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1.  Protocol for a randomized controlled trial of early prophylactic feeding via gastrostomy versus standard care in high risk patients with head and neck cancer 
BMC Nursing  2014;13:17.
Patients with head and neck cancer are at high risk of malnutrition and dysphagia. Enteral tube feeding via a gastrostomy or nasogastric tube is often required in response to dysphagia, odynophagia or side effects of treatment that lead to dehydration and/or weight-loss. A recent systematic review concluded that the optimal method of tube feeding remains unclear; however prophylactic gastrostomy, placed in anticipation of its use during and after treatment, is common practice, following a number of demonstrated benefits. However the majority of these studies have been undertaken in patients receiving radiotherapy alone. More recent studies in patient populations receiving concurrent chemoradiotherapy are showing that despite prophylactic gastrostomy placement significant weight loss still occurs, placing the patient at risk of the consequences of malnutrition. Therefore we set out to investigate innovative prophylactic nutrition support via the gastrostomy to optimise the nutritional outcomes of patients with head and neck cancer.
Patients with head and neck cancer will be eligible for this single centre randomised controlled trial if they are identified for referral for a prophylactic gastrostomy using local guidelines. Patients will be excluded if they are: under the age of eighteen; pregnant; unable to give informed consent; or severely malnourished or moderately malnourished with significant dysphagia requiring a liquid or puree diet. All eligible patients who consent for the study will be allocated randomly to either the intervention or control group (usual care). The intervention group will commence prophylactic supplementary nutrition support via the gastrostomy immediately following placement compared to usual care where nutrition support is commenced via the gastrostomy when clinically indicated during treatment. Key outcome measures will be percentage weight loss, body composition, nutritional status and quality of life, measured at baseline and three months post treatment.
To our knowledge this is the first study to evaluate the effectiveness of early prophylactic tube feeding compared to commencement of feeding during treatment, as per current standard practice, in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer.
Trial registration
This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.
PMCID: PMC4083037
Prophylactic; Gastrostomy; Head and neck cancer; Nutrition support; Enteral nutrition; Quality of life
2.  A pilot study to evaluate incorporating eye care for children into reproductive and child health services in Dar-es-Salaam, Tanzania: a historical comparison study 
BMC Nursing  2014;13:15.
Many blinding eye conditions of childhood are preventable or treatable, particularly in developing countries. However, primary eye care (PEC) for children is poorly developed, leading to unnecessary visual loss. Activities for control by health workers entail interventions for systemic conditions (measles, vitamin A deficiency), identification and referral of children with sight threatening conditions and health education for caregivers. This pilot study evaluated integrating a package of activities to promote child eye health into Reproductive and Child Health (RCH) services in Dar-es-Salaam, Tanzania.
Design: historical comparison study. Fifteen Clinical Officers and 15 nurses in 15 randomly selected RCH clinics were trained in PEC for children in July 2010. They were given educational materials (poster and manual) and their supervisors were orientated. Knowledge and practices were assessed before and 3 weeks after training. One year later their knowledge and practices were compared with a different group of 15 Clinical Officers and 15 nurses who had not been trained.
Before training staff had insufficient knowledge to identify, treat and refer children with eye diseases, even conjunctivitis. Some recommended harmful practices or did not know that cataract requires urgent referral. Eye examination, vitamin A supplementation of mothers after delivery and cleaning the eyes at birth with instillation of antibiotics (Crede’s prophylaxis) were not routine, and there were no eye-specific educational materials.
Three weeks after training several clinics delivering babies started Crede’s prophylaxis, vitamin A supplementation of women after delivery increased from 83.7% to 100%, and all staff included eye conditions in health education sessions. At one year, trained staff were more likely to correctly describe, diagnose and treat conjunctivitis (z=2.34, p=0.04)(30%-vs-60.7%). Mystery mothers observed health education sessions in 7/10 RCH clinics with trained staff, five (71.4%) of which included eye conditions.
Primary eye care for children in Dar-es-Salaam is inadequate but training RCH staff can improve knowledge in the short term and change practices. Attendance by mothers and their children is high in RCH clinics, making them ideal for delivery of PEC. Ongoing supportive supervision is required to maintain knowledge and practices, as well as systems to track referrals.
PMCID: PMC4057825  PMID: 24932133
Child eye health; Primary eye care; Reproductive and child health clinics; Tanzania
3.  Telephone follow-up by nurse following total knee arthroplasty – protocol for a randomized clinical trial (NCT 01771315) 
BMC Nursing  2014;13:14.
Due to shorter hospitalization, patients have to take responsibility for their rehabilitation period at a very early stage. The objective of this trial is to study the effects of two treatment schemes following total knee arthroplasty: conventional treatment following discharge from hospital and early follow-up by telephone consultations in addition to conventional treatment following discharge from hospital. The ultimate aim is to increase the effectiveness of the treatment by improving patients' health status, promote self-efficacy, and reduce the number of acute visits to the orthopaedic outpatient clinic during the rehabilitation period.
The design is a randomized un-blinded parallel group clinical trial conducted at the Department of Orthopaedic Surgery, Gentofte Hospital, the Capital Region of Denmark. In total, 116 patients will be allocated by an external randomization program to 2 groups: an intervention group following usual treatment after discharge supplemented by a nurse managed structured follow-up consultation conducted by telephone 4 and 14 days after discharge from hospital and a control group following treatment as usual. The consultations are structured by key subjects relevant to assess the health status according to the VIPS-model (the Swedish acronym for the concepts Well-being, Integrity, Prevention and Safety). The content of the consultations can vary according to the patients´ individual situations and needs. All consultations are conducted by the researcher responsible for the trial.
