Apps for pain self-management of older people's arthritic pain, one size doesn't fit all: A qualitative study.

Introduction Arthritic pain is a major cause of illness and disability among older people. People living with arthritic pain carry out self-management activities to adequately manage their pain. As the trend of smartphone uptake continues to rise among older people, there are opportunities to explore the role of these devices in helping older people better manage their pain. Aim: To explore the attitudes and experiences of older people with chronic arthritic pain towards using an app for their pain selfmanagement. Methods A qualitative design using semi-structured interviews with community-dwelling older Australians living with arthritic pain (n = 16). Data was analyzed using thematic analysis. Results Four themes emerged from the data: (1) Apps are valuable self-management tool, but they do have the potential for harm; (2) A pain self-management app needs to strictly align with the user's needs; (3) Clinician's involvement is crucial when integrating an app into older people's pain selfmanagement regime; and (4) pain self-management app must be designed with enduser in mind. In addition, suggestions on how to make an app more useful and userfriendly were offered by the participants. Discussion While pain self-management apps have the potential to assist older people in their pain self-management process, this modality is not of interest to all older people. Adaptable apps that offer clinician input may be best placed to offer individual level relevance to older users. Future pain selfmanagement app development endeavors should adopt a co-design approach where older people are involved through all stages of design and development.

Apps for Older People's Pain Self-Management: Perspectives of Primary Care and Allied Health Clinicians.

BACKGROUND: Chronic arthritic pain is one of the major causes of physical suffering and disability among older people. Primary care and allied health clinicians use various approaches to help their older clients better manage their arthritic pain. The growing uptake of technology among older people offers the potential for clinicians to integrate an arthritic pain app into their patients' self-management plans. This study explored the perspectives of Australian primary care and allied health clinicians regarding the use of pain self-management apps to help their older patients/clients better manage their arthritic pain. METHODS: Qualitative design using a semistructured interview approach. Interviews were conducted via telephone with primary and allied health clinicians (N = 17) across Australia. RESULTS: The overarching theme underlying participants' views on integration of apps into older people's pain self-management strategy was that this approach is an idealistic but uniquely challenging endeavor. Four subthemes emerged, namely: 1) self-management apps are a potentially useful tool but require careful consideration; 2) clinicians' involvement is crucial yet potentially onerous; 3) no single app is right for every older person with arthritic pain; and 4) patient data access is beneficial, but caution is needed for real-time data access. DISCUSSION: The predominant clinician perspective of integrating apps into their older patients/clients' pain self-management strategies was that this approach is an idealistic but uniquely challenging endeavor. Apps were seen as having potential to support various aspects of patients' self-management behaviors; however, there were notable concerns with regards to the challenges inherent in this approach for both clinicians and older users (patients/clients).

The Self-Care of Heart Failure Index: A psychometric study.

BACKGROUND: The Self-Care of Heart Failure Index is an empirically tested instrument to measure self-care of heart failure patients across different populations and cultures. AIMS: To develop and evaluate the psychometric properties of the Nepali Self-Care of Heart Failure Index. DESIGN: This psychometric study used a cross-sectional, observational, study design to collect data. The study was guided and reported following the Strengthening the Reporting of Observational Studies in Epidemiology guideline. METHODS: To develop and culturally validate Nepali Self-Care of Heart Failure Index, a combination of the recommended methods for cross-cultural validation studies were applied such as translation, back translation, expert committee review of the translated version and validity/reliability testing. Face and content validity were ensured using expert review. Construct validity was examined using exploratory factor analysis and confirmatory factor analysis. Composite reliability scores were calculated for each sub-scale of the Nepali Self-Care of Heart Failure Index. RESULTS: A total of 221 heart failure patients in Nepal were enrolled in the study. Adequate face and content validity were ensured through expert review. Exploratory factor analysis and confirmatory factor analysis supported the original three-factor model. Although the three factors explained only 41% of the variance, confirmatory factor analysis fit indexes and error measures were found reasonable. The composite reliability coefficients for self-care maintenance, management and confidence scale were 0.6, 0.7 and 0.8, respectively. CONCLUSIONS: The Nepali Self-Care of Heart Failure Index is a theoretically based, culturally acceptable and appropriate instrument for use among Nepali heart failure patients. However, further studies are needed to refine its psychometric properties. RELEVANCE TO CLINICAL PRACTICE: Access to reliable, valid and culturally appropriate instruments is crucial in describing the state of the problem as well as for developing and evaluating tailored and targeted self-care practice interventions for Nepali patients living with heart failure.

