Shared decision-making to improve medication adherence.

ABSTRACT: Shared decision-making is recommended in many clinical practice guidelines. Using a case study of medication adherence, this paper demonstrates how providers can utilize the concepts of shared decision-making to improve treatment decisions and increase patient self-efficacy in carrying out the plan of care.

Caregiver decisions along the Alzheimer's disease trajectory.

Despite the rising prevalence of Alzheimer's disease (AD), there is limited systematic evidence about disease specific decisions. The aim of this qualitative descriptive study was to identify decisions across the AD trajectory using focus groups of past and present caregivers. Qualitative content analysis revealed three main categories with corresponding categories and sub-categories. Main Category One-Decisions pertaining to self-yielded two categories: decision pertaining to the offering of self and care for the caregiver. Main Category Two-Decisions pertaining to the patient-yielded three categories: decisions about care and treatment, living arrangements, and protecting the patient from harm. Main Category Three-Communication and relationships in decisions-yielded two categories: navigation and negotiations. The results of this study will inform healthcare providers and caregivers as they work together to anticipate, prepare, and plan for care management decisions over the AD trajectory.

Effectiveness of Silexan oral lavender essential oil compared to inhaled lavender essential oil aromatherapy for sleep in adults: a systematic review.

OBJECTIVE: The objective of the review was to identify the effectiveness of Silexan oral lavender essential oil compared to inhaled lavender essential oil aromatherapy for sleep latency, sleep duration, sleep quality, disturbed sleep and anxiety in adult patients. INTRODUCTION: Insomnia is a common problem, with 10-20% of the global population using sleep aids. Benzodiazepine and non-benzodiazepine sleep aids have the potential to cause side effects which may result in falls or other injuries. Lavender oil has anxiolytic properties that may improve sleep and reduce anxiety without the potential for adverse reaction. Silexan, an oral pill produced from lavender essential oil, has limited availability. This review sought to determine if lavender essential oil aromatherapy was as effective as Silexan to enable promotion of the use of essential oil aromatherapy in markets where Silexan is not available. INCLUSION CRITERIA: This review considered both experimental and epidemiological studies that included participants 18 years and over utilizing Silexan therapy of any dose or duration compared to inhaled lavender essential oil aromatherapy. The outcomes of interest were sleep latency, sleep duration, sleep quality, disturbed sleep and anxiety. METHODS: A comprehensive search strategy aimed to find relevant published and unpublished quantitative English language studies from 2010 through to February 16, 2018. Databases searched included: PubMed, CINAHL, Cochrane Central Register of Controlled Trials and Embase. A search of gray literature was also performed. RESULTS: No studies were identified that met the inclusion criteria. CONCLUSIONS: A comprehensive search of the literature uncovered no evidence related to the effectiveness of Silexan compared to inhaled lavender essential oil aromatherapy for sleep latency, sleep duration, sleep quality, disturbed sleep or anxiety in adult patients. Research is needed to determine if lavender essential oil aromatherapy, which is readily available worldwide, can be proven to be as effective as Silexan for improving sleep and anxiety in adult patients.

Effectiveness of decision aids for smoking cessation in adults: a quantitative systematic review.

OBJECTIVE: The objective of the review was to determine the effectiveness of the use of decision aids to facilitate the shared decision-making process between a person and a healthcare provider on smoking cessation rates, knowledge of smoking cessation methods and decisional quality. INTRODUCTION: The tobacco epidemic is one of the biggest health threats in the world, and it is the single most important preventable cause of disease. In the smoking cessation process, people move through different stages in their readiness to quit. Healthcare providers are well positioned to impact smoking cessation, however, challenges continue to exist. Using decision aids in the smoking cessation decision-making process may be one means in moving people toward the decision to quit smoking. INCLUSION CRITERIA: The review considered randomized controlled trials and quasi-experimental studies which included adults, 18 years and over, who smoke tobacco products. The intervention of interest was implementation of decision aids to promote shared decision-making related to smoking cessation. The comparator was usual care without the use of decision aids. Outcomes of interest were smoking abstinence, smoking quit attempts, knowledge of smoking cessation methods and decisional quality. METHODS: A comprehensive search was undertaken to locate relevant published and unpublished quantitative English language studies from the inception of each database searched through July 30, 2017. Databases searched included: CINAHL, Cochrane Central Register of Controlled Trials, Embase, PsycINFO and PubMed. A search of gray literature was also performed. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria. Studies meeting the inclusion criteria were retrieved in full and assessed in detail against the inclusion criteria by two independent reviewers. Two reviewers independently evaluated the included studies for methodological quality using critical appraisal tools from the Joanna Briggs Institute (JBI). Data related to the methods, participants, interventions and findings were extracted by two independent reviewers using a standardized data extraction tool from JBI. Due to clinical and methodological heterogeneity in the interventions and outcome measures of the included studies, statistical meta-analysis was not possible. Results have been presented in narrative form. RESULTS: Eight papers representing seven unique studies evaluating smoking cessation decision aids were included. Of the six studies that measured abstinence, only two had positive findings, with one reaching statistical significance. The fours studies that measured quit attempts all demonstrated a trend toward an increase in the number of quit attempts, with one study reaching statistical significance. Four of the five studies that measured knowledge reported an initial increase in the knowledge of smoking cessation methods, with two studies reaching statistical significance. Two of the three studies that measured decisional quality showed an improvement in decisional quality after use of the decision aid, with one study reaching statistical significance. CONCLUSIONS: The evidence suggests that decision aids may be effective in increasing smoking cessation knowledge and decisional quality while increasing quit attempts. There is, however, inconclusive evidence to support the definitive effectiveness of decision aids for long term and sustained smoking cessation.