The effect is measured 1, 3, 6 and 12 months post-surgery. The primary outcome is self-reported physical function measured by The Western Ontario and McMaster Universities Arthritis Index. Secondary outcomes are self-reported health-related quality of life, general self-efficacy and the number of acute visits to the orthopaedic outpatient clinic.
The result of this trial is expected to provide new knowledge to support the development of targeted and effective follow-up after total knee arthroplasty in order to improve the patients´ health-related knowledge and skills of being able to take actively part in their illness and improve their health status.
Trial registration NCT01771315
PMCID: PMC4035798  PMID: 24872728
Total knee arthroplasty; Telephone follow-up; Health status; Self-efficacy
4.  Patients’ experiences of lifestyle discussions based on motivational interviewing: a qualitative study 
BMC Nursing  2014;13:13.
According to World Health Organization about 75% of cardiovascular diseases and type 2 diabetes and 40% of all cases of cancer could be prevented if the risk factors tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol could be eliminated. Patients often need help in monitoring themselves to make the proper lifestyle changes and it is important that adequate support is provided to enable the patients to take control over their health. Motivational interviewing is a framework that can help to facilitate this movement. The aim of this study was to describe how patients in primary health care settings experience lifestyle discussions based on motivational interviewing.
This study has a descriptive design and qualitative content analysis was used as the method. Sixteen patients who had each visited a registered nurse for lifestyle discussions were interviewed.
The results show that the lifestyle discussions could enable self-determination in the process of lifestyle change but that certain conditions were required. Mutual interaction between the patient and the nurse that contributes to a sense of well-being in the patients was a necessary condition for the lifestyle discussion to be helpful. When the discussion resulted in a new way of thinking about lifestyle and when patient initiative was encouraged, the discussion could contribute to change. The patient’s free will to make a lifestyle change and the nurse’s sensitivity in the discussions created fertile soil for change.
This study focuses on MI-based discussions, and the result shows that a subset of patients, who self-reported that they are motivated and aware of their role in making lifestyle changes, appreciate these strategies. However, it is not known whether discussions would be experienced in the same way if RNs used another method or if patients who were less motivated, engaged, or aware of their role in making lifestyle changes were interviewed.
PMCID: PMC4045965  PMID: 24904235
Content analysis; Lifestyle discussion; Motivational interviewing; Nurse; Patient experiences; Primary health care
5.  Nurses’ and care workers’ experiences of spiritual needs in residents with dementia in nursing homes: a qualitative study 
BMC Nursing  2014;13:12.
The aim of the study was to investigate nurses’ and care workers’ experiences of spiritual needs among residents with dementia in nursing homes. Nurses claim to practice holistic nursing. Nevertheless, there is little knowledge about how to recognise spiritual needs in residents with dementia.
The study was conducted using a qualitative method with an exploratory design. Eight focus- group interviews in four Norwegian nursing homes were performed from June 2011 – Jan 2012. Using open-ended research questions, a total of 31 participants were asked to share their understanding and experiences regarding residents’ spiritual needs. The interviews were analysed using a phenomenological – hermeneutical method.
The nurses’ and care workers’ experiences of residents’ spiritual needs were related to three main themes; i) The need for serenity and inner peace, described as “contemplative and restful moments” and “calmness due to familiarity”, ii) The need for confirmation, described as “love and proximity” and iii) The need to express faith and beliefs, described as “participate in worship and prayers” and “approaching death”.
The comprehensive analyses revealed that the nurses believe the residents’ spiritual needs were linked to the residents’ previous sources of finding meaning, in relation to inter-personal, intra-personal and trans-personal dimensions in residents’ lives.
Nurses' and care workers’ experiences of spiritual needs in people with dementia are very similar to the findings for the general population regardless of the severity of the dementia. The study’s relevance to clinical practice indicates the importance of developing more knowledge about how people with dementia in nursing homes express spiritual needs and how to observe and interpret such needs.
PMCID: PMC4011774  PMID: 24731548
Spiritual needs; Dementia; Nursing home; Phenomenological hermeneutics; Nursing care
6.  Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies 
BMC Nursing  2014;13:11.
This study aimed to reveal nurses’ experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.
A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.
Key factors affecting nursing turnover were limited career opportunities; poor support; a lack of recognition; and negative staff attitudes. The nursing working environment is characterised by inappropriate skill-mix and inadequate patient-staff ratios; a lack of overseas qualified nurses with appropriate skills; low involvement in decision-making processes; and increased patient demands. These issues impacted upon heavy workloads and stress levels with nurses feeling undervalued and disempowered. Nurses described supportive strategies: improving performance appraisals, responsive preceptorship and flexible employment options.
Nursing turnover is influenced by the experiences of nurses. Positive steps can be made towards improving workplace conditions and ensuring nurse retention. Improving performance management and work design are strategies that nurse managers could harness to reduce turnover.
