Development and Validation of a Multidimensional Short Version Zarit Burden Interview (ZBI-9) for Caregivers of Persons With Cognitive Impairment.

BACKGROUND: There is a lack of appreciation of the full dimensionality of the original 22-item Zarit Burden Interview (ZBI) in the development of short versions. Existing short versions are premised upon a 1-factor or 2-factor structure or statistical techniques for item selection. Thus, there is a need for ZBI short versions that considers the multidimensional constructs of role strain, personal strain, and worry about performance (WaP) during item selection to provide a more holistic and comprehensive evaluation. PURPOSE: To develop and validate a short version of ZBI through a combined quantitative and qualitative approach that incorporates the validated 4-factor structure of role strain demands; role strain-control; personal strain, and WaP. PATIENTS: We studied 202 caregivers of patients with dementia (84.2%) or mild cognitive impairment (15.8%) attending a memory clinic in Singapore. METHODS: Confirmatory factor analysis and qualitative considerations from expert consensus were used for item selection. Confirmatory factor analysis fit statistics support the 4-factor structure. The 9-item ZBI-9 showed good internal consistency (Cronbach's α=0.87) and convergent validity with anxiety and depression (Pearson correlation: Hospital Anxiety and Depression sub-scales, r≥0.56, P <0.001; ZBI- 22, r=0.95, P <0.001). Using a cut-off score of ≥13, ZBI-9 displayed good discriminatory ability for depressive symptoms (area under curve=0.79, P <0.001; sensitivity=70%, specificity=75%). The ZBI-9 also displayed comparable performance to the 22-item full version and three 12-item short versions. CONCLUSION: The ZBI-9 is a multidimensional short-version assessment tool for caregivers of persons with dementia and mild cognitive impairment that is reliable, valid, and discriminates depressive symptoms.

The systemic challenges of non-palliative care professionals caring for end-of-life patients: A lived experience study.

OBJECTIVES: The aims of this study are to identify the challenges faced by non-palliative care professionals (NPCPs) in caring for end-of-life patients; determine how these challenges interact with and influence each other systemically; and advance the theories and practices for supporting NPCPs in the provision of quality end-of-life care beyond the boundaries of palliative medicine. METHODS: A constructivist phenomenological research design with an Interpretive-Systemic Framework of inquiry was adopted. Thirty-five physicians, 35 nurses, and 35 Medical Social Workers who play critical roles in caring for end-of-life patients and belonging to the 9 major medical disciplines of Cardiology, Geriatric, Intensive Care Medicine, Internal Medicine, Nephrology, Neurology, Oncology, Respiratory Medicine, and Surgery were recruited through purposive snowball sampling from 3 major public hospitals. RESULTS: Framework analysis revealed 5 themes and 17 subthemes that illuminate the individual, relational, cultural, institutional, and structural challenges that NPCPs faced in rendering end-of-life care. These challenges influence each other within the health-care ecosystem, serving to perpetuate or heighten care obstacles. SIGNIFICANCE OF RESULTS: This is the first known study exploring the systemic challenges of NPCPs spanning 9 major medical disciplines and encompassing 3 professional stakeholders responsible for the care for end-of-life patients, thus ensuring perspective inclusivity across the health-care system. Recommendations that consider the complexity of the interactions between these systemic challenges are presented in detail.

Applying the RE-AIM framework to evaluate a holistic caregiver-centric hospital-to-home programme: a feasibility study on Carer Matters.