Advance care planning and anticipatory decision making in patients with Alzheimer disease.

Early advance care planning and anticipatory decision making in the Alzheimer disease (AD) trajectory is a strategy NPs can incorporate to improve managing uncertainty around common decisions. This article explores decisions patients and caregivers face along the AD trajectory and provides resources for patients, caregivers, and NPs.

Shared Decision-Making for Nursing Practice: An Integrative Review.

BACKGROUND: Shared decision-making has received national and international interest by providers, educators, researchers, and policy makers. The literature on shared decision-making is extensive, dealing with the individual components of shared decision-making rather than a comprehensive process. This view of shared decision-making leaves healthcare providers to wonder how to integrate shared decision-making into practice. OBJECTIVE: To understand shared decision-making as a comprehensive process from the perspective of the patient and provider in all healthcare settings. METHODS: An integrative review was conducted applying a systematic approach involving a literature search, data evaluation, and data analysis. The search included articles from PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and PsycINFO from 1970 through 2016. Articles included quantitative experimental and non-experimental designs, qualitative, and theoretical articles about shared decision-making between all healthcare providers and patients in all healthcare settings. RESULTS: Fifty-two papers were included in this integrative review. Three categories emerged from the synthesis: (a) communication/ relationship building; (b) working towards a shared decision; and (c) action for shared decision-making. Each major theme contained sub-themes represented in the proposed visual representation for shared decision-making. CONCLUSION: A comprehensive understanding of shared decision-making between the nurse and the patient was identified. A visual representation offers a guide that depicts shared decision-making as a process taking place during a healthcare encounter with implications for the continuation of shared decisions over time offering patients an opportunity to return to the nurse for reconsiderations of past shared decisions.

Effectiveness of decision aids on smoking cessation in adult patients: a systematic review protocol.

REVIEW QUESTION: The objective of this review is to determine the effectiveness of the use of decision aids in a shared decision-making encounter between any healthcare provider and adult patients who smoke, compared to standard education on smoking cessation, in any healthcare setting.Specifically, the review questions are: What is the effectiveness of the use of decision aids in a shared decision-making encounter in any healthcare setting between the healthcare provider and adult patients who smoke compared to standard education, based on the patient's.

Effectiveness of Silexan oral lavender essential oil compared to inhaled lavender essential oil aromatherapy on sleep in adults: a systematic review protocol.

REVIEW OBJECTIVE: The objective of this review is to identify the effectiveness of Silexan oral lavender essential oil compared to inhaled lavender essential oil aromatherapy on sleep latency, sleep duration, sleep quality, disturbed sleep and anxiety in adult patients.

Effectiveness of structured multidisciplinary rounding in acute care units on length of stay and satisfaction of patients and staff: a quantitative systematic review.