PMCID: PMC3985533  PMID: 24708565
Nursing staff; Hospital personnel; Turnover; Personnel management
7.  A cross sectional study on factors influencing professionalism in nursing among nurses in Mekelle Public Hospitals, North Ethiopia, 2012 
BMC Nursing  2014;13:10.
Professionalism is defined as the conceptualization of obligations, attributes, interactions, attitudes, and role behaviors required of professionals in relationship to individual clients and to society as a whole. Professionalism attributes include knowledge, spirit of inquiry, accountability, autonomy, advocacy, innovation and visionary, collaboration and collegiality, and ethics. The study assessed level and attributes of professionalism in nursing in Mekelle, Tigray, Ethiopia.
Institutional based cross sectional study supplemented by qualitative design was employed. Self administered semi structured questionnaire developed from RANO guideline was used. The FGD guideline was developed from different literatures. Data was analyzed using SPSS 16.0. Descriptive statistics and significance was checked at p < 0.05. Professionalism was measured using ANOVA. Qualitative of data were analyzed using coding technique. Written informed consent was obtained from the nurses and confidentiality was assured for all the information provide.
The mean scores for the nurses in Mekelle public hospitals on the professionalism were 140.50, knowledge (25.06), followed by ethics (25.00). The attitudes of respondents on professionalism were at high, moderate, low and very low level. Pearson product–moment correlation analysis revealed small yet significant associations among several professionalism attributes and characteristics of nurses in Mekelle Public hospitals. Age of respondents and work experience were significantly correlated with total professionalism. Work setting in Mekelle hospital was significantly associated with professionalism. Depending on FGD, the major factors were workload, had no vision, FMOH did not focused nursing as a profession, Weakness of the Ethiopian Nursing Association, lack of life insurance as well as the Health professionals and society’s views of the profession.
Nurses with longer years of experience and the older respondents had significantly related with professionalism. Nurses who join professional organizations had high score on professionalism; and nurses working in Military Hospital had high score of professionalism.
PMCID: PMC3992135  PMID: 24708544
Attributes of professionalism; Mekelle public hospital nurses; Nursing; Professionalism
8.  Hardy personality and burnout syndrome among nursing students in three Brazilian universities—an analytic study 
BMC Nursing  2014;13:9.
Nursing students may exhibit the characteristics of resistance to stress, such as hardiness, which can reduce the risk of burnout. However, we found only one published study about these phenomena among nursing students. Thus, we investigated the association between hardiness and burnout in such students.
An analytic, cross-sectional study was conducted among 570 nursing students from three Brazilian universities. Data were collected relating to sociodemographic characteristics, hardiness, and burnout, which we analyzed using inferential statistics.
We observed that 64.04% of nursing students in the sample had a high level of emotional exhaustion, 35.79% had a high level of cynicism, and 87.72% had a low level of professional efficacy: these are dimensions of burnout. We also found that 48.77% had a high level of control, 61.40% a high level of commitment, and 35.44% a high level of challenge: these are dimensions of hardiness. Only 24.74% of the students experienced burnout, and 21.93% met the criteria for a hardy personality. There was a statistically significant difference between the frequency of hardiness and burnout (p = 0.033), with 68.00% of hardy students not exhibiting burnout.
Although nursing students live with educational stressors, burnout was not preponderant in our sample students; this may be linked to hardiness. Thus, given its benefits to student life and health, we recommend the development of strategies to promote hardiness among nursing students.
PMCID: PMC3975133  PMID: 24678676
Burnout; Nursing; Nursing education; Students; Stress; Psychological adaptation; Professional burnout
9.  Evidence based practice beliefs and implementation among nurses: a cross-sectional study 
BMC Nursing  2014;13:8.
Having a positive attitude towards evidence-based practice and being able to see the value of evidence-based practice for patients have been reported as important for the implementation of evidence-based practice among nurses.
The aim of this study was to map self-reported beliefs towards EBP and EBP implementation among nurses, and to investigate whether there was a positive correlation between EBP beliefs and EBP implementation.
We carried out a cross-sectional study among 356 nurses at a specialist hospital for the treatment of cancer in Norway. The Norwegian translations of the Evidence-based Practice Belief Scale and the Evidence-based Practice Implementation Scale were used.
In total, 185 nurses participated in the study (response rate 52%). The results showed that nurses were positive towards evidence-based practice, but only practised it to a small extent. There was a positive correlation (r) between beliefs towards evidence-based practice and implementation of evidence-based practice (r = 0.59, p = 0.001).
There was a statistical significant positive, but moderate correlation between all the four subscales of the EBP Beliefs Scale (beliefs related to: 1) knowledge, 2) resources, 3) the value of EBP and 4) difficulty and time) and the EBP Implementation Scale, with the highest correlation observed for beliefs related to knowledge (r = 0.38, p < .0001). Participants who had learned about evidence-based practice had significantly higher scores on the Evidence-based Practice Belief Scale than participants who were unfamiliar with evidence-based practice. Those involved in evidence-based practice working groups also reported significantly higher scores on the Evidence-based Practice Belief Scale than participants not involved in these groups.
This study shows that nurses have a positive attitude towards evidence-based practice, but practise it to a lesser extent. There was a positive correlation between beliefs about evidence-based practice and implementation of evidence-based practice. Beliefs related to knowledge appear to have the greatest effect on implementation of evidence-based practice. Having knowledge and taking part in evidence-based practice working groups seem important.
