Nurse-led care for the management of rheumatoid arthritis: a review of the global literature and proposed strategies for implementation in Africa and the Middle East.

Globally, increasing demand for rheumatology services has led to a greater reliance on non-physician healthcare professionals (HCPs), such as rheumatology nurse specialists, to deliver care as part of a multidisciplinary team. Across Africa and the Middle East (AfME), there remains a shortage of rheumatology HCPs, including rheumatology nurses, which presents a major challenge to the delivery of rheumatology services, and subsequently the treatment and management of conditions such as rheumatoid arthritis (RA). To further explore the importance of nurse-led care (NLC) for patients with RA and create a set of proposed strategies for the implementation of NLC in the AfME region, we used a modified Delphi technique. A review of the global literature was conducted using the PubMed search engine, with the most relevant publications selected. The findings were summarized and presented to the author group, which was composed of representatives from different countries and HCP disciplines. The authors also drew on their knowledge of the wider literature to provide context. Overall, results suggest that NLC is associated with improved patient perceptions of RA care, and equivalent or superior clinical and cost outcomes versus physician-led care in RA disease management. Expert commentary provided by the authors gives insights into the challenges of implementing nurse-led RA care. We further report practical proposed strategies for the development and implementation of NLC for patients with RA, specifically in the AfME region. These proposed strategies aim to act as a foundation for the introduction and development of NLC programs across the AfME region.

Work environment-related factors and nurses' health outcomes: a cross-sectional study in Lebanese hospitals.

BACKGROUND: Worldwide, studies show a relationship between nurses' health and some work environment factors; however, data on nurses' health and self-perceived workload and nursing task allocation are lacking, particularly for Lebanese nurses. We assessed the relationship of several work environment factors: overall workload and specific temporal, physical, mental, effort, frustration, and performance demands (NASA Task Load Index), staffing resources and adequacy and leadership (Practice Environment Scale of Nursing Work Index), teamwork climate (Safety Attitudes Questionnaire), and nursing task allocation (Basel Extent of Rationing of Nursing Care)) with self-reported musculoskeletal, cardiovascular, skin, and mental health diseases (Work Ability Index) and emotional exhaustion (Maslach Burnout Inventory) among Lebanese nurses. METHODS: A cross-sectional self-report survey was distributed to all 289 registered nurses (RNs) in the medical, surgical, and pediatric units in two Lebanese university-affiliated hospitals; 170 RNs had complete data. Adjusted multivariable logistic regression models were used to estimate the association between work environment factors and health outcomes. RESULTS: The most prevalent outcomes were musculoskeletal disease (69%), emotional exhaustion (59%), and mental health problems (56%); 70% of RNs had ≥2 and 35.29% had ≥4 co-occurring health problems. Musculoskeletal disease was associated with higher overall (OR = 1.36 (95%CI = 1.03, 1.80)), temporal (OR = 1.30 (95%CI = 1.09, 1.55)), and physical demands (OR = 1.20 (95%CI = 1.03, 1.49)), higher task allocation to RNs (OR = 1.11 (95%CI = 1.01, 1.23)) and lower teamwork climate (OR = 0.60 (95%CI = 0.36, 0.98). Higher odds of mental/emotional problems were associated with higher overall, temporal, frustration, and effort demands, and lower teamwork climate, performance satisfaction, and resources adequacy (increased odds ranging from 18 to 88%). Work environment indicators were associated with higher co-occurrence of health problems. CONCLUSIONS: Results show elevated health burden and co-morbidity among Lebanese RNs and highlight the value of comprehensive approaches that can simultaneously improve several work environment factors (namely self-perceived workload, teamwork,, resources, and nursing task allocation) to reduce this burden.

Trends and variability of implicit rationing of care across time and shifts in an acute care hospital: A longitudinal study.