BACKGROUND: Prolonged caregiving of an older adult can cause family caregivers to be overwhelmed, potentially affecting the well-being of both the caregivers and their care-recipients. Carer Matters is a holistic hospital-to-home programme, centred on caregivers' needs as their care-recipients transit from hospital to home. The programme was piloted to support caregivers through caregivers needs assessment, tailored resources, tele-support, training courses, and community support network. This study aimed to examine the feasibility of Carer Matters in a tertiary hospital in Singapore. METHODS: This feasibility study was conducted on the pilot implementation from January to December 2021, during the Covid-19 pandemic. It adopted the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The study highlighted quantitative data collected from key process indicators, such as number of caregivers screened, assessed on their needs and provided with assistance. Additionally, qualitative data was collected from in-depth interviews with 51 stakeholders involved in the implementation to examine their perspectives and experiences. These included family caregivers, clinician caregiver support nurses, hospital leaders and community partners. RESULTS: During the pilot, 550 caregivers were enrolled. All caregivers received educational resources when they completed the needs assessment, while 69 of them who reported high burden were given tele-support and 252 attended our caregiver training courses. Despite initial recruitment challenges and obstacles to adoption, stakeholders interviewed found Carer Matters to be effective in providing caregivers with emotional support, knowledge and skills that improved their caregiving abilities, and reduced their sense of isolation and caregiving stress. Among caregivers, the training courses were effective with majority of caregivers agreeing that the courses addressed their needs (99%) and improved their knowledge of the relevant disease conditions (97%). Programme maintenance considered among stakeholders included strategies such as multipronged approach in recruiting caregivers and inviting caregiver advocates to share their experiences. CONCLUSION: This feasibility study highlights that Carer Matters is a valuable component to the ecosystem of support for family caregivers and their care recipients. Carer Matters extends the current patient-centric care model to a more holistic post-discharge continuity of care for both caregivers and their care-recipients, improving and maintaining their overall well-being to better allow transition from hospital-to home. TRIAL REGISTRATION: Feasibility Study of Project Carer Matters for Family Caregivers of Persons with Dementia (NCT number: NCT05205135 ).

Delivering a holistic hospital-to-home framework to support family caregivers of persons with dementia: Protocol for a feasibility study.

AIM: To evaluate the feasibility of the Carer Matters holistic hospital-to-home framework for family caregivers of people with dementia. BACKGROUND: Family caregivers of persons with dementia face a unique blend of stressors, from behavioural management to navigating the healthcare system. It is important to provide support and assistance to help caregivers cope to enable a sustained capacity for caregiving. This led to our establishment of Carer Matters, the first holistic caregiver-centric hospital-to-home framework of support for caregivers of persons with dementia in Singapore. METHODS: A multimethod study design will be used. We will assess the programme's feasibility and effectiveness using a Theory of Change approach, with findings synthesized using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Our study will involve six inpatient wards of a 1700-bedded acute care hospital over 12 months. Qualitative data will be obtained from interviews of stakeholders-caregivers, healthcare professionals, hospital leaders and community leaders. Quantitative data will be collected from programme logs, surveys and evaluation forms that capture self-reported levels of mastery, anxiety, burden, and depression. Funding has been approved by the Geriatric Education and Research Institute (GERI) Intramural Project Grant (GERI Ref: GERI1626) on May 2020 for this study (£103,659), to be conducted from December 2020 to June 2022. DISCUSSION: The stresses faced by caregivers of persons with dementia are wide and complex, necessitating a multi-faceted caregiver-oriented solution to provide sustained support, empower better management and continued capacity to care. Our study would provide insights on the feasibility and effectiveness of a caregiver-centric support programme stretching from the hospital into the community. IMPACT: These findings will provide a blueprint on how to implement a hospital-to-home patient-caregiver framework and provide policymakers, clinicians, and advocacy groups with critical insights on the potential patient-caregiver-healthcare system outcomes that can be derived.

Tenacious team, precarious patient: A phenomenological inquiry into interprofessional collaboration during ICU resuscitations.

AIMS: The study aims to explore the lived experiences of interprofessional collaboration among ICU nurses, doctors, and respiratory therapists in managing resuscitations in the ICUs. DESIGN: Descriptive phenomenological design, underpinned by Husserl's philosophy. METHODS: ICU nurses, doctors and respiratory therapists who have experience in managing resuscitations with the interprofessional team were recruited through purposive sampling from April to December 2019. Sixteen ICU professionals participated in individual, semi-structured, in-depth interviews which were audio recorded, and transcribed verbatim. Findings were analysed using Colaizzi's 7-step analysis. RESULTS: The essence of interprofessional collaboration during resuscitations can be described in four main themes. 'Ruminating about professional boundaries' signifies how ICU professionals acknowledged the roles and boundaries that surrounded their scope of practice during resuscitations. 'Rallying the interprofessional team' illustrates how the interprofessional team rapidly band together amongst the aid and hindrance of contextual enablers and inhibitors. 'Responding to interprofessional conflicts' depicts how intra- and interprofessional tensions can occur during resuscitations that can impact patient safety. 'Reaching collective leadership' proposes enhanced resuscitation care through the collective leadership of the interprofessional team. CONCLUSION: Resuscitations represent a precarious turn of events for the critically ill patient where the interprofessional team undergoes a cyclic sequence of teamwork and conflict while attempting to drive the resuscitation into a positive outcome. As ICU professionals attempt to optimise interprofessional collaboration during resuscitations, findings call for enhanced team training initiatives encompassing the interprofessional team, with an emphasis on collective leadership. IMPACT: ICU professionals experience of interprofessional collaboration during resuscitations is poorly understood. By understanding their lived experience, targeted interventions to improve interprofessional collaboration can be conceptualised and implemented. Findings will set pace for future evaluation research on interprofessional collaboration and patient outcomes during resuscitations.