PMCID: PMC3987836  PMID: 24661602
Evidence-based practice; Beliefs; Behaviour; Implementation; Nurses; Survey
10.  Pain-related psychological cognitions and behaviours associated with sick leave due to neck pain: findings from the Nurses and Midwives e-Cohort Study 
BMC Nursing  2014;13:5.
Sick leave due to neck pain (NP-SL) is costly and negatively impacts the productivity of the nursing and midwifery workforce. Identification of modifiable risk indicators is necessary to inform preventive efforts. This study aimed to investigate the role of pain-related psychological features (pain catastrophizing, fear of movement, and pain coping) in NP-SL alongside other potential risk indicators.
A cross-sectional analysis of a large cohort study of Australian and New Zealand nurses and midwives, established between 1st April 2006 to 30th March 2008, was undertaken. Recruitment procedures adopted within each Nursing Council jurisdiction were governed by the individual regulatory authorities and their willingness to engage with the study. Invitations directed potential participants to a purpose-built internet-based survey, where study information was provided and consent requested. Once consent was obtained, a range of standardized tools combined into one comprehensive electronic questionnaire was elicited. Exposure variables assessed included pain characteristics and a broad range of psychological, psychosocial, occupational, general health and demographic factors. Two-way interactions between age and gender and candidate exposures were also assessed. Binary logistic regression was performed using manual backward stepwise elimination of non-significant terms.
The cohort included 4,903 currently working nurses or midwives aged 18–65 years. Of these, 2,481 (50.6%) reported neck pain in the preceding 12 months. Our sample comprised of 1,854 working nurses and midwives with neck pain in the preceding year who supplied sick leave data. Of these, 343 (18.5%) reported taking sick leave in the preceding year due to their neck pain. The final most parsimonious multivariable model demonstrated neck pain severity (adjusted odds ratio, [aOR] = 1.59), passive pain coping (aOR = 1.08) and fear of movement (aOR = 1.06) increased the likelihood of NP-SL in the previous year. Interactions between demographic and general health factors exhibited both protective and risk relationships with NP-SL, and there was no association between pain catastrophizing and NP-SL.
Findings demonstrate that sick leave due to neck pain was associated with pain severity, fear of movement and passive pain coping. In addition, there were complex interactions found between demographic and general health factors. These features represent potentially modifiable targets for preventive programs.
PMCID: PMC3939627  PMID: 24559152
Neck pain; Sick leave; Psychosocial factors; Nursing and midwifery; Epidemiology
11.  Musculoskeletal disorder risk factors among nursing professionals in low resource settings: a cross-sectional study in Uganda 
BMC Nursing  2014;13:7.
Musculoskeletal disorders (MSD) constitute one of the main occupational hazards among health care workers. However, few epidemiological studies on work related MSD among nursing professionals have been carried out in Africa. The purpose of this study was to assess the work related musculoskeletal disorders and associated risk factors among nursing professionals in Uganda.
This was a cross-sectional study of MSD among 880 nursing professionals from five selected hospitals in Uganda. Data was collected using a questionnaire adapted from the Dutch Musculoskeletal and Nordic Musculoskeletal questionnaires. Descriptive (mean, standard deviation and percentages) and inferential (Chi square test and logistic regression analysis) statistics were used to analyse data. Alpha level was set at p < 0.05.
A total of 741 completed questionnaires were analysed (response rate 85.4%). The average age of the respondents was 35.4 (SD 10.7) years and a majority were female (85.7%). The average working hours per week was 43.7 (SD 18.9 hours). The 12-month period-prevalence of MSD at anybody site was 80.8%. The most common site of MSD was the lower back (61.9%). Significant risk factors for reported MSD included often working in a slightly bent posture (adjOR 2.25, 95% CI 1.20-4.26), often working in a slightly twisted posture for long (adjOR 1.97, 95% CI 1.03-3.77), mental exhaustion (adjOR 2.05, 95% CI 1.17-3.5), being absent from the work station for more than 6 months due to illness or an accident (adjO|R, 4.35, 95% CI 1.44-13.08) and feeling rested after a break (adjOR 2.09, 95% CI 1.16-3.76).
Musculoskeletal disorders affect more than 80% of nursing professionals in Uganda with the most commonly, affected site being the lower back. Significant risk factors for MSD include; being absent from the work station for more than 6 months due to illness or an accident, working in awkward postures, pushing/pulling of heavy loads and mental exhaustion. There is a need for greater advocacy, better working conditions and adoption of strategies to reduce occupational injuries.
PMCID: PMC3940025  PMID: 24565421
Musculoskeletal disorders; Risk factors; Uganda
12.  Pressure ulcer prevention knowledge among Jordanian nurses: a cross- sectional study 
BMC Nursing  2014;13:6.
Pressure ulcer remains a significant problem in the healthcare system. In addition to the suffering it causes patients, it bears a growing financial burden. Although pressure ulcer prevention and care have improved in recent years, pressure ulcer still exists and occurs in both hospital and community settings. In Jordan, there are a handful of studies on pressure ulcer. This study aims to explore levels of knowledge and knowledge sources about pressure ulcer prevention, as well as barriers to implementing pressure ulcer prevention guidelines among Jordanian nurses.