BACKGROUND: Consistent, concise and timely communication between a multidisciplinary team of healthcare providers, patients and families is necessary for the delivery of quality care. Structured multidisciplinary rounding (MDR) using a structured communication tool may positively impact length of stay (LOS) and satisfaction of patients and staff by improving communication, coordination and collaboration among the healthcare team. OBJECTIVES: To evaluate the effectiveness of structured MDR using a structured communication tool in acute care units on LOS and satisfaction of patients and staff. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Adult patients admitted to acute care units and healthcare providers who provide direct care for adult patients hospitalized in in-patient acute care units. TYPE OF INTERVENTION: The implementation of structured MDR utilizing a structured communication tool to enhance and/or guide communication. TYPES OF STUDIES: Quasi-experimental studies and descriptive studies. OUTCOMES: Length of stay, patient satisfaction and staff satisfaction. SEARCH STRATEGY: The comprehensive search strategy aimed to find relevant published and unpublished quantitative English language studies from the inception of each database searched through June 30, 2015. Databases searched include Cumulative Index to Nursing and Allied Health Literature, PubMed, Excerpta Medica Database, Health Source, Cochrane Central Register of Controlled Trials and Scopus. A search of gray literature was also performed. METHODOLOGICAL QUALITY: All reviewers independently evaluated the included studies for methodological quality using critical appraisal tools from the Joanna Briggs Institute (JBI). DATA EXTRACTION: Data related to the methods, participants, interventions and findings were extracted using a standardized data extraction tool from the JBI. DATA SYNTHESIS: Due to clinical and methodological heterogeneity in the interventions and outcome measures of the included studies, statistical meta-analysis was not possible. Results are presented in narrative form. RESULTS: Eight studies were included, three quasi-experimental studies and five descriptive studies of quality improvement projects. In the three quasi-experimental studies, one had a statistically significant decrease (p = 0.01), one no change (p = 0.1) and one had an increase (p = 0.03) in LOS; in the two descriptive studies, one had a statistically significant decrease (p = 0.02) and the other reported a trend toward reduced LOS. Two studies evaluated patient satisfaction, one showed no change (p = 0.76) and one showed a trend toward increased patient satisfaction at 12 months. Six studies demonstrated an improvement in staff satisfaction (p < 0.05) after implementation of structured MDR. CONCLUSION: The evidence suggests that MDR utilizing a structured communication tool may have contributed to an improvement in staff satisfaction. There was inconclusive evidence to support the use of structured MDR to improve LOS or patient satisfaction. The use of a structured communication tool during MDR is one means to facilitate communication and collaboration, thus improving satisfaction among the multidisciplinary team. More rigorous research using higher level study designs on larger samples of diverse patient populations is needed to further evaluate the effectiveness of structured MDR on patient care outcomes and satisfaction of patients and providers.

The effectiveness of tight glycemic control on decreasing surgical site infections and readmission rates in adult patients with diabetes undergoing cardiac surgery: A systematic review.

OBJECTIVE: A systematic review of the effects of tight glycemic control with a continuous insulin infusion to achieve blood glucose levels ≤ 200 mg/dL on surgical site infections and readmission rates in adult patients with diabetes after cardiac surgery. METHODS: A quantitative systematic review of the literature. Databases, including PubMed, CINAHL, EMBASE, and CENTRAL, were searched for relevant studies from database inception through August 2014. Randomized and quasi-experimental studies were included. RESULTS: A meta-analysis of ten studies demonstrated that glycemic control with a continuous insulin infusion to achieve blood glucose levels ≤ 200 mg/dL significantly reduced surgical site infection rates (odds ratio 0.35, 95% confidence interval 0.25-0.49; Z = 6.0, P < 0.00001) compared with standard diabetes management. CONCLUSIONS: Maintaining blood glucose levels ≤ 200 mg/dL with a continuous insulin infusion in all stages of the perioperative period in cardiac surgery patients with diabetes can reduce the incidence of surgical site infections.

Interpreting and using meta-analysis in clinical practice.

Systematic reviews, which can include a meta-analysis, are considered the gold standard for determination of best practice. Meta-analysis combines the results from many primary studies to identify patterns among the individual study results and then assesses the overall effectiveness of a specific healthcare intervention. The purpose of this article was to describe the process of performing a meta-analysis, discuss advantages and disadvantages of meta-analyses, and interpret the results of a meta-analysis from current research relevant to orthopaedic nursing practice.

The effectiveness of web-based programs on the reduction of childhood obesity in school-aged children: A systematic review.