Four of a kind: Salient caregiver archetypes to better understand the psychosocial needs and behavioral patterns of dementia caregivers in Singapore.

BACKGROUND: Family caregivers' lived experiences are often perceived as a homogenous entity, preventing effective identification of unique caregiving needs and appropriate support. Our study examined and classified the varying dementia caregiving experiences in an Asian setting, through establishing caregiver archetypes. METHODS: Secondary analysis of semi-structured interviews conducted with 16 dementia family caregivers in a Singapore hospital was performed. Thematic analysis and typological analysis were utilized. RESULTS: Four caregiver archetypes (Reluctant, Ambivalent, Enlightened, and Selfless) were identified: Reluctant caregivers possessed poor understanding of dementia and experienced immeasurable distress; Ambivalent caregivers carried mixed feelings towards caregiving and felt unsupported; Enlightened caregivers preserved care-recipients' dignity and accepted challenges with priority on sustainable care; Selfless caregivers were overly-devoted and enmeshed in the caregiver identity. CONCLUSION: Our findings are useful in providing a framework for: (1) rapid understanding of informal caregivers' varying needs, (2) targeted support in a holistic caregiver-centered manner.

The hand-brain-heart connection: ICU nurses' experience of managing patient safety during COVID-19.

BACKGROUND: COVID-19 has challenged critical care nursing through increased critical care service utilization. This may have a profound impact on intensive care unit (ICU) nurses' ability to maintain patient safety. However, the experiences of ICU nurses in managing patient safety during an infectious disease outbreak remains unexplored. AIMS AND OBJECTIVES: To explore ICU nurses' narratives in managing patient safety in the outbreak ICUs during the COVID-19 pandemic. DESIGN: A narrative inquiry design. METHODS: A purposive sample of 18 registered nurses who practiced in the outbreak ICUs during the COVID-19 pandemic were recruited between June and August 2020. Individual semi-structured interviews were conducted, transcribed verbatim, and narratively analysed. RESULTS: Findings reviewed an overarching anatomy-specific storyline of a 'hand-brain-heart' connection that describes nurses' experience with managing patient safety during the COVID-19 pandemic. Firstly, stories on 'the hands of clinical practice' revealed how critical care nursing is practiced and adapted by ICU nurses during the pandemic. In particular, ICU nurses banded together to safeguard patient safety by practicing critical care nursing with mastery. Secondly, stories on 'the brain of psychosocial wellness' highlights the tumultuous impact of COVID-19 on the nurses' psychosocial well-being and how nurses demonstrated resilience to continually uphold patient safety during the pandemic. Lastly, stories on 'the heart of nursing' drew upon the nurses' intrinsic professional nursing identity and values to safeguard patient safety. Specific patient tales further boosted the nurses' commitment to render safe nursing care during the pandemic. CONCLUSIONS: Through their stories, ICU nurses reported how they continually seek to uphold patient safety through clinical competence, resilience, and heightened nursing identity. RELEVANCE TO CLINICAL PRACTICE: ICU nurses require sustainable clinical resources and references such as clinical instructors, as well as visible psychosocial support channels, for ICU nurses to continue to uphold patient safety during COVID-19.

'From Expert to Novice', Perceptions of General Ward Nurses on Deployment to Outbreak Intensive Care Units during the COVID-19 Pandemic: A Qualitative Descriptive Study.