BACKGROUND: Implicit rationing of nursing care is associated with work environment factors. Yet a deeper understanding of trends and variability is needed. AIMS: To explore the trends and variability of rationing of care per shift between individual nurses, services over time, and its relationship with work environment factors. METHODS: Longitudinal study including 1,329 responses from 90 nurses. Intraclass correlation coefficients (ICC) were computed to examine variability of rationing per shift between individual nurses, services, and data collection time; generalized linear mixed models were used to explore the relationship with work environment factors. RESULTS: Percentage of rationing of nursing activities exceeded 10% during day and night shifts. Significant variability in rationing items was observed between nurses, with ICCs ranging between 0.20 and 0.59 in day shifts, and between 0.35 and 0.85 in night shifts. Rationing of care was positively associated with nurses' self-perceived workload in both shifts, but not with patient-to-nurse ratios. CONCLUSION: Most variability in rationing over time was explained by the individual. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and leaders need to develop and implement educational programs on implicit rationing of nursing care to strengthening nurses' skills related to decision-making, prioritization and time management.

A longitudinal study on implicit rationing of nursing care among Lebanese patients - Study protocol.

AIM: To gain an in-depth understanding of the variations and trends of implicit rationing of nursing care, of its associated factors and of its relation to with nurse and patient outcomes. BACKGROUND: Maintaining and improving the quality of nursing care and patient safety have been the focus of health services researchers over the last decade. Cross-sectional studies have showed the magnitude of implicit rationing of nursing care and its associations with negative patient and nurse outcomes. DESIGN: Observational longitudinal study. METHOD: Two-year funded study (between 2018-2020), including a sample of 317 Registered Nurses working on 19 units in two large Lebanese urban hospitals. The study included a cross-sectional baseline survey followed by multiple follow-up assessments over 90 days. The repeated measurements on each of the units include repeated surveys on nurses' rationing of care, hospital administration reported nurse-sensitive indicators, nurse staffing levels, and patient mortality data. DISCUSSION: The study results will describe variations and trends of implicit rationing of nursing care in hospital units over time and whether and which elements of the nurses' work environment are associated with these variations. Data will inform on the impact of implicit rationing of care on patient and nurse outcomes. These data are needed to advance future planning and interventional research to efficiently reduce rationing of nursing care and improve the quality of care. IMPACT: Generating new knowledge (variations and trends) on the association between rationing of care and other element of nurses' work environment and nurse and patient outcomes.

A mapping of nursing and midwifery research in the Eastern Mediterranean Region, 2006-2016.

BACKGROUND: Nurses and midwives constitute the largest group of health care professionals globally. Challenges to these professions make it difficult to set regional priorities for policies and research development. AIMS: The purpose of this study was to map current nursing and midwifery research in the Eastern Mediterranean Region. METHODS: Nursing and midwifery schools were identified by each country's nursing and midwifery board and ministries of education/public health. Information was collected for the years 2006-2016 via surveys, websites, Google scholar and expert informants. RESULTS: A total of 299 schools were identified and 241 of these were contacted; 85 completed surveys from 15 countries were analysed. A total of 1116 research topics covered by 3287 publications were identified, many of which were clustered into the five World Health Organization priority areas. The least developed areas were disaster management and emergency preparedness. CONCLUSIONS: This study provides a database of nursing and midwifery research in the Region. Some gaps were identified based on the research priorities of the Region, but these gaps could be addressed by close collaboration among local researchers.

PALLIATIVE CARE FOR OLDER ADULTS: STATE OF THE ART IN LEBANON.

Palliative care (PC) for older adults constitutes an important human rights challenge and a major public health care priority due to the aging of the population and the lack of health care services addressing the needs of the older people. In Lebanon, the surge in the number of older people with complex needs is unmatched by any increase in the services offered to them. PC in Lebanon is still under- developed and is subject to a number of challenges. These challenges are alarming and must be overcome through introducing health care providers to basic PC principles as recommended by the National Committee for Pain Relief and Palliative Care (NCPRPC).

Surviving testicular cancer: the Lebanese lived experience.