REVIEW OBJECTIVE: The objective of this review is to synthesise the best available evidence on the effectiveness of web-based programs on the reduction of childhood obesity in school age children. BACKGROUND: Childhood obesity is one of the most serious public health challenges of the 21st century. The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings.[1] The prevalence has increased at an alarming rate globally.[2] The International Association for the Study of Obesity; estimates that up to 200 million school aged children are either overweight or obese, of those 40-50 million are classified as obese. Obesity has negative health impact in childhood, as well as in the long term.Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health. Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity. It is defined as a person's weight in kilograms divided by the square of his/her height in meters (kg/m). The World Health Organization defines overweight as BMI greater than or equal to 25 and BMI greater than or equal to 30 as obesity. Children two years of age or older with a BMI between the 85 and 94 percentile on age-growth charts are considered overweight; children with a BMI greater than the 95 percentile are considered obese. BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages worldwide. Measures of central obesity such as the waist:hip ratio and waist circumference can provide more robust indices of overall obesity-related health risk than BMI alone. A BMI z-score is a quantitative measure of the deviation of a specific BMI percentile from the mean of that population. A positive z-score indicates a child is heavier than the mean and a negative z-score indicates a child is lighter than the mean. Thus, a z-score compares the BMI of a given child to the BMI distribution for a population of children of the same age and sex.The incidence of obesity has more than doubled since 1980. Overweight and obesity now ranks as the fifth leading global risk for mortality. Sixty-five percent of the world's population lives in countries where childhood overweight and obesity kills more people than being underweight. In addition, 44% of the diabetes burden, 23% of the ischemic heart disease burden, and between 7% and 41% of certain cancer burdens are attributable to overweight and obesity.Childhood obesity continues to be a significant health problem in the United States. There has been a rapid rise in obesity among the school-age population despite efforts made by Healthy People 2010 in promoting weight management and physical activity. These on-going efforts have been extended to be part of the goals for Healthy People 2020. The United States Centers for Disease Control and Prevention calculated that approximately 17% children between the ages of two to nineteen years of age were at or above the 97 percentile for being obese. These figures are more than three times the anticipated 5% set in the Healthy People 2010 report.Overweight and obese children are likely to stay obese into adulthood and are more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age. In addition to a higher risk of obesity and non-communicable diseases later in life, affected children experience adverse outcomes such as breathing difficulties, increased risk of fractures, hypertension, and early markers of cardiovascular disease, different forms of cancers, insulin resistance, and psychological effects. Childhood obesity is associated with a higher chance of obesity, premature death, and disability in adulthood. If a child is overweight before eight years of age, obesity in adulthood is likely to be more severe.Child and adolescent obesity is also associated with increased risk of emotional problems. Teens with weight problems tend to have much lower self-esteem and are less popular with their peers. Depression, anxiety, and obsessive compulsive disorder can also occur as a result of childhood obesity.In addition to the diseases associated with obesity, the economic consequences of obesity are enormous for families, health care systems, and the global economy. Direct medical costs include preventative, diagnostic, and treatment services related to overweight and associated co-morbidities. European nations spend 2-8% of their health care budgets on obesity, equating to 0.6% of their gross domestic product. In the United States, estimates based on 2008 data indicated that overweight and obesity account for $147 billion in total medical expenditure. This shows an increase from the $117 billion spent in the year 2000.While indirect costs of overweight and obesity on society can be significantly higher, they are often overlooked. These costs stem from childhood obesity continuing on to obesity in adulthood, which can then results in income lost from decreased productivity, reduced opportunities and restricted activity, illness, absenteeism, and premature death. In addition, there are high costs associated with the numerous infrastructure changes that societies must make to cope with obese people such as reinforced beds, operating tables and wheel chairs; enlarged turnstiles and seats in in public gathering spaces; and modifications to transportation safety standards.Obesity is reaching pandemic proportions across much of the world, and its consequences are set to impose unparalleled health, financial and social burdens on global society unless effective actions are taken to reverse the trend. Reducing the incidence of obesity in childhood can help children grow into adults with normal body weights and the tools necessary to sustain a health weight.Haerens, et al. explains the importance of school-based programs in dealing with the serious problem of childhood obesity and overweight. The school setting is known as having a powerful influence on student's eating and physical activities. Programs that may have a more positive impact are those that help increase physical activity and promote healthy foods in youth. Previous studies looking at the implementation of diet and exercise programs in schools were effective in changing food habits and increasing physical activity; however, few of these studies showed a reduction in body weight. The Planet Health study, conducted over a period of two years, focused on healthy life style and showed a reduction in obesity in girls but not in boys. The M-span study, a two-year study involving proper diet, exercise, and parental support showed a reduction of BMI only in boys. Haerens, et al. further explains that the above mentioned studies needed to be done in a more personalised manner in order to achieve more positive result; however, they are limited by the time consumption and financial demands necessary to carry out the proposed intervention.Haerens, et al. conducted a two year study of the effect of a program including physical activity, healthy eating, and parental support with a computer-tailored component on BMI and BMI z-score in boys and girls. This intervention resulted in significant reduction in BMI in girls only. Carlson, et al. conducted a 12-month web-based weight loss intervention program which included physical activity and dietary behaviour. The program was found to be a potential low cost method to positively impact public health and health behaviours. Furthermore, 55% of the participants in the intervention group compared with 35% in the control group made an improvement in moderate-to-vigorous physical activity and diet. Doyle, et al. conducted an randomised controlled trial evaluating the effects of an Internet delivered program targeting weight loss on 80 overweight ethnically diverse 12-17 year olds. BMI z-scores were reduced in the intervention group compared with the usual care group post intervention and the intervention group maintained their reduction in BMI z-score at the four month follow up; however, statistical significance was not achieved at the four month follow up due to improvements in weight loss in the usual care group over time.The United States Department of Health and Human Services report of 2009 indicates that school aged children spend an average of 7 hours and 11 minutes per day watching television, using a computer, and playing video games. Using these technology devices as educational tools could have significant impact by increasing knowledge about healthy choices.Web-based technology has become part of our children's life in the last decade providing the foundation to a large number of daily activities. The use of web-based technology may be one method to provide a more personalised intervention to reduce obesity in school-aged children.The search for previously conducted systematic reviews on the effectiveness of web based programs on obesity in children identified a systematic review conducted by An, et al., which included studies published between 1995 and April 2009. A critical appraisal of this systematic review determined it to be of reduced quality due to lack of transparency in reporting the details of the search strategy, inclusion and exclusion criteria, and assessment of the primary studies' methodological quality. The proposed systematic review will expand on the prior systematic review using the rigorous search strategy and assessment for methodological quality outlined below to identify the best available research to determine the effectiveness of web-based programs on childhood obesity. The current review will also seek to identify any more current research on the topic while expanding the inclusion criteria from the internet-based interventions included in An, et al. to other forms for web-based technologies, such as smart phones, that have becomeincreasingly popular with this population.The use of the web for communication purposes came into existence in 1991, but it was not really until the mid to late 1990's that information professionals understood its usefulness and the magnitude of a medium that would have far-reaching positive consequences. This systematic review will include studies published from 1991 to the present date to identify all relevant studies on this topic.

