care practitioners who had experienced the phenomena of family presence during resuscitation or invasive procedures.Family members and health care practitioners experience of family presence during resuscitation or invasive procedures.Qualitative evidence consisting of, but not limited to, designs such as interpretive, descriptive-exploratory, observational, phenomenology, ethnography, grounded theory, hermeneutics, participatory action research, and critical theory were included in the review. SEARCH STRATEGY: The search strategy sought to find both published and unpublished research articles from 1985 to 2009. The review was limited to papers written in English. METHODOLOGICAL QUALITY: Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the standardised tools developed by the Joanna Briggs Institute. DATA COLLECTION: Data were using standardized data extraction tools developed by the Joanna Briggs Institute. DATA SYNTHESIS: The Joanna Briggs Institute' approach for meta-synthesis by meta-aggregation was used. RESULTS: 25 studies were included in the review. 154 findings were extracted and synthesized into 14 categories and 5 synthesized findings. CONCLUSIONS: A tension is created between the belief of most family members that being present is a right and health care practitioners who believe they should have control over the circumstances of the practice. Although healthcare practitioners express concern that the practice will cause the family to experience psychological trauma the data does not suggest that this is the case. Most family members describe their presence as an opportunity to comfort and to gain closure. IMPLICATIONS FOR PRACTICE: IMPLICATIONS FOR RESEARCH.

How professional nurses working in hospital environments experience moral distress: a systematic review.

BACKGROUND: Jameton who first conceptualized moral distress, described it as arising when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. The phenomenon of moral distress is well documented in the nursing literature but no systematic review exists. The plethora of literature on moral distress would suggest that attention to this phenomenon is deemed noteworthy by the profession. A synthesized understanding of how nurses experience the phenomenon of moral distress is presented. OBJECTIVES: The overall objective of this review was to appraise and synthesize the best available evidence on how professional nurses working in hospital environments experience ethical/moral distress. INCLUSION CRITERIA: This review considered qualitative research including descriptive/exploratory studies whose participants were professional nurses working in hospital environments and experienced either moral or ethical distress as a result of their patient care responsibilities. Studies were included that described participant's own experience of moral distress. SEARCH STRATEGY: The search strategy sought to find both published and unpublished research studies. This review was limited to papers in English. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of text words contained in the title and abstract, and of index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. METHODOLOGICAL QUALITY: Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the Qualitative Assessment and Review Instrument (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third party reviewer. DATA COLLECTION: Information was extracted by two reviewers from each paper using the Qualitative Assessment and Review data extraction tool (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer. DATA SYNTHESIS: Data synthesis aimed to portray an accurate interpretation and synthesis of themes arising from the selected participant's experience of moral distress. RESULTS: A total of 50 studies were identified and of those 39 were included in the review. These qualitative studies examined how professional nurses working in hospital environments experienced moral/ethical distress. Findings were analyzed using the JBI-QARI tool. The process of meta-synthesis using this program involved categorizing findings and developing synthesized topics from the categories. Four syntheses were developed related to the experience of moral distress: human reactivity, institutional culpability, patient pain and suffering, and unequal power hierarchies. CONCLUSION: Nurses who experience moral distress respond with a myriad of biological, psychological and stress reactions. Moral distress is experienced when nurses feel the need to advocate for patients well-being, while coping with institutional constraints. The perception of patient pain and suffering as a result of medical decisions of which the nurse has little power to influence also contributed to the experience. Unequal power structure prevalent in institutions exacerbates the problem. IMPLICATIONS FOR PRACTICE: In order to mitigate the effects of moral distress institutions need to design structures of support for nurses that provide education on the effects of moral distress, give nurses authentic voice in expressing ethical concerns and allow them to practice nursing in a way that does not violate their core professional values. IMPLICATIONS FOR RESEARCH: Further research is needed on the effectiveness of interventions designed to decrease the effect of moral distress on the workplace environment. Additionally, measuring the effectiveness of strategies designed to provide nurses a platform to openly express their ethical concerns and provide them an authentic voice would inform the profession. Research on the hierarchical structures of the nurse-physician relationship within the hospital environment and its effect on patient care outcomes would enrich the literature.