BACKGROUND: Testicular cancer is thought to have a great impact on its survivors, yet there has been limited literature on the topic globally and no literature on the topic in Lebanon and the Arab region. OBJECTIVE: The purpose of this study was to explore the lived experience of Lebanese testicular cancer survivors and gain an in-depth understanding of the psychosexual aspect of their experience. METHODS: A hermeneutic phenomenological approach with semistructured digitally recorded interviews and observational field notes was utilized. A purposive sample of Lebanese testicular cancer survivors, aged between 18 and 50 years, in remission for at least 3 years, and willing to share personal information was recruited. Interviews were transcribed verbatim in Arabic. Data saturation was achieved at the seventh interview; a total of eight informants were recruited. The opening question was, "Tell me about your life since you got treated for testicular cancer," and was followed by probing questions. Two to three weeks after the initial interview, informants were called to validate the investigators' primary analysis. RESULTS: Six core themes emerged: cancer perception in the Lebanese culture; "do not show, do not tell"; cancer experience is a turning point; fertility, manhood, and relationships; coping with cancer; and preserved aspects of life. DISCUSSION: The findings provide an in-depth understanding of the experience of Lebanese testicular cancer survivors with a focus on the psychosexual aspect of this experience. The results suggest the need to educate patients about testicular cancer and its effect on their fertility.

Quality of palliative care in children with cancer in Lebanon.

OBJECTIVE: There is a growing research interest in pediatric palliative care in Lebanon. To date the existing studies have focused on the perspective of parents of children with cancer. The purpose of this study was to evaluate the quality of life (QoL), symptom prevalence and management, functional ability, and the quality of care among children with cancer at the Children's Cancer Center of Lebanon. METHODS: A cross-sectional survey design was used. A convenience sample of 85 patients on therapy aged 7 to 18 years participated in the study between 2010 and 2011. Using face to face interviews, a combination of four instruments were administered in Arabic. RESULTS: The mean age of the participants was 12.5 years, with the majority having leukemia. Overall, the children had satisfactory health-related QoL, with the exception of the nausea and worry subscales, had no limitations in functional abilities, and were satisfied with the care that they received. In children between 7 to 12 years, the most common symptoms were lack of appetite, pain, and nausea, while adolescents between 13 to 18 years experienced lack of energy, irritability, and pain. Pain and nausea were the most frequently treated symptoms. CONCLUSION: Although the participants reported satisfactory QoL, yet symptom management was inadequate and mainly focused on treating the physical symptoms. It is recommended to provide both pharmacological and psychological interventions in order to alleviate symptom burden and hence improve QoL in children with cancer.

Predictors of quality of life in older adult patients in Lebanon: a cross sectional study.

BACKGROUND: The older adult population in Lebanon is anticipated to double by year 2030. The health care resources available for the geriatric population is limited and there is much reliance on the social support of family caregivers. Older adults have double the rate of hospital utilization in comparison to the regular Lebanese population where 4.5% are hospitalized more than once per year. This study aims to describe self-reported quality of life (QoL) among hospitalized patients "with palliative care needs" and investigate the relationship with its four health domains. METHODS: An observational survey design with a convenience sample of 203 hospitalized patients with palliative care needs above 65 years of age were recruited from three hospitals. Descriptive statistics and regression analysis were used to describe and determine the association between health domains and QoL. RESULTS: Mean age of participants was 78.5 years with the majority being male and married. Participants reported low overall QoL with a mean score of 35.43 (SD =23.45). Anxiety and depression were common findings. "Worrying" (83%), "Feeling nervous" (80%), "Feeling sad" (76%) were dominant psychological symptoms. Low scores were also observed for physical, role and social functioning. Participants suffered from lack of energy (94%), pain (72%), difficulty sleeping (73%) and shortness of breath (64%). CONCLUSIONS: The findings suggest that QoL in the aging Lebanese population is burdened with physical and psychological symptoms. A comprehensive approach that attends to the psychosocial as well as the physical problems in older adults with early integration of symptom management and palliation could improve QoL.

Quality of palliative care. Perspective of Lebanese patients with cancer.

