Benefits of Being Teamed with a Service Dog for Individuals Living with Visible and Invisible Disabilities.

Over 61 million people in the United States are living with disabilities. Less than one percent are teamed with service dogs. A service dog is a type of assistance dog specifically trained to perform a disability-related task(s) to assist the person and support their independence. Service dogs may also provide valuable secondary benefits. The aim of this survey research is to add empiric data on benefits of being teamed with a service dog. Two hundred and four individuals teamed with service dogs responded to demographic and survey questions that included the benefits they experience from being teamed with a service dog. Overwhelmingly, respondents agreed or strongly agreed to benefits of emotional connection (96%), community participation (97%), physical activity (96%), psychological wellbeing (98%), quality of life (97%), a reduction in prescribed medications (78%), and a decrease in paid or unpaid assistance hours (83%), which extend beyond their primary disability need. It is clear that many others may benefit from being teamed with a service dog. Greater evidence is needed to increase tangible support for those who desire to be teamed with a service dog and can meet the Americans with Disabilities requirements. Additionally, to support individuals with service dogs now and in the future, healthcare professionals need to be knowledgeable about and culturally competent in caring for patients teamed with service dogs. Service dogs, when indicated, may benefit individuals living with disabilities by meeting primary and secondary needs that support independence.

Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review.

OBJECTIVE: The objective of this review was to evaluate the effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults 18 years and over. INTRODUCTION: Stress has reached epidemic proportions globally. Unidentified sequela of physiological and psychological stress can result in anxiety, depression, heart disease, cancer, immunologic conditions and death. There is a high cost associated with the treatment of stress related health conditions in the United States and worldwide. Many treatments are pharmacologic and cannot be self-initiated. Therefore, it is critical to identify evidence-based, low-cost, non-pharmacologic, self-administered interventions that can mitigate physiological and psychological stress. INCLUSION CRITERIA: This review considered adults 18 years and over engaged in diaphragmatic breathing as an isolated intervention to reduce physiological and psychological stress. There were no exclusions based on physical or psychological conditions. The comparator was no treatment or usual treatment, which may constitute ordinary breathing. METHODS: The comprehensive literature search included published and unpublished studies in English from the beginning of the databases through January 2018. The databases searched included: PubMed, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, PsycINFO, ProQuest Nursing and Allied Health and Health Source: Nursing/Academic Edition. The recommended JBI approach to critical appraisal, study selection, data extraction and data synthesis was used. RESULTS: Three studies met the criteria for review: one randomized controlled trial and two quasi-experimental studies. Statistical pooling was not possible due to clinical and methodological heterogeneity of interventions and outcome measures of the included studies. All three studies demonstrated the effectiveness of diaphragmatic breathing on reducing stress. One study showed improvement in the biomarkers of respiratory rate and salivary cortisol levels, one showed improvement in systolic and diastolic blood pressure, and one study showed an improvement in the stress subscale of the Depression Anxiety Stress Scales-21 (DASS-21) after implementation of a diaphragmatic breathing intervention. Although there were limitations across the studies, such as sample size, and length and duration of the intervention over time, ranging from one 20-minute intervention to nine months, the studies demonstrated that diaphragmatic breathing had a positive effect on lowering physiological and psychological stress. CONCLUSIONS: The evidence suggests that diaphragmatic breathing may decrease stress as measured by physiologic biomarkers, as well psychological self-report tools. Given the benefits of diaphragmatic breathing on stress reduction, ongoing research is needed to continue to establish the evidence-base for this self-administered, low-cost, non-pharmacologic intervention.

Effectiveness of diaphragmatic breathing on physiological and psychological stress in adults: a quantitative systematic review protocol.

REVIEW QUESTION: What is the effectiveness of diaphragmatic breathing on physiological and psychological stress in adults?

Grieving the Loss of Self: Challenges in Type 2 Diabetes Mellitus Self-Management.