A systematic review on the effectiveness of continuity of care and its role in patient satisfaction and decreased hospital readmissions in the adult patient receiving home care services.

BACKGROUND: Continuity of care, a concept that in its broadest terms describes patient and provider coordination across time and settings, has evidenced a positive correlation with patient satisfaction and hospital readmission rates. Home health care, where patients receive care from a variety of healthcare practitioners, is one area where these measures are being investigated to determine the effectiveness of continuity of care. OBJECTIVE: To examine and synthesize the best available evidence related to the effectiveness of continuity of care interventions and their impact on patient satisfaction and all-cause hospital readmissions rates in the adult patient who is receiving home care services. INCLUSION CRITERIA: Male and female aged 18 years or older receiving home care services, regardless of diagnosis, stage or severity of disease, co-morbidities, or previous treatment received.All types and models of interventions for continuity of care delivered by nurses to patients receiving home care services were considered for inclusion in the review.Patient satisfaction and hospital readmissions.In this review randomised controlled trials were considered for inclusion. In their absence, other research designs, such as non-randomised controlled trials, quasi-experimental studies, and before and after studies were considered for inclusion. SEARCH STRATEGY: Published and unpublished literature in the English language was sought from the inception of the databases through November 1, 2011.The databases searched included: Academic Search Premier, CINAHL ERIC, Health Reference Center Academic, MEDLINE via PubMed, ProQuest Nursing and Allied Health Source, ProQuest Health Management, Cochrane Central Register of Controlled Trials, EMBASE, Health Source Nursing Academic, PsycINFO and Bio-Med. A search of the grey literature and virtual hand searching of relevant journals was also performed. METHODOLOGICAL QUALITY: Two reviewers evaluated the included studies for methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute. DATA COLLECTION: Data were extracted using standardised data extraction instruments from the Joanna Briggs Institute. DATA SYNTHESIS: Statistical pooling via meta-analysis was not possible. The results are presented in narrative form. RESULTS: Two randomised controlled trails and two quasi-experimental studies were included in this review. In one randomised controlled trial, 66% of patients rated their overall satisfaction with care as very good or excellent as compared with 63% of those receiving usual care at 24 months (p=0.31). Another randomised controlled trial reported no statistically significant difference between groups (p value not reported). In one quasi-experimental study there was higher satisfaction rate amongst intervention patients with a mean difference of 16.88 (95%CI[16.32, 17.43] compared with 14.65 (95%CI[13.61, 15.68] in the control group (p=0.001).In one randomised controlled trial there was no statistically significant difference between intervention and control groups in hospital admission rates per 1000 at year two (700 vs. 740; p=0.66). Another randomised controlled trial showed no difference in readmissions at 90 days between groups (36% vs. 35%; no p value reported). In one quasi-experimental study, the mean number of hospital readmissions per patient was higher in the intervention group compared to the control group (0.75; 95% CI[ 0.47, 1.03] vs. 0.66; 95% CI[ 0.40, 0.91]; p=0.599), In another quasi-experimental study, a statistically significant higher number of intervention group patients in the intervention group were discharged and remained at home (34 or 82.9%), compared to the control group (20 or 51.3%) (p<0.05). CONCLUSIONS: Home care interventions that include nurses and advanced practice nurses with specialised training in the care of the population served as the direct provider along with collaboration with an interdisciplinary team in a high-risk patient populations contributed to reduced hospital readmission rates. The outcomes of the included studies suggest that consistently scheduled home care services promote patient satisfaction.This review concluded that the utilisation of an advanced practice nurse with specialised training in a specific disease process in collaboration with a multidisciplinary team can affect readmission rates and patient satisfaction.Further research is needed that captures a diverse patient population in terms of age and illness and the role that an advanced practice nurse can play.