The number of cancer patients in Lebanon is increasing, and patients are living longer due to early detection and enhanced methods of treatment. The purpose of this study was to evaluate the quality of life, symptom management, functional ability, and the quality of palliative care in adult Lebanese cancer patients at the American University of Beirut-Medical Center. A cross sectional survey design was used. A number of internationally validated instruments were translated into Arabic. A total of 200 cancer patients participated in the study; the majority was female with breast cancer and mean age 54. The cognitive functioning domain of the Quality of Life scale was found to have the highest score and social functioning the lowest. The most prevalent symptom was lack of energy and the least prevalent was shortness of breath. Nausea and pain were the symptoms mostly treated. In conclusion, this sample reported a fair quality of life and social functioning with high prevalence of physical and psychological symptoms. Inadequate symptom management was reported especially for the psychological symptoms. Participants reported a satisfactory level with the quality of care. Based on these results, providing adequate symptom management and social support to Lebanese cancer patients is highly recommended.

Pediatric palliative care through the eyes of healthcare professionals, parents and communities: a narrative review.

BACKGROUND AND OBJECTIVE: Pediatric palliative care is a holistic approach that aims to enhance the quality of life of seriously ill children and their families. Despite the documented benefits, many barriers challenge early integration of such care. The lack of knowledge and negative attitudes and beliefs toward pediatric palliative care are often cited among these barriers. This narrative review aims to summarize the existing literature regarding knowledge, attitudes and beliefs toward pediatric palliative care among healthcare professionals, parents and communities. METHODS: Four databases were searched: Medline, EMBASE, PsychINFO, and Cumulative Index to Nursing and Allied Health Literature Complete. The search strategy combined Medical Subject Headings, terms and keywords using Boolean operators to retrieve references addressing each concept of interest within the English literature. The initial search was conducted in August 2020 and updated in August 2021. No date limits were set. Two independent authors screened the retrieved papers for eligibility. KEY CONTENT AND FINDINGS: The majority of the 60 retrieved articles (n=49, 82%) were derived from high-income countries, with almost half of them from the United States. The references from developing countries were scattered across continents. The perspectives of healthcare professionals were more extensively explored compared to parents and community samples. Reports describe confusion between pediatric palliative care and end-of-life care. Yet, a positive attitude toward pediatric palliative care prevails whenever respondents possess accurate information about such care.

Repeated assessments and predictors of nurses' shift-specific perceived workload.

BACKGROUND: Workload perception is of interest to researchers and policymakers as it captures subjective assessments of nurses' workload which has implications for staffing and patient outcomes. AIMS: We aimed to describe repeated assessments of nurses' perceived workload among registered nurses (RNs) in day and night shifts and to examine the association of perceived workload with workdays, units, and nurse-staffing. METHODS: Repeated data on the indictors of interest were collected from 90 RNs across 91 shifts in a Lebanese acute-care hospital. Perceived workload was assessed using the NASA-Task-Load Index (NASA-TLX). Linear mixed-effect models were used for analysis. RESULTS: Mean perceived workload was high reaching 6.63 (95% confidence interval [CI] = 6.34, 6.92) in day and 5.90 (95% CI = 5.43, 6.36) in night shifts. In mixed-effect models, perceived workload was lower on weekends/holidays as compared to weekdays in day (ß = -.32; 95% CI = -0.53, -0.12) and night (ß = -.46; 95% CI = -0.85, -0.07) shifts. Higher perceived workload (ß = .19; 95% CI = 0.04, 0.33) was associated with higher patient-to-nurse ratio in the day but not night shifts. CONCLUSION: Repeated workload assessments support the presence of elevated perceived workload among RNs which is related to weekdays and higher patient-to-nurse ratio. Future investigations would benefit from better characterization of workload particularities to address perceived burden and improve organizational and management decisions.

Variability, shift-specific workloads and rationed care predictors of work satisfaction among Registered nurses providing acute care: A longitudinal study.