AIMS AND OBJECTIVES: This study aimed to explore the perceived preparedness and psychosocial well-being of general ward nurses prior to their deployment into the outbreak intensive care units (ICUs) during the COVID-19 pandemic. BACKGROUND: With the surge in COVID-19 cases requiring ICU care, non-ICU nurses maybe deployed into the ICUs. Having experienced through SARS, hospitals in Singapore instituted upskilling programs to secure general ward nurses' competency in providing critical care nursing. However, no studies have explored the perceptions of general ward nurses on deployment into the ICUs during the COVID-19 pandemic. DESIGN: Qualitative descriptive study. METHODS: The study was conducted at Singapore's epicentre of COVID-19 management. Five focus groups were conducted following purposive sampling of 30 general ward nurses identified for outbreak ICU deployment. Focus groups were audio-recorded, transcribed verbatim and data thematically analysed. This study was conducted and reported in accordance with the COREQ checklist. RESULTS: Three salient themes arose, exemplifying the transition from clinical experts in the general wards to practising novices in the outbreak ICUs. Firstly, 'Into the deep end of the pool' described general ward nurses' feelings of anxiety and stress associated with higher exposure risk and expanded responsibilities to nurse critically ill patients. Secondly, 'Preparing for "war"' illustrated deployed nurses' need for clear communication and essential critical care nursing training. Lastly, 'Call of duty' affirmed the nurses' personal and professional commitment to embrace this transition into the ICUs, and their desire for greater psychosocial support. CONCLUSION: The study findings highlight that though general ward nurses perceived their impending ICU deployment positively, they require ongoing support to facilitate a smoother transition. RELEVANCE TO CLINICAL PRACTICE: Findings provided an evidence base to improve the preparedness of general ward nurses deployed into the ICUs during the COVID-19 pandemic within key areas of training, information dissemination and psychosocial resilience.

Patient Activation and its Predictors in Hospitalized Older Adults in Singapore.

BACKGROUND: Patient activation is critical in hospitalized older adults preparing for discharge as it enhances their ability to self-care at home. Little is known about how person-centred care and demographic predictors could influence activation in Asian patients. AIMS: To explore patient activation and its predictors in hospitalized older adults in Singapore. METHODS: Multi-centre cross-sectional survey of hospitalized older adults. Multivariable analysis conducted with age, gender, education, socioeconomic status, functional dependency and perception of person-centred care as potential predictors to patient activation. RESULTS: 300 older adults were surveyed, 65% were at the top two levels of activation. Perception of person-centred nursing care was the strongest predictor with the largest effect on patient activation, (ß=0.22, b=3.48, 95% CI:1.70-5.26, p<0.001). Other predictors were age, education, income and independence in care. CONCLUSION: Our study highlights the importance of person-centred nursing care in raising patient activation in hospitalized older adults, enhancing their capacity to self-care.

The early stages of caregiving: A qualitative study into the caregiving experiences of Asian family caregivers of persons with newly-diagnosed dementia.

In Asian societies, the responsibility of caring for persons with dementia often falls upon an immediate family member. However, little attention has been paid to the early stages of caregiving, as well as their transition into a more experienced caregiver. Thus, a qualitative descriptive study involving a purposive sample of 11 main family caregivers of a person with newly diagnosed dementia was recruited from a tertiary hospital in Singapore. Three themes emerged from the data analysis: (1) Suspicions to seeking confirmation of dementia, (2) Grappling with dementia diagnosis, and (3) Making adjustments for the future. Areas of needs and support identified during the early caregiving journey suggest the need for caregivers to be prepared for the practical and emotional challenges. Unique to the Asian culture, our findings put forth the advocacy of engaging persons with dementia in the discussions of their long-term care and options.

Effectiveness of skin cleanser and protectant regimen on incontinence-associated dermatitis outcomes in acute care patients: A cluster randomised trial.

Skin cleansers and protectants protect skin from incontinent matter to reduce the risk of incontinence-associated dermatitis (IAD), but their effectiveness treating established IAD in the tropics is unknown. We conducted an open-label cluster randomised trial to compare the effectiveness of a combined regimen of (1) specialised skin cleansers with disposable body wipes and (2) either an acrylic terpolymer (T1) or zinc oxide (T2) skin protectant against disposable body wipes and zinc oxide protectant (control) in promoting IAD healing and reducing the risk of deterioration. Eighty-four patients were recruited in a tertiary hospital in Singapore between April 2019 and January 2020 (T1: n = 23; T2: n = 37; Control: n = 24). Although not statistically significant, patients treated with T1 and T2 were 1.5 times as likely to experience IAD healing within seven days compared with the control (P = .66). Healing was more pronounced in participants with skin loss treated with T1 or T2. No treatment was superior in preventing IAD deterioration, the prevalence of which remained small (8%-14%). While skin cleaning and protectants reduced the overall risk of skin deterioration, the addition of skin cleansers enhanced IAD healing within a short period, an important consideration for future research examining IAD treatment in acute care.