The aim of this study was to understand and describe the experience of diabetes self-management among patients not meeting glycemic control (A1C > 9). Type 2 diabetes mellitus (T2DM) is a complex chronic disease process. Diabetes self-management is equally complex and critical to patient outcomes and quality of life. The components for self-management include: knowledge, skills/abilities, and support. Few studies have reported on the experiences of self-management for patients with T2DM to reach and sustain glycemic control. This study used a qualitative descriptive design. Semistructured interviews were conducted with 13 patients receiving care at a diabetic clinic at a major health-care system in New York City. An interview guide was developed based on diabetes self-management which guided the interviews. All data were analyzed using qualitative content analysis. Initially, three themes that describe each component of diabetes mellitus self-management (DMSM) and impact the patients' reaching the desired outcome were identified: acceptance of knowledge, motivation for skills and abilities, and variability and vulnerability of support. Further analysis of the three themes led to the identification of an overarching, theme: loss of self. This overarching theme helped to explain the stages of grief illustrated across the themes in the participants DMSM experiences. The participants in this study identified loss of self, and the accompanying grief and grieving process related to the loss of self in response to their T2DM diagnosis. Participants were "stuck" in a stage of loss of self, which presented challenges to acceptance of their diagnosis, barriers to DMSM, and optimizing glycemic control.

Evidence-Based Practice Beliefs and Implementation in Doctor of Nursing Practice Students.

BACKGROUND: Doctors of Nursing Practice focus on leadership in evidence-based practice (EBP). EBP is influenced by one's beliefs in and implementation of EBP. Little is known to date about the EBP beliefs and implementation of Doctor of Nursing Practice students and outcomes of Doctor of Nursing Practice education. AIMS: Guided by the Advancing Research and Clinical practice through close Collaboration (ARCC) Model, the Evidence-Based Practice Beliefs (EBPB) and Implementation (EBPI) tools were used to assess the impact of EBP as a program pillar, curricular thread, and content area on EBPB and EBPI of Doctor of Nursing Practice-Family Nurse Practitioner students. METHODS: Five cohorts who completed the same curriculum were studied. Fifty-four of the 89 students across the five cohorts began and completed the study. RESULTS: Paired t-test for group effects showed statistical significance from pre- to post-measure in students overall EBPB, t = 4.4 (52), p < .001, and EBPI, t = 8.4 (52), p < .001. A large effect size of .75 standard deviation (SD) gain above the mean for EBPB, and a very large effect size of 1 SD gain above the mean for EBPI were observed. Repeated measures ANOVA showed that all cohorts made gains across the curriculum. Effect sizes for EBPB ranged from .25 to 1 SD above the mean, and .75 to 1.5 for EBPI. LINKING EVIDENCE TO ACTION: DNP students who are educated to be EBP leaders must have a curriculum that supports them in the knowledge and skill-set needed to translate evidence into practice. The ARCC Model can guide faculty in EBP curriculum development. EBPB and EBPI are valid and reliable measures to assess for gains across a curriculum. Through educational outcomes, educators can assess desired student outcomes for EBP across a curriculum and can build an evidence base for ongoing curriculum development.

An Enhanced Cultural Competence Curriculum and Changes in Transcultural Self-Efficacy in Doctor of Nursing Practice Students.

PURPOSE: The Doctor of Nursing Practice (DNP) degree is the most advanced clinical leadership role in nursing. Curricula prepare these students to design, implement, evaluate, and continuously improve high-quality culturally specific health care delivery and outcomes. DESIGN: Guided by the cultural competence and confidence model, the Transcultural Self-Efficacy Tool was used to assess the impact of an enhanced cultural competence curriculum on transcultural self-efficacy perceptions of DNP students ( n = 54). METHOD: The study used a pre-post paired t test, nonexperimental design. FINDINGS: A significant gain from pre- to postmeasure in students' overall transcultural self-efficacy was demonstrated. DISCUSSION: Changes in DNP students' transcultural self-efficacy were identified after completing an enhanced cultural competence curriculum. CONCLUSIONS: Transcultural self-efficacy may be influenced by formal education and learning experiences of DNP students. IMPLICATION FOR PRACTICE: Educational outcomes research can demonstrate the impact of a DNP programs curriculum on meeting national and professional goals for culturally competent nursing practice.