AIMS: The aim of this study was to explore nurses' shift-work satisfaction variability across time and its shift-specific predictors: perceived workload, patient-to-nurse ratio and rationing of nursing care. DESIGN: Longitudinal study of 90 Registered nurses (N = 1,303 responses) in a Lebanese hospital over 91 days of data collection. METHODS: Intraclass correlation coefficients (ICCs) were computed to determine shift-work satisfaction variability between individual nurses and working-unit clusters. Generalized linear mixed models were used to explore the workloads and rationed care predictors of nurses' shift-work satisfaction separately for day and night shifts. RESULTS: Variability in shift-work satisfaction was noted between individual nurses in day (ICC = 0.43) and night shifts (ICC = 0.37), but not between medical/surgical units. Nurses satisfied with their shift-specific work were less probably to ration necessary nursing care (OR = 0.68; 95% CI = 0.60-0.77) in day shifts and to perceive high workload demands in both, day (OR = 0.29; 95% CI = 0.23-0.37) and night (OR = 0.29; 95% CI = 0.18-0.47) shifts. Monitoring and lowering workload demands while observing rationing of care is necessary to improve nurses' shift-work satisfaction.

Chronic pain: a review.

Chronic pain has been increasing in prevalence. It is considered the most underestimated health care problem impacting quality of life. A number of epidemiological studies conducted in different parts of the world, reported prevalence rates of chronic pain ranging from 12-80%. Chronic pain has detrimental effects on physical and mental health, daily activities, family relationships, employment, and economic well-being of the sufferers and family caregivers. Since the epidemiological studies about chronic pain in Lebanon are limited, the aim of this article is to help understand the magnitude of the problem and to depict strategies for the prevention and management of chronic pain. The article provides a review of the literature on the prevalence of chronic pain and the factors associated with it in adults.

Determinants of Self-Care in Patients With Heart Failure: Observations From a Developing Country in the Middle East.

Introduction: Self-care is recognized as a means for improving outcomes of heart failure (HF), yet studies have not addressed what predicts successful self-care in collectivist cultures like Lebanon. Methodology: Self-care was measured, using the Arabic Self-Care of HF index, in 100 participants with HF (76% males; mean age 67.59) recruited from a tertiary medical center. Results: Self-care was suboptimal, with mean scores of 67.26, 66.96, and 69.5 for self-care maintenance, management, and confidence. Better HF knowledge, social support, and self-care confidence and lower New York Heart Association score predicted better self-care maintenance. Better knowledge, social support, and self-care maintenance, no recent hospitalization, and being unemployed predicted better self-care confidence. Better self-care confidence, maintenance, and HF knowledge predicted better self-care management. Discussion: HF self-care in Lebanon is suboptimal. Nurses need to identify facilitators of and barriers to self-care particular to this population. Interventions targeting HF knowledge, confidence, and caregiver support are expected to improve self-care in Lebanese patients.

Palliative care in Lebanon: knowledge, attitudes and practices.

AIM: To determine the knowledge, attitudes, and practices of palliative care nurses in Lebanon. METHOD: Cross-sectional descriptive survey using self-administered questionnaire; 1873 nurses from 15 hospitals were included. RESULTS: Non-clinical nurses had better knowledge on the outcomes of palliative care than all other specialties. Oncology nurses had more favourable attitudes than other specialties with regard to informing patients about their diagnosis, patients having the right to 'do-not-resuscitate', involving patients in treatment choices, and respecting their wishes for alternative therapy. Surgical, acute critical care, and obstetric/gynaecology nurses had significantly more negative attitudes towards patients' and families' questions and concerns than other specialties. CONCLUSION: Formal education in palliative care and development of palliative care services are needed in Lebanon to provide quality care to terminally ill patients.

Perspectives on palliative care in Lebanon: knowledge, attitudes, and practices of medical and nursing specialties.

OBJECTIVE: Our objective was to determine the knowledge, attitudes, and practices of physicians and nurses on Palliative Care (PC) in Lebanon, across specialties. METHOD: We performed a cross-sectional descriptive survey using a self-administered questionnaire; the total number of completed and returned questionnaires was 868, giving a 23% response rate, including 74.31% nurses (645) and 25.69% physicians (223). RESULTS: Significant differences were found between medical and surgical nurses and physicians concerning their perceptions of patients' and families' outbursts, concerns, and questions. Knowledge scores were statistically associated with practice scores and degree. Practice scores were positively associated with continuing education in PC, exposure to terminally ill patients, and knowledge and attitude scores. Acute critical care and oncology were found to have lower practice scores than other specialties. SIGNIFICANCE OF RESULTS: Formal education in palliative care and development of palliative care services are very much needed in Lebanon to provide holistic care to terminally ill patients.