My health, myself: a qualitative study on motivations for effective chronic disease self-management among community dwelling adults.

BACKGROUND: Chronic diseases continue to be a significant cause of morbidity and mortality despite modifiable risk factors. This suggests that current primary healthcare provision needs to delve beyond patient education, to understand the motivators that drive patients to undertake chronic disease self-management. Understanding these motivations within the context of a multi-cultural community can facilitate tailored support for chronic disease self-management. OBJECTIVES: To explore the motivations behind effective chronic disease self-management in community dwelling adults in Singapore. METHODS: A qualitative descriptive study was carried out in five clinics in a large medical centre. Twelve participants who were assessed to be optimally managing their chronic diseases were recruited using purposive sampling. Individual in-depth interviews were conducted until data saturation, with data thematically analysed. RESULTS: Three salient themes emerged from the data. Firstly, 'Regaining self-control, avoiding complications' describes the participants' journey towards personal mastery in self-management, as well as a fear of debilitating complications resulting in their desire for good health. Secondly, 'Preserving social identities and roles' illustrates how participants yearn to maintain their pre-existing roles and functions through maintenance of their health. Finally, 'Accessing proximal support systems' highlights resources and supports surrounding the participants that encourage continued chronic disease self-management. Within each theme, specific motivators and challenges encountered by participants in their self-management journey were discussed. CONCLUSIONS: Findings can prompt primary healthcare providers to leverage on the patients' life goals and social roles in chronic disease self-management support. This may empower patients to engage in self-management and strengthen primary care provision.

Interprofessional collaboration during medical emergencies among doctors, nurses, and respiratory therapists in the intensive care unit: A phenomenological study protocol.

AIM: The aim of this study was to explore the lived experiences of interprofessional collaboration among nurses, doctors, and respiratory therapists during medical emergencies in the intensive care unit. DESIGN: Descriptive phenomenological study. METHOD: Participants will be recruited through purposive sampling with maximum variation across the ICUs in a tertiary hospital in Singapore. Guided by data saturation, data collection will include individual semi-structured interviews with ICU nurses, physicians, and respiratory therapist who have attended to medical emergencies such as cardiopulmonary arrest or difficult airway management in the ICUs. Interviews will be audio recorded, transcribed verbatim, and analysed via Colaizzi's descriptive phenomenology method. Research Ethics Committee approval was sought from the National Healthcare Group, Domain Specific Review Board (April 2019). The study is funded by the National Healthcare Group - Health Outcomes and Medical Education Research Grant (April 2019). The study is expected to be concluded by April 2020. DISCUSSION: Whilst interprofessional collaboration remains a major interest among nursing research, there is a paucity of evidence surrounding interprofessional collaboration in the specific context of medical emergencies in the ICUs. This is especially crucial as the failure of interprofessional collaboration during medical emergencies can be catastrophic to patient safety. Hence, this study will adopt a qualitative approach to contribute to the evidence base surrounding this lesser known phenomenon. The findings generated from this study will inform future team training initiatives, advance nursing leadership initiatives, and identify barriers and facilitators towards fostering greater interprofessional collaboration during medical emergencies. IMPACT: The evidence gained from this study contributes to the limited knowledge base of interprofessional collaboration during medical emergencies. Findings will have vast impact on nursing and interprofessional programs such as crisis leadership and management. The findings could also inform practice frameworks during medical emergencies to support interprofessional collaboration and optimize patient care.

Older patients' perception of engagement in functional self-care during hospitalization: A qualitative study.

BACKGROUND: Participation in functional self-care can delay functional decline during older adults' hospitalization. AIMS: To explore facilitators and barriers to older adults' participation in self-care during hospitalization, in an Asian setting. METHODS: Qualitative descriptive study using in-depth interviews, in a Singaporean hospital. Older adults were recruited using purposive sampling. Interviews were recorded and transcribed verbatim. Thematic analysis was used. RESULTS: Data saturation was reached with 17 participants. Three themes were identified: patient factors, healthcare provision and hospital environment. Facilitators included: patients' positive mindset, nurses' encouragement, and age-friendly environment. Barriers included: patients' and nurses' attitudes towards functional self-care, patients' and nurses' fear of inpatient falls, healthcare-imposed restrictions. Patients' notion of a 'good patient' can either facilitate or hinder their self-care engagement. CONCLUSION: This study offers insights from older adults in an Asian hospital setting. The findings can be used to develop strategies, care models, and facilities to promote functional self-care during hospitalization.