Effectiveness of school-based family asthma educational programs in quality of life and asthma exacerbations in asthmatic children aged five to 18: a systematic review.

BACKGROUND: Asthma is a common, chronic, non-communicable respiratory disease that affects millions of children worldwide. Asthma exacerbations can range from mild to severe and can have an unfavorable impact on the quality of life of children and their caregivers. Asthma exacerbations often result in absenteeism from school or work, activity intolerance and emergency hospital visits. One strategy to address this health issue in an attempt to improve health outcomes is school-based asthma educational programs. A review of the literature revealed that previous systematic reviews have examined similar topics on the effectiveness of school-based asthma educational programs that have included collaborative efforts between parents and schools. No systematic reviews were found that examined the effectiveness of school-based asthma educational programs that exclusively included children and their caregivers. Research has not been systematically reviewed to determine the effectiveness of a school-based asthma educational program within a familial context. OBJECTIVES: To identify the best available evidence on the effectiveness of school-based family asthma educational programs that exclusively included both children and caregivers on the quality of life and number of asthma exacerbations of children aged five to 18 years with a clinical diagnosis of asthma. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Children aged five to 18 years of any gender, race or ethnicity with a clinical diagnosis of asthma and their caregivers. TYPES OF INTERVENTION(S): School-based family asthma educational programs. TYPES OF STUDIES: Randomized controlled trials. OUTCOMES: Quality of life and the number of asthma exacerbations measured by either missed days from school or work, and/or physical activity intolerance, and/or emergency hospital visits. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies from inception of the database to August 21, 2015. METHODOLOGICAL QUALITY: Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity before inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION: Data were extracted from articles included in the review using the standardized data extraction tool from the Joanna Briggs Institute. The data extracted included specific details about the populations, interventions, study methods and outcomes of significance to the review question and its specific objectives. DATA SYNTHESIS: Due to the heterogeneity among the included studies, statistical pooling and meta-analysis was not possible. Results are presented in narrative form. RESULTS: Six studies examining the intervention were included in this review. All six of the included studies were randomized controlled trials (RCTs). All six studies compared the effects of school-based asthma education to no school-based asthma education/usual care on quality of life and number of asthma exacerbations. Three out of four RCTs showed that children who participated in school-based family asthma educational programs demonstrated a statistically significant improvement in overall quality of life (P < 0.05). All six studies showed improvement in the number of asthma exacerbations that resulted in one or all of the measured outcomes of either missed days from school or work, physical activity intolerance and/or decreased emergency hospital visits. CONCLUSION: School-based family asthma educational programs for children that include caregivers can have a positive impact on the quality of life and asthma management of children with asthma. Other outcomes that can be positively affected by school-based family asthma educational programs include absenteeism from school or work, physical activity intolerance and emergency hospital visits as result of asthma exacerbations.

The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admissions and re-admissions: a systematic review.

