Predictors of preparedness for recovery following colorectal cancer surgery: a latent class trajectory analysis.

AIM: With an interest in providing knowledge for person-centred care, our overall goal is to contribute a greater understanding of diversity among patients in terms of their preparedness before and up to six months after colorectal cancer surgery. Our aim was to describe and provide a tentative explanation for differences in preparedness trajectory profiles. MATERIAL AND METHODS: The study was explorative and used prospective longitudinal data from a previously published intervention study evaluating person-centred information and communication. The project was conducted at three hospitals in Sweden. Patient-reported outcomes measures, including the Longitudinal Preparedness for Colorectal Cancer Surgery Questionnaire, were collected before surgery, at discharge, and four to six weeks, three months, and six months after surgery. Clinical data were retrospectively obtained from patients' medical records. We used latent class growth models (LCGMs) to identify latent classes that distinguish subgroups of patients who represent different preparedness trajectory profiles. To determine the most plausible number of latent classes, we considered statistical information about model fit and clinical practice relevance. We used multivariable regression models to identify variables that explain the latent classes. RESULTS: The sample (N = 488) comprised people with a mean age of 68 years (SD = 11) of which 44% were women. Regarding diagnoses, 60% had colon cancer and 40% rectal cancer. The LCGMs identified six latent classes with different preparedness for surgery and recovery trajectories. The latent classes were predominantly explained by differences in age, sex, physical classification based on comorbidities, treatment hospital, global health status, distress, and sense of coherence (comprehensibility and meaningfulness). CONCLUSION: Contrary to the received view that emphasizes standardized care practices, our results point to the need for adding person-centred and tailored approaches that consider individual differences in how patients are prepared before and during the recovery period related to colorectal cancer surgery.

Sex-specific time trends of long-term graft survival after kidney transplantation - a registry-based study.

BACKGROUND: Sex-specific trends over time with respect to kidney graft survival have scarcely been described in earlier studies. The present study aimed to examine whether kidney graft survival differs between women and men over time. METHODS: This study was based on prospectively collected data extracted from a quality registry including all kidney transplant patients between January 1965 and September 2017 at the transplantation center of a university hospital in Sweden. The transplantation center serves a population of approximately 3.5 million inhabitants. Only the first graft for each patient was included in the study resulting in 4698 transplantations from unique patients (37% women, 63% men). Patients were followed-up until graft failure, death, or the end of the study. Death-censored graft survival analysis after kidney transplantation (KT) was performed using Kaplan-Meier analysis with log-rank test, and analysis adjusted for confounders was performed using multivariable Cox regression analysis. RESULTS: Median age at transplantation was 48 years (quartiles 36-57 years) and was similar for women and men. Graft survival was analyzed separately in four transplantation periods that represented various immunosuppressive regimes (1965-1985, 1986-1995, 1996-2005, and 2006-2017). Sex differences in graft survival varied over time (sex-by-period interaction, p = 0.026). During the three first periods, there were no significant sex differences in graft survival. However, during the last period, women had shorter graft survival (p = 0.022, hazard ratio (HR) 1.71, 95% confidence interval (CI) 1.1-2.7, adjusted for covariates). Biopsy-proven rejections were more common in women. CONCLUSIONS: In this registry-based study, women had shorter graft survival than men during the last observation period (years 2006-2017).

The sense of coherence scale in a clinical nursing perspective: A scoping review.

BACKGROUND: The concept of sense of coherence explains a person's resources to maintain health during times of considerable strain and is suggested to be applicable in nursing. A summary of how it has been applied and adapted in clinical nursing is warranted for further conceptual development and research. OBJECTIVE: The scoping review aimed to explore how the sense of coherence scale has been used from a clinical nursing research perspective. METHOD: Published articles (N = 2812) through December 2018 were identified in the PubMed, Cinahl and PsychInfo databases. A total of 298 articles were included in the review. A five-stage process was used to extract data based on pre-determined selection criteria. Summative content analysis was used for the categorisation of the data. The PRISMA-ScR checklist was chosen. RESULTS: A majority of the articles were published within the Nordic countries and the short version SOC-13 was the most frequently used scale. Most studies stated the significant relationship of a higher sense of coherence and higher emotional and psychosocial well-being, quality of life, and well-being irrespective of condition. Other articles proposed identifying patients' degree of sense of coherence either to individualise care or to plan an intervention to strengthen sense of coherence. CONCLUSIONS: The sense of coherence scale has been widely used within nursing and identified as an important factor to individualise care. Future research should focus on rigorous intervention studies to determine if recognising patients' degree of sense of coherence in clinical nursing enables tailored care for patients when dealing with a disease-related condition. More evidence is needed when seeking to improve sense of coherence. RELEVANCE TO CLINICAL PRACTICE: These results show an expansion of the concept of sense of coherence and endorses its use in nursing care for identifying patients' needs in the process of presenting individualised care.

Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting.

BACKGROUND: Delirium is common in older hospitalized patients. It has serious consequences e.g., poor health outcomes, mortality and increased costs. Despite that, many cases are undetected. Early detection of delirium is important in improving outcomes and use of assessment tools improves detection rates. The 4AT is a brief screening tool for delirium detection, which has not previously been translated into Swedish. The study aim was to evaluate diagnostic accuracy and clinical applicability of a Swedish version of the screening tool 4AT for delirium detection. METHOD: This diagnostic test accuracy study used a quantitative and a qualitative approach and evaluated the patients' and the health care professionals' experiences of the tool. Study included 200 patients ≥65 years from a university hospital and a county hospital in two Swedish regions. Medical specialties were geriatric stroke/neurology, geriatric multimorbidity, severe cognitive impairment, orthopaedic, and urology. The translated 4AT was tested against the reference standard DSM-IV-TR criteria, based on the Organic Brain Syndrome scale and patient records. The 4AT was assessed simultaneously and independently by two assessors. Additionally, data was collected through patient record reviews, and questions about applicability to the patients (n = 200) and the assessors (n = 37). Statistical analyses, and qualitative content analyses were conducted. RESULTS: By reference standard 18% had delirium, and by 4AT 19%. The overall percent agreement was 88%, AUROC 0.808, sensitivity 0.70 (95% CI 0.51-0.84) and specificity 0.92 (95% CI 0.87-0.96). In the ward for severe cognitive impairment (n = 63) the 4AT was less sensitive and less specific. In the other wards (n = 132) sensitivity was 0.77 (95% CI 0.50-0.93), specificity 0.93 (95% CI 0.87-0.97), and AUROC 0.848. Interrater reliability (Kappa) was 0.918, p = < 0.001 (n = 144). The 4AT was well tolerated by patients, easy to use for health care professionals, and took a few minutes to conduct. CONCLUSION: The Swedish version of 4AT is an accurate and applicable tool to use in clinical practice for detecting delirium in hospitalized patients across different medical specialities, and to use by different professionals and levels of seniority. To improve patient outcomes, we recommend the 4AT to be incorporated in clinical practice in health care settings in Sweden.

Symptoms and Well-Being in Older Hospitalized Patients with Cognitive Impairment, As Self-Reported and Reported in Patient Records: A Quantitative Exploratory Subgroup Analysis.

INTRODUCTION: Given the aging population and the high prevalence of cognitive impairment in older hospitalized patients, it is essential to provide good fundamental care to these vulnerable patients, who easily might be affected by poor outcomes as delirium. Risk factors for delirium are, for example, cognitive impairment, old age, pain, and sleep deprivation. Different symptoms are often unidentified in hospitals, and associated with poor well-being, but this is rarely studied in older patients with cognitive impairment. The study aim was to examine symptoms and sense of well-being in older hospitalized patients with cognitive impairment, as self-reported and reported in patient records. METHODS: Exploratory quantitative subgroup (n = 25) analysis of a point-prevalence study (n = 210). Inclusion criteria were age ≥65, and cognitive impairment. Data were collected through structured interviews, validated instruments, and patient records. Associations between well-being and symptoms, and concordance between the occurrence of self-reported symptoms and symptoms reported in patient records were analyzed. RESULTS: The patients reported severe and distressing symptoms that were sparsely reported (14%) in their records. As well were cognitive impairment, and the patients' own descriptions of their well-being. Some symptoms and the total symptom burden were associated with poor well-being. DISCUSSION/CONCLUSION: To our knowledge, this hypothesis-generating study is one of few studies that describe both symptoms and well-being as self-reported and reported in patient records, in vulnerable patients due to old age, cognitive impairment, and hospitalization. Despite the limited sample size, the results indicate that symptoms were more insufficient alleviated in these patients compared to patients with normal cognitive function in other studies. To our knowledge, this has not been shown previously. Additionally, patients' own experiences were sparsely reported in their records. A larger sample size and longitudinal design has the potential to determine if symptom alleviation differs between patients with and without cognitive impairment, and if a total symptom burden increases the risk of poor outcomes as delirium in vulnerable patients.