The effectiveness of delegation interventions by the registered nurse to the unlicensed assistive personnel and their impact on quality of care, patient satisfaction, and RN staff satisfaction: a systematic review.

BACKGROUND: Delegation by the registered nurse is a decision making process that includes assessment, planning, implementation, and evaluation. Due to an ever-expanding global shortage of nurses, registered nurses are increasingly dependent on unlicensed assistive personnel to assist in the provision of safe patient care. Delegation is recognised as a fundamental nursing skill that can be utilised effectively to improve quality care. OBJECTIVE: To examine and synthesize the best available evidence regarding the impact of delegation interventions used by the registered nurse with the unlicensed assistive personnel and their impact on quality of care, patient satisfaction, and registered nurse staff satisfaction. INCLUSION CRITERIA: Registered nurses and unlicensed assistive personnel in patient care settings where delegation occurs.This review considered studies that evaluated the effectiveness of delegation interventions by registered nurses to unlicensed assistive personnel.The outcomes examined were quality of care, patient satisfaction, and/or registered nurse staff satisfaction as measured by validated and reliable tools.The review first considered randomised controlled trials; in their absence other research designs, such as non-randomised controlled trials, or other quasi-experimental studies, observational studies and descriptive studies were considered for inclusion in the systematic review. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies in the English language from the inception of the included databases through December 2011. The databases searched included the Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, CINAHL, Healthsource Nursing/Academic edition, and PsycINFO. A search of the grey literature and electronic hand searching of relevant journals was also performed. METHODOLOGICAL QUALITY: The studies selected for retrieval were critically evaluated by two independent reviewers for methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute. DATA COLLECTION: Data were extracted using standardised data extraction instruments from the Joanna Briggs Institute. DATA SYNTHESIS: Studies were found to have significant heterogeneity between the populations and interventions of the included studies; therefore, pooled statistical meta-analysis could not be completed. The findings are presented in narrative form. RESULTS: Two quasi-experimental studies were identified. In one study, the women counselled by the lay nurse aides received 80% of recommended messages compared to 75% received by the women counselled by the nurse-midwives (ß= 4.7, 95%CI: -1.7, 11.0; Non-inferiority). Non-inferiority was demonstrated between the lay nurse aides and the nurse-midwives with respect to communication techniques. The mean performance was high, 95% and 98% among nurse-midwives and lay nurse aides respectively (ß =2.4, 95%CI: -0.2, 5.0; Non-inferiority). No difference was found between the nurse-midwives and the lay nurse aides in providing antenatal counselling, education, and maternal-newborn care when proper training and supervision was given. The other study examined six hypotheses that looked at quality of care outcomes in a care model where the registered nurse delegated tasks to unlicensed assistive personal. Five of these outcomes showed no significant improvement as a result of the intervention. Patient knowledge about intravenous therapy was the only quality of care outcome that showed improvement post-intervention with scores increasing from 27% at baseline to 78% at 12 months. There was no improvement in the one hypotheses evaluating registered nurses job satisfaction. CONCLUSIONS: There is a paucity of evidence on the effectiveness of delegation interventions and strategies by registered nurses to unlicensed assistive personnel. Delegation interventions require characteristics such as teamwork, training, support, supervision, communication, and evaluation to positively impact quality of care, patient satisfaction, and registered nurse staff satisfaction outcomes. IMPLICATIONS FOR PRACTICE: Task shifting could have a positive impact on quality of care and staff satisfaction while providing the registered nurse with an opportunity to increase efficiency. IMPLICATIONS FOR RESEARCH: The areas of feedback and evaluation in the registered nurse / unlicensed assistive personnel relationship needs further study.