Caregiving experiences, coping strategies and needs of foreign domestic workers caring for older people.

BACKGROUND: In societies with ageing populations, foreign domestic workers are essential to provide care for older people in the community. Despite an increasing trend of employing foreign domestic workers as live-in caregivers to older people, limited research has been done to understand their caregiving experiences and coping strategies. AIMS AND OBJECTIVES: To explore the caregiving experiences and coping strategies of foreign domestic workers caring for older people in Singapore. DESIGN: Descriptive qualitative study. METHODS: This study was conducted in a large hospital in Singapore. Purposive sampling was used. Participants had to be able to converse in English and employed as foreign domestic workers to provide care to individuals aged 60 years and above, and needed assistance in at least one activity of daily living. Face-to-face in-depth interviews were conducted until data saturation was achieved. Interviews were audio-recorded and transcribed verbatim. Transcribed data were analysed using thematic analysis. RESULTS: We interviewed 11 participants. Their mean age was 35 years, and they provided caregiving for about 20 hours daily. Eleven subthemes were identified and were organised into four main themes. These themes were "Juggling with Caregiving and Additional Responsibilities," "Facing Challenges," "Coping strategies" and "Seeking support." CONCLUSIONS: Findings showed that many foreign domestic workers lacked the needed physical rest and support for them to recharge, and they were stressed caring for older people with behavioural issues. The findings highlighted the need for more physical rest, social support and caregiver training on behavioural management for foreign domestic workers. RELEVANCE TO CLINICAL PRACTICE: The findings could aid the understanding of the challenges and needs of foreign domestic workers and thereafter assist in development of relevant community nursing, social support and training on disruptive behavioural management for foreign domestic workers for them to effectively care for older people in the community.

Older patients' participation in physical activity during hospitalization: A qualitative study of ward nurses' perceptions in an Asian context.

Maximizing the functional ability of older patients through participation in physical activities during hospitalization could prevent functional decline. This study describes nurses' perceptions of facilitators and barriers to hospitalized older patients' physical activity participation in an acute Asian setting. An exploratory qualitative study employing thematic analysis was used. Semi-structured, audio recorded, focus group interviews on 30 nurses from a hospital in Singapore, were conducted until data saturation. Facilitators included seeing physical activity engagement as a fundamental facet of nursing, drawing social contracts and motivating patients, and engaging a multidisciplinary team approach. Barriers included psychological factors, falls culture, nurses' heavy workload and language impediment. Barriers more unique to the Asian culture were patients' adoption of sick-role behavior, reliance on domestic helpers and social suppositions on paid service. These findings can be used to develop culturally appropriate interventions to promote physical activity participation for patients in acute settings in Asia.

Crossing, Trudging and Settling: A phenomenological inquiry into lived experience of Asian family caregivers of older persons with dementia.

Throughout Asian societies, family members often adopt the role of caregiving for older persons, providing essential care for loved ones with dementia. To date, there has been limited insight into the lived experience and meaning ascribed to the journey of these caregivers. This descriptive phenomenological study aims to explore the lived experience of Asian family caregivers of persons with dementia. Semi-structured face-to-face interviews were conducted with 16 family members caring for aged persons with dementia. Interviews were audio-recorded and data analysed using Colaizzi's technique. Analysis revealed the essential structure of a caregiver's journey with three major transitions, namely: (1) Crossing the threshold from ordinary world into caregiving world, (2) Trudging on the road of trials and obstacles, and (3) Settling into a new normalcy. Understanding the lived experience of Asian caregivers can help clinicians in targeting relevant support and information, and prepare new caregivers for the demands of their role.

Nurse-Led Tele-Coaching on Modifiable Cardiovascular Risk Factors in People with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis.