Using a cross-sectional study design and a self-administered questionnaire, data was collected from 194 baccalaureate and master’s level staff nurses working in eight Jordanian hospitals. From September to October of 2011, their knowledge levels about pressure ulcer prevention and the sources of this knowledge were assessed, along with the barriers which reduce successful pressure ulcer care and prevention.
ANOVA and t-test analysis were used to test the differences in nurses’ knowledge according to participants’ characteristics. Means, standard deviation, and frequencies were used to describe nurses’ knowledge levels, knowledge sources, and barriers to pressure ulcer prevention.
The majority (73%, n = 141) of nurses had inadequate knowledge about pressure ulcer prevention. The mean scores of the test for all participants was 10.84 out of 26 (SD = 2.3, range = 5–17), with the lowest score in themes related to PU etiology, preventive measures to reduce amount of pressure/shear, and risk assessment. In-service training was the second source of education on pressure ulcer, coming after university training. Shortage of staff and lack of time were the most frequently cited barriers to carrying out pressure ulcer risk assessment, documentation, and prevention.
This study highlights concerns about Jordanian nurses’ knowledge of pressure ulcer prevention. The results of the current study showed inadequate knowledge among Jordanian nurses about pressure ulcer prevention based on National Pressure Ulcer Advisory Panel guidelines. Also, the low level of nurses’ pressure ulcer knowledge suggests poor dissemination of pressure ulcer knowledge in Jordan, a suggestion supported by the lack of relationship between years of experience and pressure ulcer knowledge.
PMCID: PMC3946597  PMID: 24565372
Pressure ulcer; Knowledge; Sources; Barriers; Nurses; Jordan
13.  Preventing falls among older people with mental health problems: a systematic review 
BMC Nursing  2014;13:4.
Falls are a leading cause of mortality and morbidity in older people and the risk of falling is exacerbated by mental health conditions. Existing reviews have focused on people with dementia and cognitive impairment, but not those with other mental health conditions or in mental health settings. The objective of this review is to evaluate the effectiveness of fall prevention interventions for older people with mental health problems being cared for across all settings.
A systematic review of fall prevention interventions for older people with mental health conditions. We undertook electronic database and lateral searches to identify studies reporting data on falls or fall related injuries. Searches were initially conducted in February 2011 and updated in November 2012 and October 2013; no date restrictions were applied. Studies were assessed for risk of bias. Due to heterogeneity results were not pooled but are reported narratively.
Seventeen RCTs and four uncontrolled studies met the inclusion criteria; 11 involved single interventions and ten multifactorial. Evidence relating to fall reduction was inconsistent. Eight of 14 studies found a reduction in fallers (statistically significant in five), and nine of 14 reported a significant reduction in rate or number of falls. Four studies found a non-significant increase in falls. Multifactorial, multi-disciplinary interventions and those involving exercise, medication review and increasing staff awareness appear to reduce the risk of falls but evidence is mixed and study quality varied. Changes to the environment such as increased supervision or sensory stimulation to reduce agitation may be promising for people with dementia but further evaluation is needed. Most of the studies were undertaken in nursing and residential homes, and none in mental health hospital settings.
There is a dearth of falls research in mental health settings or which focus on patients with mental health problems despite the high number of falls experienced by this population group. This review highlights the lack of robust evidence to support practitioners to implement practices that prevent people with mental health problems from falling.
PMCID: PMC3942767  PMID: 24552165
Systematic review; Falls; Older people; Mental health
14.  BMC Nursing reviewer acknowledgement, 2013 
BMC Nursing  2014;13:3.
Contributing reviewers
The editors of BMC Nursing would like to thank all our reviewers who have contributed to the journal in Volume 12 (2013).
PMCID: PMC3912497  PMID: 24490695
15.  CuidaCare: effectiveness of a nursing intervention on the quality of life’s caregiver: cluster-randomized clinical trial 
BMC Nursing  2014;13:2.
In Spain, family is the main source of care for dependent people. Numerous studies suggest that providing informal (unpaid) care during a prolonged period of time results in a morbidity-generating burden. Caregivers constitute a high-risk group that experiences elevated stress levels, which reduce their quality of life.
Different strategies have been proposed to improve management of this phenomenon in order to minimize its impact, but definitive conclusions regarding their effectiveness are lacking.
A community clinical trial is proposed, with a 1-year follow-up period, that is multicentric, controlled, parallel, and with randomized allocation of clusters in 20 health care centers within the Community of Madrid. The study's objective is to evaluate the effectiveness of a standard care intervention in primary health care (intervention CuidaCare) to improve the quality of life of the caregivers, measured at 0, 6, and 12 months after the intervention.
One hundred and forty two subjects (71 from each group) ≥65 years, identified by the nurse as the main caregivers, and who provide consent to participate in the study will be included.
The main outcome variable will be perceived quality of life as measured by the Visual Analogue Scale (VAS) of EuroQol-5D (EQ-5D). The secondary outcome variables will be EQ-5D Dimensions, EQ-5D Index, nursing diagnosis, and Zarit's test. Prognostic variables will be recorded for the dependent patient and the caregiver.
The principle analysis will be done by comparing the average change in EQ-5D VAS value before and after intervention between the two groups. All statistical tests will be performed as intention-to-treat. Prognostic factors' estimates will be adjusted by mixed-effects regression models. Possible confounding or effect-modifying factors will be taken into account.