Feasibility evaluation of a pain self-management app-based intervention among older people living with arthritic pain: study protocol.

BACKGROUND: Optimal management of chronic arthritic pain experienced by older adults involves applying active self-management strategies every day. Cost-effective and innovative strategies to help build older people's pain self-management capability are required. This study protocol is designed to evaluate the feasibility, acceptability, and preliminary outcomes of a pain self-management app among older people living in the community with arthritic pain. METHODS/DESIGN: This is a phase I feasibility study. A pre-post test study design will be used to trial a freely available pain self-management app named Rheumatoid Arthritis Information Support and Education ("RAISE") for 14 days. Thirty community-dwelling older people living with arthritic pain who use a smartphone will be recruited from (1) various community-based social clubs/organizations/groups or (2) via Facebook groups with potentially high number of older members. In addition, snowballing sampling approach will also be utilized.These participants will trial the RAISE app, which was selected following a systematic evaluation of all available chronic pain apps by the investigator team. A face-to-face or telephone-based meeting will be organized with all consenting participants in order to seek their informed consent, download and set up the intervention app on their mobile device, be provided with app training, and complete the pre-test data (Time 1 (T1)). Participants will be asked to use the RAISE app as desired for 14 days. Post-test data collection (Time 2 (T2)) will occur on day 15. Data collected includes participant's demographic and clinical information, pain scores, pain self-efficacy, and online technology self-efficacy. Participants will be invited to take part in a semi-structured telephone interview at T2 to explore their experiences of using the app.An evaluation of patterns of app use, recruitment, retention, attrition rates, and analysis of the missing data will inform the study and intervention feasibility. Preliminary outcomes are participant's pain intensity and interference, pain self-efficacy, and online technology self-efficacy. DISCUSSION: This study will help us better understand the feasibility and acceptability of using this novel intervention among community-dwelling older people living with arthritic pain. The results will also help inform future pain app studies. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry: ACTRN12617000921381.

Effectiveness of the spaced education pedagogy for clinicians' continuing professional development: a systematic review.

CONTEXT: Ensuring clinical practice reflects current evidence is challenging given the rapid proliferation of new knowledge. Changing entrenched clinical behaviours and facilitating the adoption of best practice evidence requires a range of strategies, including affordable, scalable and effective continuing professional development (CPD). Yet, identifying the CPD delivery method most likely to effectively change and improve patient outcomes is difficult given the variability in the evidence for different learning approaches. Although there is moderate level evidence for outreach education, audit and feedback, and face-to-face or online learning, little is known about the capacity of spaced education to change ineffective clinical practice(s). Spaced education harnesses the power of spacing, repetition and testing learning content to increase topic-specific knowledge. Although spaced education is widely used in undergraduate and postgraduate medical programmes, its effectiveness as a CPD delivery method that improves patient outcomes is less certain. AIM: To determine the effectiveness of the spaced education CPD programmes to change targeted clinical knowledge and practice(s) to improve patient outcomes. METHOD: A systematic review, appraising the spaced education CPD evidence generated from searching six specialist medical and psychosocial databases. Studies published in English peer-reviewed journals from 1 January, 2000 to 31 August, 2018 were eligible for inclusion. A modified Kirkpatrick four levels of evaluation framework assisted with appraising the effect of spaced education CPD interventions on clinicians and patients. RESULTS: Of the 2396 studies identified, 17 met the inclusion criteria, involving 2701 practising clinicians from multiple disciplines and specialties. Five randomised controlled trials generated level II evidence, with the remaining 12 studies generating lower levels of evidence. The majority of studies (n = 14) involved the delivery of online spaced education. All studies were evaluated using the modified Kirkpatrick four levels of evaluation framework with: 10 studies demonstrating significant increases in participants' knowledge; seven studies reporting significant changes in clinician behaviour; four studies showing significant increases in clinician confidence; and three studies identifying significant and sustained increases in participants' clinical skills. Only two studies reported positive improvements in patient outcomes. CONCLUSION: Spaced education via an online platform offers a scalable CPD format that can increase clinical knowledge and change practice. However, further adequately powered randomised controlled trials are required to confirm that spaced education CPD can impact positively on patients' reported outcomes.