BACKGROUND: Tele-coaching has been used by nurses as one of the accessible and sustainable interventions for individuals with type 2 diabetes mellitus. However, evidence has been lacking to demonstrate its effectiveness in mitigating the related cardiovascular risk factors. AIMS: To systematically evaluate the effectiveness of nurse-led tele-coaching on the modifiable cardiovascular risk factors (glycated hemoglobin, blood pressure, & lipid levels) among individuals with type 2 diabetes mellitus. METHODS: A systematic search of eight databases (Cochrane Library, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, PsycINFO, Web of Science, & ProQuest Dissertations and Theses) was conducted for randomized controlled trials of nurse-led tele-coaching for individuals with type 2 diabetes mellitus published in English up to October 30, 2018. A meta-analysis was conducted for the primary outcomes of the studies. RESULTS: Twelve randomized controlled trials were selected that included 3,030 participants. Results from the meta-analysis revealed statistically significant reductions for not only glycated hemoglobin (pooled mean difference = -1.23, 95% CI: -1.63 to -0.8, I2  = 0%, p < .00) but also systolic blood pressure (SBP; pooled mean difference = -2.22, 95% CI: -3.95 to -0.49, I2  = 0%, p < .01); such findings are supportive of the use of nurse-led tele-coaching on the primary outcome. LINKING EVIDENCE TO ACTION: Results from the meta-analyses have shown that nurse-led tele-coaching is an effective and accessible intervention that could improve the glycemic control and SBP among individuals with type 2 diabetes mellitus.

Dietary and fluid restriction perceptions of patients undergoing haemodialysis: an exploratory study.

AIMS AND OBJECTIVES: To explore the perspectives of patients undergoing haemodialysis in Singapore on an imposed dietary and fluid restriction regime. BACKGROUND: Adherence to prescribed dietary and fluid restriction constructs the fundamental basis of self-care with improved morbidity and mortality. However, most patients have struggled to adhere in this aspect. Existing studies have presented limited understanding on the facilitators and barriers of dietary and fluid adherence among haemodialysis patients. DESIGN: An exploratory qualitative study. METHODS: A purposive sample of 14 patients undergoing haemodialysis was recruited from a renal unit of a tertiary hospital in Singapore. Data were collected through face-to-face individual interviews and subsequently analysed by thematic analysis. RESULTS: Four themes emerged: (1) Pessimism, (2) Existing struggles, (3) Perceived quality of support, and (4) Immensity of self-discipline. CONCLUSIONS: The imposed dietary and fluid restriction is a constant struggle and a cause of suffering among haemodialysis patients in Singapore. Nonetheless, they are generally submissive to their fluid restrictions for the sake of survival or to meet the expectations of their loved ones. The imposed dietary restrictions are generally neglected. RELEVANCE TO CLINICAL PRACTICE: The findings from this study can provide useful information in reviewing existing educational strategies, policies and nursing care. This is especially important because most patients exhibit high reliance on healthcare professionals.

Femoral nerve blocks for acute postoperative pain after knee replacement surgery.