BACKGROUND: Patient satisfaction and hospital re-admission rates are the two major outcomes for measuring quality of healthcare delivery. Interdisciplinary collaboration, a concept that describes coordination of care between multiple healthcare professionals and patients and families to deliver the highest quality of care across settings, is fundamental to improving patient outcomes. Home hospice care is palliative in nature and is a critical segment of patient care. To date, no systematic review has been undertaken to determine the effectiveness of structured interdisciplinary collaboration in the home hospice setting in relation to patient satisfaction and hospital readmission. OBJECTIVE: The aim of the review was to synthesize the best available evidence on the effectiveness of structured interdisciplinary collaboration on patient satisfaction and hospital admission and re-admission rates for adults receiving home hospice services. INCLUSION CRITERIA: Adults, male and female (18 years old or older), receiving home hospice services or transitioning from hospital to home hospice servicesThe studies that evaluate interdisciplinary collaboration among the hospice team providing home hospice services in the home care settingsIn this review, randomized controlled trials and quasi-experimental studies were considered for inclusion.Patient satisfaction and all cause hospital admissions and re-admission rates. SEARCH STRATEGY: Published and unpublished literature in the English language was sought from the inception of the databases through August 15, 2014. The databases searched included: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Nursing & Allied Health Source, Health Source: Nursing/Academic Edition and ProQuest Health Management. A search of grey literature and any relevant homecare/hospice websites was also performed. RESULTS: There were no studies located that met the inclusion requirements of this review. There were no text or opinion pieces that were specific to structured interdisciplinary collaboration among the hospice team in home care settings on patient satisfaction and hospital readmission. CONCLUSION: There is currently no evidence available to determine the effectiveness of structured interdisciplinary collaboration among hospice teams in home care settings in regard to patient satisfaction and hospital readmission. IMPLICATIONS FOR PRACTICE: No conclusive recommendations can be made regarding the effectiveness of structured interdisciplinary collaboration among home hospice teams in home care settings in regard to patient satisfaction and hospital readmission. IMPLICATIONS FOR RESEARCH: Quantitative and qualitative research studies are urgently required to determine the effectiveness of structured interdisciplinary collaboration among home hospice teams in home care settings in regard to patient satisfaction and hospital readmission.

Effectiveness of Child Advocacy Centers and the multidisciplinary team approach on prosecution rates of alleged sex offenders and satisfaction of non-offending caregivers with allegations of child sexual abuse: a systematic review.

BACKGROUND: Child sexual abuse is a multifaceted issue that negatively affects the lives of millions of children worldwide. These children suffer numerous medical and psychological long-term adverse effects both in childhood and adulthood. It is imperative to implement evidence- based interventions for the investigation of this crime. The use of Child Advocacy Centers and the multidisciplinary team approach may improve the investigation of child sexual abuse. OBJECTIVE: To evaluate the effectiveness of Child Advocacy Centers and the multidisciplinary team approach on prosecution rates of alleged sex offenders and satisfaction of non-offending caregivers of children less than 18 years of age, with allegations of child sexual abuse. TYPES OF PARTICIPANTS: Children under 18 years, of any race, ethnicity or gender with allegations of child sexual abuse. Other participants included in this review are non-offending caregivers of children with allegations of child sexual abuse, and alleged sex offenders. Type of intervention : The use of Child Advocacy Centers and the multidisciplinary team approach on child sexual abuse investigations. Types of outcomes : Prosecution rates of alleged sex offenders and the satisfaction of non-offending caregivers of children with allegations of child sexual abuse. Types of studies: This review includes quasi-experimental and descriptive studies. SEARCH STRATEGY: The search strategy aimed to find published and unpublished articles in the English language published from 1985 through April 2015 for inclusion. The databases searched include: PubMed, CINAHL, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Health Source: Nursing/Academic Edition, Criminal Justice Periodicals, ProQuest Dissertations & Theses and Criminal Justice Collections. An additional grey literature search was conducted. METHODOLOGICAL QUALITY: Two reviewers evaluated the included studies for methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION: Data were extracted using standardized data extraction instruments from the Joanna Briggs Institute. DATA SYNTHESIS: Due to heterogeneity between the included studies, statistical meta-analysis was not possible. Results are presented in a narrative form. CONCLUSIONS: The use of Child Advocacy Centers and the multidisciplinary team approach in child sexual abuse investigation may have positive benefits in increasing non-offending caregivers' satisfaction and prosecution rates of alleged sex offenders. IMPLICATIONS FOR PRACTICE: Utilization of Child Advocacy Centers and the multidisciplinary team approach for child sexual abuse investigations may be beneficial in improving prosecution rates and the experiences of families involved. The use of satisfaction surveys for non-offending caregivers may be an effective tool to evaluate the satisfaction with services rendered by Child Advocacy Centers. Findings from this review may help to guide reforms. It is hoped that client satisfaction may lead to or improve utilization of services important for the healing process of victims of abuse. Child Advocacy Center multidisciplinary team interventions may improve prosecution rates and satisfaction of non-offending caregiver' in children less than 18 years of age with allegations of child sexual abuse (Grade B). When available, children with allegations of child sexual abuse should be referred to Child Advocacy Centers for evaluation (Grade B). The use of non-offending caregiver satisfaction survey is recommended to evaluate the ongoing effectiveness of the Child Advocacy Centers multidisciplinary team approach. The quality improvement process will help measure the quality of care rendered by a Child Advocacy Centers and identify areas in need of improvement so a Child Advocacy Centers can continue to provide optimal care in the investigation of child sexual abuse while improving the utilization of services important for the healing process for victims of abuse (Grade B). IMPLICATIONS FOR RESEARCH: Future studies may consider interventions that include greater sample size and more diverse ethnic groups to promote generalizability of findings.