Clinicians' perceptions of opioid error-contributing factors in inpatient palliative care services: A qualitative study.

BACKGROUND: Opioid errors are a leading cause of patient harm and adversely impact palliative care inpatients' pain and symptom management. Yet, the factors contributing to opioid errors in palliative care are poorly understood. Identifying and better understanding the individual and system factors contributing to these errors is required to inform targeted strategies. OBJECTIVES: To explore palliative care clinicians' perceptions of the factors contributing to opioid errors in Australian inpatient palliative care services. DESIGN: A qualitative study using focus groups or semi-structured interviews. SETTINGS: Three specialist palliative care inpatient services in New South Wales, Australia. PARTICIPANTS: Inpatient palliative care clinicians who are involved with, and/or have oversight of, the services' opioid delivery or quality and safety processes. METHODS: Deductive thematic content analysis of the qualitative data. The Yorkshire Contributory Factors Framework was applied to identify error-contributing factors. FINDINGS: A total of 58 clinicians participated in eight focus groups and 20 semi-structured interviews. Nine key error contributory factor domains were identified, including: active failures; task characteristics of opioid preparation; clinician inexperience; sub-optimal skill mix; gaps in support from central functions; the drug preparation environment; and sub-optimal clinical communication. CONCLUSION: This study identified multiple system-level factors contributing to opioid errors in inpatient palliative care services. Any quality and safety initiatives targeting safe opioid delivery in specialist palliative care services needs to consider the full range of contributing factors, from individual to systems/latent factors, which promote error-causing conditions.

Quality and Usability of Arthritic Pain Self-Management Apps for Older Adults: A Systematic Review.

Objective: To appraise the quality and usability of currently available pain applications that could be used by community-dwelling older adults to self-manage their arthritic pain. Methods: A systematic review. Searches were conducted in App Store and Google Play to identify pain self-management apps relevant to arthritic pain management. English language pain management apps providing pain assessment and documentation function and pain management education were considered for inclusion. A quality evaluation audit tool based on the Stanford Arthritis Self-Management Program was developed a priori to evaluate app content quality. The usability of included apps was assessed using an established usability evaluation tool. Results: Out of the 373 apps that were identified, four met the inclusion criteria. The included apps all included a pain assessment and documentation function and instructions on medication use, communication with health professionals, cognitive behavioral therapy-based pain management, and physical exercise. Management of mood, depression, anxiety, and sleep were featured in most apps (N = 3). Three-quarters (N = 3) of the apps fell below the acceptable moderate usability score (≥3), while one app obtained a moderate score (3.2). Conclusions: Few of the currently available pain apps offer a comprehensive pain self-management approach incorporating evidence-based strategies in accordance with the Stanford Arthritis Self-Management Program. The moderate-level usability across the included apps indicates a need to consider the usability needs of the older population in future pain self-management app development endeavors.

Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department 'near miss' for breathlessness: a strengths-based qualitative study.

OBJECTIVES: Breathlessness 'crises' in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED 'near misses' where they considered going to the ED but successfully self-managed instead. DESIGN AND METHODS: A qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen's Transactional Model of Stress and Coping informed interpretive themes. RESULTS: Interviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services. CONCLUSIONS: In addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients' generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness.

Contributions of a hand-held fan to self-management of chronic breathlessness.