Quality of care, spirituality, relationships and finances in older adult palliative care patients in Lebanon.

BACKGROUND: Despite making up a big proportion of the world population, older adults received little palliative care services. Moreover, palliative quality of care provided to older adults has been shown to be poor. Adequate clinician communication, familial support, and religious/spiritual support have been identified as main factors in providing good quality of care. The purpose of our study on Lebanese older adult palliative care patients is to assess the quality of palliative care in terms of access to care, patient-clinician relationship, and clinician-clinician communication, assess the degree of spirituality/religiousness of patients and their sense of purpose, to explore patients' relationships including friendships and social support and to assess the degree of financial hardship during the illness. METHODS: An observational cross-sectional design was used in this study of hospitalized older adults in three major medical centers in Lebanon over a period of 2 years from 2015 to 2017. Key physicians from each of the three medical centers recruited participants into the study to obtain a convenience sample (N=203). Quality of care was measured using 20 selected items from the Needs at the End of life Screening Tool (NEST). RESULTS: Patients reported easy access to care expressed by low median item scores ranging from the lowest 1.0 pertaining to lack of a problematic doctor choice to the highest 3.0 for ease of securing a hospital bed. Difficulty expressing their feelings to their healthcare providers had an average median of 5.0 with other items on communication having higher medians. The sample considered themselves to be highly religious or spiritual with a median score of 9.0 and identified an inclination to be more religious or spiritual after their illness with a median of 7.0. Social support was found to be good and financial hardships had low median scores ranging from 3.0 to 5.0. CONCLUSIONS: Older adults receiving palliative care reported ease of access to medical care, average communication, good spiritual and social status and minimal financial hardships. The authors recommend integrating spiritual and social aspects into the patients' palliative care to improve quality of care and quality of life.

Pediatric palliative care. State of the art.

Advances in medicine have significantly reduced child mortality worldwide; however those caring for children with life-threatening medical conditions are usually committed to employing curative and life-prolonging treatments until death is at hand. This type of intensive care and attention can expose children and their families to unnecessary suffering, particularly if inadequate attention is paid to the children's physical and emotional distress. This review presents healthcare providers with the basic concepts of pediatric palliative care (PPC) available to assist them in the care of the child with life-threatening medical conditions. It defines PPC and the principles guiding it; it reviews the reasons behind PPC emphasizing developmental and epidemiological aspects of childhood death; it discusses the needs of children with life-threatening conditions and the needs of their families; and it examines PPC services available, and the obstacles and challenges faced in providing PPC.

Implementation of palliative care in Lebanon: past, present, and future.

The goal of palliative care (PC) is to relieve suffering. PC is an urgent humanitarian need worldwide for people with cancer and other chronic fatal diseases. PC in Lebanon has made some important strides in the last decade but it is still in its infancy. More attention needs to be given in the near future to the implementation of the recommendations already listed by previous meetings and workshops. In order to do so, it is necessary to change the legislative system in Lebanon in order to recognize and to integrate this new discipline. Education and training of health professionals in PC should be provided by medical and nursing schools throughout the country. Postgraduate education in medicine and nursing and ensuing certification should be made available. Ideally, PC services should be provided from the time of diagnosis of life-threatening illness, adapting to the increasing needs of cancer patients and their families as the disease progresses into the terminal phase. They should also provide support to families in their bereavement. It is as important and essential to involve policy makers in the development of pain relief and PC services and clinics which meet the needs of the population in Lebanon. Effective PC services should be integrated into the existing health system at all levels of care, especially community and home-based care. They involve the public and the private sector and are adapted to the specific cultural, social and economic setting. In order to respond to the cancer priority needs in a community and make the best use of scarce resources, PC services should be strategically linked to cancer prevention, early detection and treatment services. The time will come for Lebanon to form the National Council for Pain Relief and Palliative Care as an advocacy and coordination body for pain relief and PC in the near future. To that effect, we believe the future is near.