A qualitative systematic review of internal and external influences on shared decision-making in all health care settings.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared-decision making for adult patients and health care providers in all health care settings.The specific questions to be answered are: BACKGROUND: Patient-centered care is emphasized in today's healthcare arena. This emphasis is seen in the works of the International Alliance of Patients' Organizations (IAOP) who describe patient-centered healthcare as care that is aimed at addressing the needs and preferences of patients. The IAOP presents five principles which are foundational to the achievement of patient-centered healthcare: respect, choice, policy, access and support, as well as information. These five principles are further described as:Within the description of these five principles the idea of shared decision-making is clearly evident.The concept of shared decision-making began to appear in the literature in the 1990s. It is defined as a "process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient-centered care." The details of the shared decision-making process are complex and consist of a series of steps including:Three overall representative decision-making models are noted in contemporary literature. These three models include: paternalistic, informed decision-making, and shared decision-making. The paternalistic model is an autocratic style of decision-making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision-making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement. Finally, the shared decision-making model is representative of a sharing and a negotiation towards treatment decisions. Thus, these models represent a range with patient non-participation at one end of the continuum to informed decision making or a high level of patient power at the other end. Several shared decision-making models focus on the process of shared decision-making previously noted. A discussion of several process models follows below.Charles et al. depicts a process model of shared decision-making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included:This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker. This model also depicts the need to take steps to participate in the shared decision-making process. To take steps means that there is an agreement between and among all involved that shared decision-making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision-making and the actuality of shared decision-making in practice is not strong. Research concerning patients and patient preferences on shared decision-making points to variations depending on age, education, socio-economic status, culture, and diagnosis. Healthcare providers may also hold preferences for shared decision-making; however, research in this area is not as comprehensive as is patient focused research. Elwyn et al. explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision-making process. An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patient's preference is different from clinical practice guidelines. This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.The notion of information sharing as a prerequisite to shared decision-making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision-making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision-making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patient's ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al. portrays shared decision-making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the "test of a shared decision (as distinct from the decision-making process) is if both parties agree on the treatment option."Towle and Godolphin developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision-making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision-making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include:Patient competencies include:This model illustrates the shared decision-making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model. This model, however, gives greater emphasis to the process of the co-participation of the healthcare provider and the patient. The co-participation depicts a mutual partnership with mutual responsibilities that can be seen as "reciprocal relationships of dialogue." For this to take place the relationship between and among the participants of the shared decision-making process is important along with other internal and external influences such as communication, trust, mutual respect, honesty, time, continuity, and commitment. Cultural, social, and age group differences; evidence; and team and family are considered within this model.Elwyn et al. presents yet another model that depicts the shared decision-making process; however, this model offers a view where the healthcare provider holds greater responsibility in this process. In this particular model the process focuses on the healthcare provider and the essential skills needed to engage the patient in shard decisions. The competencies outlined in this model include:The healthcare provider must demonstrate knowledge, competencies, and skills as a communicator. The skills for communication competency require the healthcare provider to be able to elicit the patient's thoughts and input regarding treatment management throughout the consultation. The healthcare provider must also demonstrate competencies in assessment skills beyond physical assessment that includes the ability to assess the patient's perceptions and readiness to participate. In addition, the healthcare provider must be able to assess the patient's readiness to learn the information that the patient needs to know in order to fully engage in the shared decision-making process, assess what the patient already knows, what the patient does not know, and whether or not the information that the patient knows is accurate. Once this assessment is completed the healthcare provider then must draw on his/her knowledge, competencies, and skills necessary to teach the patient what the patient needs to know to be informed. This facilitates the notion of the tailor-made information noted previously. The healthcare provider also requires competencies in how to check and evaluate the entire process to ensure that the patient does understand and accept with comfort not only the plan being negotiated but the entire process of sharing in decision-making. In addition to the above, there are further competencies such as competence in working with groups and teams, competencies in terms of cultural knowledge, competencies with regard to negotiation skills, as well as, competencies when faced with ethical challenges.Shared decision-making has been associated with autonomy, empowerment, and effectiveness and efficiency. Both patients and health care providers have noted improvement in relationships and improved interactions when shared decision-making is inevidence. Along with this improved relationship and interaction enhanced compliance is noted. Additional research points to patient satisfaction and enhanced quality of life. There is some evidence to suggest that shared decision-making does facilitate positive health outcomes.In today's healthcare environment there is greater emphasis on patient-centered care that exemplifies patient engagement, participation, partnership, and shared decision-making. Given the shift from the more autocratic delivery of care to the shared approach there is a need to more fully understand the what of shared decision-making as well as how shared decision-making takes place along with what internal and external influences may encourage, support, and facilitate the shared decision-making process. These influences are intervening variables that may be of significance for the successful development of practice-based strategies that may foster shared decision-making in practice. The purpose of this qualitative systematic review is to identify internal and external influences on shared decision-making in all health care settings.A preliminary search of the Joanna Briggs Library of Systematic Reviews, MEDLINE, CINAHL, and PROSPERO did not identify any previously conducted qualitative systematic reviews on the meaningfulness of internal and external influences on shared decision-making.