The effectiveness of school-based family asthma educational programs on the quality of life and number of asthma exacerbations of children aged five to 18 years diagnosed with asthma: a systematic review protocol.

REVIEW OBJECTIVE: The objective of this review is to identify the best available quantitative evidence related to the effectiveness of school-based family asthma educational programs on the quality of life and number of asthma exacerbations of children aged five to18 years with a diagnosis of asthma. BACKGROUND: Asthma is a serious public health issue globally and nationally. The World Health Organization (WHO) Global Asthma Report 2014 estimates that 334 million people worldwide currently suffer from asthma. In the United States, asthma currently affects about 25 million people. Although asthma can occur at any age, it most often begins early in life, and is the most common non-communicable disease among children. Approximately 14% of the world's children have asthma. In the United States, 7.1 million children have asthma. Globally, the burden of asthma, measured by disability and premature death, is greatest in children approaching adolescence (ages 10-14). Asthma is also a serious economic concern in primary health care worldwide. In the United States, the estimated total cost of asthma to society was US$56 billion in 2007, or US$3259 per person. In 2008 asthma caused 10.5 million missed days from school and 14.2 missed days from work for caregivers. The estimated total cost of loss of productivity resulting from missed school or work days is US$3.8 billion per year, and premature death US$2.1 billion per year. Globally, asthma ranks 14 in terms of disability adjusted life years (DALYs), which are the number of years lost to ill health, disability or death attributed to asthma. According to a 2011 European study, the estimated total cost of asthma was €19.3 billion among people aged 15 to 64 years. A study conducted in the Asia-Pacific region reported that the direct and indirect costs of asthma per person ranged from US$184 in Vietnam to US$1189in Hong Kong in 2000. A Canadian study showed that C$184 loss of productivity during one week was attributed to asthma in 2012. In Australia, AU$655 million was spent on asthma for 2008-09.Asthma is a chronic respiratory disease that affects millions of people of all ethnicities, ages and genders worldwide. The pathophysiology of asthma is multifaceted, and is characterized by restriction of airflow into and out of the lungs, airway inflammation with increased mucus production, and bronchial hyper-reactivity caused by exposure to environmental irritants and chemicals, often referred to as triggers, which in some cases are modifiable. Asthma triggers include respiratory infections, weather changes, stress, excitement, exercise and other physical activities, allergic hypersensitivity reactions, food additives, animal dander, dust mites, cockroaches, outdoor and indoor pollutants, certain medications and cigarette smoke. Asthma is characterized by recurrent, episodic, reversible symptoms often referred to as asthma exacerbations, or asthma attacks. Asthma symptoms include coughing, shortness of breath, chest tightness and wheezing that most frequently occur at night or in the early morning. Asthma symptoms vary in severity and frequency in affected individuals, and can occur several times a day or week. Asthma symptoms may be mild, moderate, or severe, and are classified according to presenting symptoms and quantitative measurements of lung function using a peak expiratory flow meter (PEF), or of forced expiratory volume in one second (FEV1). Asthma symptoms can be so severe that, if left untreated, death can occur.Exacerbations of asthma symptoms often result in school and work absenteeism, activity intolerance and emergency hospital visits for asthma. Nocturnal asthma exacerbations frequently cause sleeplessness, which may result in daytime fatigue. Asthma symptoms can interfere and disrupt activities of daily life, and can have an unfavorable impact on the quality of life for people with the disease, including children and their caregivers. For this review, quality of life represents how well the asthmatic child is able to manage symptoms of the disease and lead a normal healthy life. Caregiver refers to the primary person who takes care of a child with asthma. Family refers to the caregiver and the child.According to the United States Centers for Disease Control and Prevention (CDC), epidemiologists and clinical researchers concur that the burden of asthma is higher among children compared to adults. Asthma prevalence in children varies within and across countries. Asthma disparities also exist along ethnic and racial lines. The International Study of Asthma and Allergies in Childhood (ISAAC) quantified the prevalence of asthma symptoms of children from around the world. In the United States, non-Hispanic Black and Puerto Rican children have higher asthma prevalence compared to