Assistance for the caregiver should be integrated into primary care services. In order to do so, incorporating standard, effective interventions with relevant outcome variables such as quality of life is necessary. Community care nurses are at a privileged position to develop interventions like the proposed one.
Trial registration
This trial has been registered in under code number NCT 01478295.
PMCID: PMC3915556  PMID: 24467767
Caregivers; Nursing; Primary care; Quality of life; Social support; Psychological adaptation; Caregiver burden
16.  Psychometric evaluation of the French version of the questionnaire attitudes towards morphine use; a cross-sectional study in Valais, Switzerland 
BMC Nursing  2014;13:1.
In Switzerland, nurses are allowed to prescribe and administer morphine in emergency situations without a doctor. Still, nurses and other health professionals are often reluctant to prescribe and administer morphine for pain management in patients. No valid French-speaking instrument is available in Switzerland to assess the attitudes of nurses and other health professionals towards the prescription and administration of morphine. In this study, we evaluated the psychometric properties of the French version of the questionnaire “Attitudes towards morphine use”.
The instrument was derived from an Italian version. Forward and back translations of the questionnaire were performed. Item analysis and construct validity were assessed between April and December 2010 in a cross sectional study including five Swiss hospitals in a sample of 588 health professionals (533 nurses, mean age 38.3 ± 10.2 years). Thirty subjects participated in test-retest reliability.
The time to complete the instrument ranged between 12 and 15 minutes and neither floor nor ceiling effect were found. The initial 24-item instrument showed an intraclass correlation (ICC) of 0.69 (95% CI: 0.64 to 0.73, P < 0.001), and a Cronbach’s α of 0.700. Factor analysis led to a six-component solution explaining 52.4% of the total variance. After excluding five items, the shortened version showed an ICC of 0.74 (95% CI, 0.70 to 0.77, P < 0.001) and a Cronbach’s α of 0.741. Factor analysis led to a five-component solution explaining 54.3% of the total variance. The five components were named “risk of addiction/dependence”; “operational reasons for not using morphine”; “risk of escalation”; “other (non-dependence) risks” and “external (non-operational) reasons”. In test-retest, the shortened instrument showed an ICC of 0.797 (95% CI, 0.630 to 0.911, P < 0.001) and a Cronbach’s α of 0.797.
The 19-item shortened instrument assessing attitudes towards the prescription and administration of morphine showed adequate content and construct validity.
PMCID: PMC4029768  PMID: 24406097
Instrument validation; Morphine use; Attitudes; Psychometrics; Switzerland
17.  The influence of relationships on personhood in dementia care: a qualitative, hermeneutic study 
BMC Nursing  2013;12:29.
In dementia personhood can be understood as increasingly concealed rather than lost. The sense of being a person evolves in relationships with others. The aim of this study was to increase the understanding of the nature and quality of relationships between persons with dementia, family carers and professional caregivers and how these relationships influenced personhood in people with dementia.
This Norwegian study had a qualitative hermeneutical design based on ten cases. Each case consisted of a triad: the person with dementia, the family carer and the professional caregiver. Inclusion criteria for persons with dementia were (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2 ie. moderate dementia (4) able to communicate verbally.
A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day care centre. Data were analysed in two steps: (1) inductive analysis with an interpretive approach and (2) deductive analysis, applying a theoretical framework for person-centred care.
Relationships that sustained personhood were close emotional bonds between family carers and persons with dementia and professional relationships between caregivers and persons with dementia.
Relationships that diminished personhood were task-centred relationships and reluctant helping relationships between family carers and persons with dementia and unprofessional relationships between caregivers and persons with dementia.
A broad range of relationships was identified. Understanding the complex nature and quality of these relationships added insight as to how they influenced the provision of care and the personhood of persons with dementia. Personhood was not only bestowed upon them by family carers and professional caregivers; they themselves were active agents who gained a sense of self by what they said and did.
PMCID: PMC3878215  PMID: 24359589
Dementia; Relationships; Personhood; Person-centred care
18.  Parents of preterm-born children; sources of stress and worry and experiences with an early intervention programme – a qualitative study 
BMC Nursing  2013;12:28.
Preterm-born children are at increased risk of adverse developmental outcomes, and their parents may experience increased stress levels. The Mother–Infant Transaction Program (MITP) is an early intervention that aims to enhance the parent–infant relationship and child development. The present study investigated differences in parents’ experience of stress and concerns about caring for their preterm-born child according to whether they participated in the programme. Parental satisfaction with the intervention was also explored.
As part of a follow-up study at 36 months, a randomized controlled trial of the MITP—14 parents of 11 children from the intervention group, and 17 parents of 14 children from the control group were interviewed by the use of semi-structured focus group interviews. The interviews were analysed thematically.
The intervention parents reported that the knowledge, advice, guidance and emotional support given during the intervention made them feel less stressed and more confident, competent and secure caring for their preterm born child than they would otherwise have been. The control parents described feeling less involved and emotionally supported, and seemed more anxious about their child’s development than the intervention parents. All parents were vigilant and alert to their child’s needs and monitored developmental milestones carefully.
This qualitative exploration of the influences of the MITP revealed a positive impact of the intervention and seems to be an important educational and supportive initiative. Thus, reducing parental stress and enhancing confidence in the parental role.