The effectiveness of group visits for patients with heart failure on knowledge, quality of life, self-care, and readmissions: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to identify the effectiveness of group visits for patients with heart failure (HF) on knowledge, quality of life, self-care behaviors, and hospital readmissions. RESEARCH QUESTIONS: BACKGROUND: Heart failure (HF) continues to be a major health burden throughout the world. There are currently over 5.7 million Americans, 15 million Europeans, and 277,800 Australians living with HF. These numbers are expected to double by 2040. Patients and caregivers perform the majority of HF care in the home. Patients with HF need to learn to be successful in self-managing their condition to lessen the burden of symptoms such as fatigue, dyspnea, and edema.Patient education is the primary process used to increase knowledge of self-care practices for patients with HF. Patients with HF need to follow a complex medical regimen while adhering to a low sodium diet and prescribed fluid restrictions. In addition patients monitor their physical condition daily for exacerbation of symptoms or signs of fluid overload. Education, behavior modification, and skill development are necessary for a patient with HF to be successful in self-managing their condition.Most HF education occurs during one-on-one visits between the patient and the health care provider in an examination room during a regular clinic visit. However, there is usually limited time to address all of the needed education topics in an in-depth, meaningful manner with information the patient can take home and utilize in their daily routines.Group visits provide an alternative venue to provide care for this complex patient population. A group visit is an interactive process between a health care provider and a small group of patients and their caregivers who usually share a common medical concern. The participants of group visits can benefit from the knowledge and experiences of the other participants while providing support and encouragement to each other as they learn to cope with living with a chronic condition.The process of the group visit was first developed in 1991 by Dr. John C. Scott at the Kaiser Permanente system in Colorado, United States. Dr. Scott and a nurse held monthly group visits lasting 60 minutes with a group of 15 to 20 patients to manage their complex medical conditions. The group visit model can vary across settings, including from 6-20 patients over a 1-2 hour period with varying times devoted to education and discussion of health concerns. The group visit typically incorporates a one-on-one physical examination with a physician or nurse practitioner in conjunction with a group discussion and medical management. Group visits have shown to be beneficial in improving patient outcomes for conditions such as diabetes, hypertension, and other chronic illness.The goal of group visits for patients with HF is to increase patient knowledge and self-care abilities, while improving self-efficacy. Self-care incorporates the decision making process a patient undergoes when deciding on a course of action to maintain stability as a result of a change in symptoms. Improved self-care can improve symptoms, which will likely result in an increase in quality of life and a reduction in hospitalizations related to decompensation. Quality of life (QOL) refers to a patient's perception of the impact of a health condition and treatment on the patient's health status and can be measured with valid and reliable tools such as the Minnesota Living with Heart Failure Questionnaire (MLHFQ) or the Kansas City Cardiomyopathy Questionnaire (KCCQ). Self-care abilities can be measured using an instrument such as the Self-Care Heart Failure Index (SCHFI). HF knowledge can be measured using an instrument such as the Atlanta Heart Failure Knowledge Test. Group visits can be used to continue to optimize medication therapy while providing a forum for knowledge acquisition and fostering support.A search of the Cochrane Library of Systematic Reviews, the Joanna Briggs Library of Systematic Reviews, MEDLINE, and CINAHL did not identify any previously conducted systematic reviews on the effectiveness of group visits on outcomes for patients with heart failure. Therefore, this review seeks to identify studies evaluating the effectiveness of group visits for patients with heart failure on patient knowledge, quality of life, self-care behaviors, and hospital readmissions.