This study explored the benefits of a hand-held fan as perceived by patients with chronic breathlessness and their carers.A secondary multimethod analysis was conducted of interview data collected in three clinical trials. Two researchers independently coded level of benefit qualitatively reported by each patient. Univariate and multivariate statistics were used to explore perceived benefit as a factor of sex, age and diagnosis. Qualitative analysis used an integrative method.133 patients commented on the fan, of whom 72 had a carer. Diagnoses included nonmalignant (n=91, 68.4%) and malignant (n=21, 15.8%) conditions. Of 111 patients who provided codable data, four (3.6%) perceived no benefit, 16 (14.4%) were uncertain, 80 (72.0%) perceived some benefit and 11 (10.0%) perceived very substantial benefit. Multivariate analysis was inconclusive. Benefit was described in terms of shorter recovery time, especially after activity. 10 (7.5%) patients said the fan reduced their need for home oxygen or inhaled ß-agonist medications. Negative perceptions of a few included dislike of the cooling sensation and embarrassment in public.Findings suggest that a hand-held fan is a portable intervention with few disadvantages from which most patients with chronic breathlessness will derive benefit alongside other nonpharmacological and pharmacological strategies. Research is needed to optimise guidance on fan administration.

The role of digital health technologies in management of pain in older people: An integrative review.

Pain is one of the most distressing and debilitating health issues faced by older people. The burden of unrelieved pain experienced by older people and its associated high symptom and economic costs demands consideration of new strategies to better this condition. As the global uptake of digital technology increases, exploring its potential to impact positively on older peoples' pain self-management practices warrants investigation. This integrative review aimed to evaluate the use of digital health technology for management of older people's pain across care-settings. Searches were conducted to identify relevant English language studies published in CINHAL, Medline, Academic Search Complete, EMBASE, Cochrane library databases, and Google and Google Scholar websites. A total of 1003 papers were identified, 9 met the inclusion criteria. The highest level of evidence (Level II) was generated by three Phase II randomized controlled trials. These trials demonstrated the feasibility of computer based interactive or instructive video interventions however there was limited evidence to support their use for reduction of pain intensity and interference. Qualitative evidence demonstrated older people's willingness to use mobile technologies (iPhone or digital pen) to help manage their pain, however, the need of device-use training and connectedness with clinicians were highlighted. In conclusion, there is some evidence that integrating digital health technology into older peoples' pain self-management plan is feasible and acceptable. However, the provision of high-quality technological interventions informed by a thorough understanding of older people's digital technology pain management needs is required to ensure greater integration of this technology in clinical practice.

Pain among hospitalized older people with heart failure and their preparation to manage this symptom on discharge: a descriptive-observational study.

Globally, heart failure (HF) is one of the major health issues faced by many older people. It causes significant symptom burden that requires ongoing management. This paper reports on a descriptive-observational study undertaken to: (1) describe the prevalence of pain and analgesic prescription usage in hospitalized older HF patients; (2) determine the degree to which these patients are provided with a pain self-management strategy prior to discharge; and (3) determine if the patients' pain self-management strategy has been detailed in the discharge summary. A total of 122 older HF patients were included in this study. Results indicated that moderate to severe pain (Numeric Rating Scale score ≥4) is experienced by a substantial number of older people hospitalized with HF. There is little documented evidence that older people are provided with adequate analgesic prescriptions and the instructions required to effectively manage their pain on discharge to the community.

Advance care planning in 21st century Australia: a systematic review and appraisal of online advance care directive templates against national framework criteria.

OBJECTIVES: A drive to promote advance care planning at a population level has led to a proliferation of online advance care directive (ACD) templates but little information to guide consumer choice. The current study aimed to appraise the quality of online ACD templates promoted for use in Australia. METHODS: A systematic review of online Australian ACD templates was conducted in February 2014. ACD templates were identified via Google searches, and quality was independently appraised by two reviewers against criteria from the 2011 report A National Frameworkfor Advance Care Directives. Bias either towards or against future medical treatment was assessed using criteria designed to limit subjectivity. RESULTS: Fourteen online ACD templates were included, all of which were available only in English. Templates developed by Southern Cross University best met the framework criteria. One ACD template was found to be biased against medical treatment--the Dying with Dignity Victoria Advance Healthcare Directive. CONCLUSIONS: More research is needed to understand how online resources can optimally elicit and record consumers' individual preferences for future care. Future iterations of the framework should address online availability and provide a simple rating system to inform choice and drive quality improvement.