Caucasian children. Children from the Ivory Coast, Costa Rica and Wales have higher asthma prevalence compared to children from Kenya, Brazil and England respectively. Indigenous Australians, Aboriginal and Torres Strait Islander Australian children have a higher prevalence of asthma compared to non-Indigenous Australian children. The international prevalence of asthma prompted governments and communities to create initiatives and strategies to address this public health issue.The global burden of asthma led to the development of the Global Initiative for Asthma (GINA). Formed in 1993, in collaboration with theNational Heart, Lung, and Blood Institute, National Institutes of Health, United States of America and the WHO, GINA's goals include working with healthcare providers and public health officials worldwide to reduce asthma prevalence, morbidity and mortality. In an effort to increase public awareness of the global burden of asthma, GINA created World Asthma Day, which is held annually on the first Tuesday in May. The burden of asthma in the United States fostered the creation of the National Asthma Education and Prevention Program (NAEPP). This program is designed to raise awareness about asthma and the major public health concern it poses to society. In addition to conducting asthma prevention activities, NAEPP collaborates with other stakeholders to develop asthma educational programs for minority populations who are disproportionately affected by asthma. The program believes that adequate control of asthma, through modern treatment and educational programs, can be reinforced by the development of partnerships with caregivers, schools and healthcare providers. The NAEPP Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma (EPR-3), has a provision that specifies that asthma education programs for children should include their caregivers. Caregivers' involvement is crucial for achieving the goals of asthma management in children, which supports the interest of GINA and NAEPP to include caregivers in school-based asthma education programs for children. The guidelines recommend education for asthma management should occur at all points of care, including schools. According to the EPR-3, schools are ideal locations to facilitate asthma education programs because they provide access to large numbers of children in an environment in which they are accustomed to learning. The long term effects of these approaches are improved healthcare practices, reduced mortality and morbidity, and reduced costs of asthma care.Although there is no cure for asthma, research evidence has demonstrated that asthma symptoms can be well-controlled with the appropriate medications, adherence to treatment, avoidance of asthma triggers, and education about disease management. Research studies that have investigated the effectiveness of school-based asthma education programs that have included caregivers have demonstrated beneficial effects of these programs on the quality of life and disease management of children with asthma, versus no school-based family asthma education programs.A randomized controlled trial (RCT) conducted by Clark et al. that included 835 children and their parents examined the effects of comprehensive school-based asthma education programs on symptoms, grades and school absences, and parents' asthma management practices. The interventions consisted of six components for children, their parents, classmates and school personnel. One of the six components included "Open Airways for Schools" disease management training for children, which also included handouts and homework for the parents. One of the five interventions for the parents included school fairs with asthma care questions and answers sessions to discuss the frequency and type of asthma symptoms of their children. Results of this study demonstrated that 24 months post intervention, children from the intervention groups had better disease management, which included improved control of daytime and nighttime symptoms, and reduced absences from school and work related to asthma exacerbations, compared to the children from the control group.In another study, Bruzzese et al. conducted a pilot RCT that included 24 families. Each family consisted of an asthmatic child and a caregiver. The study examined the effects of a two-month, school-based asthma education program. The interventions consisted of six interactive 75-minute group sessions for students, held once a week for six weeks, and five 90-minute group sessions for caregivers, held once a week. The student sessions were led by a developmental psychologist, and one of the lesson topics included prevention and management of asthma. The group sessions for caregivers were led by a clinical psychologist, and one of the lesson topics included asthma self-management of their children. The interventions resulted in positive short term changes in family relations and an overall improved health status for the children. (ABSTRACT TRUNCATED)