BACKGROUND: Total knee replacement (TKR) is a common and often painful operation. Femoral nerve block (FNB) is frequently used for postoperative analgesia. OBJECTIVES: To evaluate the benefits and risks of FNB used as a postoperative analgesic technique relative to other analgesic techniques among adults undergoing TKR. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 1, MEDLINE, EMBASE, CINAHL, Web of Science, dissertation abstracts and reference lists of included studies. The date of the last search was 31 January 2013. SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing FNB with no FNB (intravenous patient-controlled analgesia (PCA) opioid, epidural analgesia, local infiltration analgesia, and oral analgesia) in adults after TKR. We also included RCTs that compared continuous versus single-shot FNB. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection and data extraction. We undertook meta-analysis (random-effects model) and used relative risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardized mean differences (SMDs) for continuous outcomes. We interpreted SMDs according to rule of thumb where 0.2 or smaller represents a small effect, 0.5 a moderate effect and 0.8 or larger, a large effect. MAIN RESULTS: We included 45 eligible RCTs (2710 participants) from 47 publications; 20 RCTs had more than two allocation groups. A total of 29 RCTs compared FNB (with or without concurrent treatments including PCA opioid) versus PCA opioid, 10 RCTs compared FNB versus epidural, five RCTs compared FNB versus local infiltration analgesia, one RCT compared FNB versus oral analgesia and four RCTs compared continuous versus single-shot FNB. Most included RCTs were rated as low or unclear risk of bias for the aspects rated in the risk of bias assessment tool, except for the aspect of blinding. We rated 14 (31%) RCTs at high risk for both participant and assessor blinding and rated eight (18%) RCTs at high risk for one blinding aspect.Pain at rest and pain on movement were less for FNB (of any type) with or without a concurrent PCA opioid compared with PCA opioid alone during the first 72 hours post operation. Pooled results demonstrated a moderate effect of FNB for pain at rest at 24 hours (19 RCTs, 1066 participants, SMD -0.72, 95% CI -0.93 to -0.51, moderate-quality evidence) and a moderate to large effect for pain on movement at 24 hours (17 RCTs, 1017 participants, SMD -0.94, 95% CI -1.32 to -0.55, moderate-quality evidence). Pain was also less in each FNB subgroup: single-shot FNB, continuous FNB and continuous FNB + sciatic block, compared with PCA. FNB also was associated with lower opioid consumption (IV morphine equivalent) at 24 hours (20 RCTs, 1156 participants, MD -14.74 mg, 95% CI -18.68 to -10.81 mg, high-quality evidence) and at 48 hours (MD -14.53 mg, 95% CI -20.03 to -9.02 mg), lower risk of nausea and/or vomiting (RR 0.47, 95% CI 0.33 to 0.68, number needed to treat for an additional harmful outcome (NNTH) four, high-quality evidence), greater knee flexion (11 RCTs, 596 participants, MD 6.48 degrees, 95% CI 4.27 to 8.69 degrees, moderate-quality evidence) and greater patient satisfaction (four RCTs, 180 participants, SMD 1.06, 95% CI 0.74 to 1.38, low-quality evidence) compared with PCA.We could not demonstrate a difference in pain between FNB (any type) and epidural analgesia in the first 72 hours post operation, including pain at 24 hours at rest (six RCTs, 328 participants, SMD -0.05, 95% CI -0.43 to 0.32, moderate-quality evidence) and on movement (six RCTs, 317 participants, SMD 0.01, 95% CI -0.21 to 0.24, high-quality evidence). No difference was noted at 24 hours for opioid consumption (five RCTs, 341 participants, MD -4.35 mg, 95% CI -9.95 to 1.26 mg, high-quality evidence) or knee flexion (six RCTs, 328 participants, MD -1.65, 95% CI -5.14 to 1.84, high-quality evidence). However, FNB demonstrated lower risk of nausea/vomiting (four RCTs, 183 participants, RR 0.63, 95% CI 0.41 to 0.97, NNTH 8, moderate-quality evidence) and higher patient satisfaction (two RCTs, 120 participants, SMD 0.60, 95% CI 0.23 to 0.97, low-quality evidence), compared with epidural analgesia.Pooled results of four studies (216 participants) comparing FNB with local infiltration analgesia detected no difference in analgesic effects between the groups at 24 hours for pain at rest (SMD 0.06, 95% CI -0.61 to 0.72, moderate-quality evidence) or pain on movement (SMD 0.38, 95% CI -0.10 to 0.86, low-quality evidence). Only one included RCT compared FNB with oral analgesia. We considered this evidence insufficient to allow judgement of the effects of FNB compared with oral analgesia.Continuous FNB provided less pain compared with single-shot FNB (four RCTs, 272 participants) at 24 hours at rest (SMD -0.62, 95% CI -1.17 to -0.07, moderate-quality evidence) and on movement (SMD -0.42, 95% CI -0.67 to -0.17, high-quality evidence). Continuous FNB also demonstrated lower opioid consumption compared with single-shot FNB at 24 hours (three RCTs, 236 participants, MD -13.81 mg, 95% CI -23.27 to -4.35 mg, moderate-quality evidence).Generally, the meta-analyses demonstrated considerable statistical heterogeneity, with type of FNB, allocation concealment and blinding of participants, personnel and outcome assessors reducing heterogeneity in the analyses. Available evidence was insufficient to allow determination of the comparative safety of the various analgesic techniques. Few RCTs reported on serious adverse effects such as neurological injury, postoperative falls or thrombotic events. AUTHORS' CONCLUSIONS: Following TKR, FNB (with or without concurrent treatments including PCA opioid) provided more effective analgesia than PCA opioid alone, similar analgesia to epidural analgesia and less nausea/vomiting compared with PCA alone or epidural analgesia. The review also found that continuous FNB provided better analgesia compared with single-shot FNB. RCTs were insufficient to allow definitive conclusions on the comparison between FNB and local infiltration analgesia or oral analgesia.