PMCID: PMC3879424  PMID: 24313957
Early intervention; Focus group interviews; Neonatal intensive care unit; NICU; Parental stress; Preterm infant; Public health nurses; Thematic analyses
19.  Variability of nursing care by APR-DRG and by severity of illness in a sample of nine Belgian hospitals 
BMC Nursing  2013;12:26.
As soon as Diagnosis related Groups (DRG) were introduced in many hospital financing systems, most nursing research revealed that DRG were not very homogeneous with regard to nursing care. However, few studies are based on All Patient refined Diagnosis related Groups (APR-DRGs) and few of them use recent data. Objectives of this study are: (1) to evaluate if nursing activity is homogeneous by APR-DRG and by severity of illness (SOI) (2) to evaluate the outlier’s rate associated with the nursing activity and (3) to compare nursing cost homogeneity per DRG and SOI.
Study done in 9 Belgian hospitals on a selection of APR-DRG with more than 30 patients (7 638 inpatient stays). The evaluation of the homogeneity is based on coefficients of variation (CV). The 75th percentile + 1.5 × inter-quartile range was used to select high outliers. 25th percentile −1.5 × inter-quartile range was used to select low outliers. Nursing costs per ward were distributed on inpatient stays of each ward following two techniques (the LOS vs. the number of nursing care minutes per stay).
The homogeneity of LOS by DRG and by SOI is relatively good (CV: 0.56). The homogeneity of the nursing activity by DRG is less good (CVs between 0.36 and 1.54) and is influenced by nursing activity outliers (high outliers’ rate: 5.19%, low outliers’ rate: 0.14%). The outlier’s rate varies according to the studied variable. The high outliers’ rate is higher for nursing activity than for LOS. The homogeneity of nursing costs is higher when costs are based on the LOS of patients than when based on minutes of nursing care (CVs between 0.26 and 1.46 for nursing costs based on LOS and between 0.49 and 2.04 for nursing costs based on minutes of nursing care).
It is essential that the calculation of nursing cost by stay and by DRG for hospital financing purposes was based on nursing activity data, that more reflect resources used in wards, and not on LOS data. The only way to obtain this information is the generalization of computerized nursing files.
PMCID: PMC3853029  PMID: 24112381
Nursing cost; DRG; Financing systems; Outliers
20.  Hostile clinician behaviours in the nursing work environment and implications for patient care: a mixed-methods systematic review 
BMC Nursing  2013;12:25.
Although there is a sizeable body of evidence regarding the nature of hostile behaviours among clinicians in the nursing workplace, what is less clear is the nature of the relationship between these behaviours and patient care. To inform the development of appropriate intervention strategies we examine the level of evidence detailing the relationships between hostile clinician behaviours and patient care.
Published qualitative and quantitative studies that examined hostile clinician behaviours and patient care were included. Quality assessment, data extraction and analysis were undertaken on all included studies. The search strategy was undertaken in July and August 2011 and comprised eight electronic databases (CINAHL, Health Collection (Informit), Medline (Ovid), Ovid Nursing Full Text, Proquest Health and Medicine, PsycInfo, Pubmed and Cochrane library) as well as hand searching of reference lists.
The search strategy yielded 30 appropriate publications. Employing content analysis four themes were refined: physician-nurse relations and patient care, nurse-nurse bullying, intimidation and patient care, reduced nurse performance related to exposure to hostile clinician behaviours, and nurses and physicians directly implicating patients in hostile clinician behaviours.
Our results document evidence of various forms of hostile clinician behaviours which implicate nursing care and patient care. By identifying the place of nurse-nurse hostility in undermining patient care, we focus attention upon the limitations of policy and intervention strategies that have to date largely focused upon the disruptive behaviour of physicians. We conclude that the paucity of robustly designed studies indicates the problem is a comparatively under researched area warranting further examination.
PMCID: PMC3851604  PMID: 24094243
Workplace bullying; Disruptive behaviour; Quality of care; Teamwork; Nurse-physician relations; Work environment; Systematic review
21.  Resident and family perceptions of the nurse practitioner role in long term care settings: a qualitative descriptive study 
BMC Nursing  2013;12:24.
Research evidence supports the positive impact on resident outcomes of nurse practitioners (NPs) working in long term care (LTC) homes. There are few studies that report the perceptions of residents and family members about the role of the NP in these settings. The purpose of this study was to explore the perceptions of residents and family members regarding the role of the NP in LTC homes.
The study applied a qualitative descriptive approach. In-depth individual and focus group interviews were conducted with 35 residents and family members from four LTC settings that employed a NP. Conventional content analysis was used to identify themes and sub-themes.
Two major themes were identified: NPs were seen as providing resident and family-centred care and as providing enhanced quality of care. NPs established caring relationships with residents and families, providing both informational and emotional support, as well as facilitating their participation in decision making. Residents and families perceived the NP as improving availability and timeliness of care and helping to prevent unnecessary hospitalization.
The perceptions of residents and family members of the NP role in LTC are consistent with the concepts of person-centred and relationship-centred care. The relationships NPs develop with residents and families are a central means through which enhanced quality of care occurs. Given the limited use of NPs in LTC settings, there is an opportunity for health care policy and decision makers to address service inadequacies through strategic deployment of NPs in LTC settings. NPs can use their expert knowledge and skill to assist residents and families to make informed choices regarding their health care and maintain a positive care experience.