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.

A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure.

BACKGROUND: Readmission rates for patients with heart failure are a major concern for hospitals worldwide. The importance of patient education and a structured care plan to ease the transition from hospital to home has been the focus of many intervention strategies to reduce readmission rates. The use of transitioning of care plans is believed to improve medication reconciliation, communication, patient education, and follow-up. To date, the evidence has not been systematically evaluated to support the effectiveness of a nurse coordinated transitioning of care for patients with heart failure in reducing readmission rates. OBJECTIVE: The objective of the systematic review was to identify the best available evidence on the effectiveness of nurse coordinated transitioning of care between hospital and home on hospital readmission rates for all causes in adult patients hospitalised with heart failure. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies in the English language from January 1975 through July 2010. A search of MEDLINE, CINAHL, PsycINFO, Healthsource Nursing/academic edition, EMBASE, the Cochrane Library, and the Joanna Briggs Institute Library of Systematic Reviews was conducted followed by a reference search of relevant studies. The initial key words searched were: heart failure, readmission, and transitional care. INCLUSION CRITERIA: Randomised controlled trials that evaluated the effect of nurse coordinated transitioning of care from hospital to home in adult patients with heart failure on readmission rates were selected. The outcome was defined as hospital readmissions for all causes following an initial admission for heart failure. DATA COLLECTION AND ANALYSIS: Studies selected for retrieval were critically evaluated by two independent reviewers for methodological validity using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data were extracted and analysed using the JBI-MAStARI program. RESULTS: A total of 16 randomised controlled studies were included. Ten of the 16 studies included in the review show that a nurse led transitioning of care intervention can reduce the rate of readmission for patients with heart failure. Interventions utilising home visits, or home visits coupled with telephone follow-up, show a more favourable reduction in readmission rates. CONCLUSIONS: Reduced readmissions occur when transitioning of care interventions are carried out by a heart failure trained nurse who conducts at least one home visit and follows the patient at least weekly for a minimum of 30 days post discharge with either additional home visits or telephone contact. IMPLICATIONS FOR PRACTICE: This review supports the development of a nurse coordinated transitioning of care plan which will require improvements in communication, in addition to changes in health policy and payment systems that align incentives and performance measures in caring for patients with heart failure. IMPLICATIONS FOR RESEARCH: Future research should evaluate the effect of the intensity and duration of the transitioning of care intervention on readmission rates in a large randomised control trial on an adult population with heart failure to determine the ideal frequency and duration of the post discharge interventions.

Strategies for learning evidence-based practice: critically appraising clinical practice guidelines.

Nurse educators have a mandate to educate our students about using an evidence-based practice approach to clinical decision making. At the Lienhard School of Nursing, Pace University, faculty have successfully integrated evidence-based practice into the family nurse practitioner curriculum. This article describes one teaching-learning strategy to help students learn how to critically appraise clinical practice guidelines using the AGREE instrument. There are several steps to the learning exercise: completing preparatory reading, obtaining the guideline that forms the focus of the assignment, working as teams, using the AGREE tool to assess the guideline's validity, and reporting team findings to the entire class. Students have found this learning activity helpful in preparing them for clinical practice.