PMCID: PMC3849937  PMID: 24074157
Nurse practitioner; Long term care; Qualitative descriptive; Perceptions; Residents; Family members; Person-centred care
22.  Patient experiences of recovery after heart valve replacement: suffering weakness, struggling to resume normality 
BMC Nursing  2013;12:23.
Heart valve disease is becoming a public health problem due to increasing life expectancy and new treatment methods. Patients are at risk of developing depression, anxiety or post-traumatic stress disorder after heart valve surgery. To better plan proper care, describing and understanding patients’ perception of recovery after heart valve replacement is essential. The objective was to describe the experience of recovery at home after heart valve replacement.
Qualitative interviews were conducted with 10 patients representing the population and these were later transcribed. The analysis was inspired by Ricoeur’s theory of interpretation, which consists of three levels: naive reading, structured analysis, and critical interpretation and discussion.
The overall concept that emerged was suffering weakness and struggling to resume normality. Patients all struggled to resume normal living, both in regaining physical strength and in reestablishing balance in overall living. The overall concept can be interpreted in terms of the following themes: Disturbed network: Invaluable relatives, Contact with healthcare staff, Rehabilitation. Disturbed body: Stressful complications, Bodily attention, Physically affected, Physical capability. Recovery: Interrupted living, Suffering weakness, Gradual recovery, Achieving normality. Reflections: Thoughts about the procedure and Feeling sad and fragile.
The study presents the main themes of network, body, recovery and reflection for ten patients after heart valve replacement. These main themes can overall be summarized as suffering weakness and struggling to resume normality. Patients felt weak with a changed body, but after a long recovery process regained vitality and returned to their daily life.
PMCID: PMC3849933  PMID: 24070399
Heart valve disease; Transcatheter aortic valve implantation; Valve surgery; Patient experience; Recovery
23.  Practicing nurses perspectives of clinical scholarship: a qualitative study 
BMC Nursing  2013;12:21.
There is a scarcity of research published on clinical scholarship. Much of the conceptualisation has been conducted in the academy. Nurse academics espouse that the practice of nursing must be built within a framework of clinical scholarship. A key concept of clinical scholarship emerging from discussions in the literature is that it is an essential component of enabling evidence–based nursing and the development of best practice standards to provide for the needs of patients/clients. However, there is no comprehensive definition of clinical scholarship from the practicing nurses. The aim of this study was to contribute to this definitional discussion on the nature of clinical scholarship in nursing.
Naturalistic inquiry informed the method. Using an interpretative approach 18 practicing nurses from Australia, Canada and England were interviewed using a semi-structured format. The audio-taped interviews were transcribed and the text coded for emerging themes. The themes were sorted into categories and the components of clinical scholarship described by the participants compared to the scholarship framework of Boyer [JHEOE 7:5-18, 2010].
Clinical scholarship is difficult to conceptualise. Two of the essential elements of clinical scholarship are vision and passion. The other components of clinical scholarship were building and disseminating nursing knowledge, sharing knowledge, linking academic research to practice and doing practice-based research.
Academic scholarship dominated the discourse in nursing. However, in order for nursing to develop and to impact on health care, clinical scholarship needs to be explored and theorised. Nurse educators, hospital-based researchers and health organisations need to work together with academics to achieve this goal.
Frameworks of scholarship conceptualised by nurse academics are reflected in the findings of this study with their emphasis on reading and doing research and translating it into nursing practice. This needs to be done in a nonthreatening environment.
PMCID: PMC3849609  PMID: 24066801
Clinical scholarship; Nursing; Research; Practicing nurses
24.  Work-aged stroke survivors’ psychosocial challenges narrated during and after participating in a dialogue-based psychosocial intervention: a feasibility study 
BMC Nursing  2013;12:22.
Studies point to the lack of psychosocial support and rehabilitation services that are adjusted to the work-aged stroke survivors’ specific needs in order to promote psychosocial well-being. The aim of the study was to illuminate the psychosocial challenges work-aged participants (i.e. aged 18–67 years) thematised during and after participating a dialogue-based psychosocial intervention during the first year following a stroke.
The study was a feasibility study guided by the UK Medical Research Council Framework for developing and evaluating complex interventions. Qualitative data from in-depth interviews with fourteen stroke-survivors aged 33–66 years, researcher field notes and log notes written during the intervention were analysed applying a hermeneutic-phenomenological approach.
The stroke and its consequences had a substantial impact on family and work life. Their experiences were summarised in the two themes The threat of becoming marginalised in family life and The threat of becoming marginalised in work life.
Life as a work-aged stroke survivor was experienced as challenging and created a threat of becoming marginalised in family and work life. The study highlights the need to understand the specific psychosocial challenges and needs facing work-aged stroke survivors’ in order to promote their psychosocial well-being. More research is needed concerning specific life-span challenges amongst work-aged stroke survivors in order to further develop appropriate interventions that helps address this issue.
PMCID: PMC3849869  PMID: 24066840
Stroke; Work-aged stroke survivors; Marginalisation; Feasibility study; Complex intervention; Qualitative method; Hermeneutic-phenomenological; Rehabilitation
25.  Nurse-patient communication in primary care diabetes management: an exploratory study 
BMC Nursing  2013;12:20.
Diabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management.
Thirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.
In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared.
This study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses’ clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations.
Conscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.
PMCID: PMC3856446  PMID: 24028348

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