Bottom-up and top-down approaches to understanding oppositional defiant disorder symptoms during early childhood: a mixed method study.

BACKGROUND: Children with clinical levels of conduct problems are at high risk of developing mental health problems such as persistent antisocial behavior or emotional problems in adolescence. Serious conduct problems in childhood also predict poor functioning across other areas of life in early adulthood such as overweight, heavy drinking, social isolation and not in employment or education. It is important to capture those children who are most at risk, early in their development. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is commonly used in clinical settings, to identify children with conduct problems such as oppositional defiant disorder (ODD).This paper presents a cross-sectional study in a clinical setting, and describes behaviors in 3- to 8-year-olds with ODD. Our aim was to investigate whether there were problematic behaviors that were not captured by the diagnosis of ODD, using two different methods: a clinical approach (bottom-up) and the nosology for the diagnosis of ODD (top-down). METHOD: Fifty-seven children with clinical levels of ODD participated in the study. The mothers were interviewed with both open questions and with a semi-structured diagnostic interview K-SADS. The data was analyzed using a mixed method, convergent, parallel qualitative/quantitative (QUAL + QUAN) design. For QUAL analysis qualitative content analysis was used, and for QUAN analysis associations between the two data sets, and ages-groups and gender were compared using Chi-square test. RESULTS: In the top-down approach, the ODD criteria helped to identify and separate commonly occurring oppositional behavior from conduct problems, but in the bottom-up approach, the accepted diagnostic criteria did not capture the entire range of problematic behaviors-especially those behaviors that constitute a risk for antisocial behavior. CONCLUSIONS: The present study shows a gap between the diagnoses of ODD and conduct disorder (CD) in younger children. Antisocial behaviors manifest in preschool and early school years are not always sufficiently alarming to meet the diagnosis of CD, nor are they caught in their entirety by the ODD diagnostic tool. One way to verify suspicion of early antisocial behavior in preschool children would be to specify in the ODD diagnosis if there also is subclinical CD.

"Since his birth, I've always been old" the experience of being parents to children displaying disruptive behavior problems: a qualitative study.

BACKGROUND: Being parents of children who display disruptive behavior problems (DBP) can pose several challenges. Interventions for children with DBP are primarily outpatient group parent training (PT) programs. The purpose of this study was to explore how parents of children with disruptive behavior problems, diagnosed with oppositional defiant disorder (ODD), describe the difficulties they face in their family and parenting situations. METHODS: Nineteen parents of children aged 3 to 8 years who had searched for help and signed up for a parent training program provided by Child and Adolescent Mental Health Service participated in the study. Semi-structured diagnostic interviews and a modified background interview adapted for the purpose of the study were conducted before parents entered the program. All children included in the study met the DSM criteria for ODD. The interviews were audiotaped and transcribed. Thematic analysis was used to examine, identify, and report patterns of meaning in the data. The analysis was conducted inductively using a contextual approach. RESULTS: Parents described their own vulnerability, how they were affected by the parent-child interaction, and the challenges they perceived in their parenting practices. The study contributes to an understanding of the complexity that parents of children with ODD perceive in everyday life. CONCLUSIONS: The parents in the study highlight the need to address parents' own mental health problems, parental alliance, capacity for emotion regulation, perceived helplessness as parents, lack of parental strategies, sense of isolation, and absence of supportive social networks. All these factors could be important when tailoring interventions aimed to help and support parents of children who display DBP, and specifically ODD.

Fascia iliaca compartment block as a preoperative analgesic in elderly patients with hip fractures - effects on cognition.

BACKGROUND: Impaired cognition is a major risk factor for perioperative delirium. It is essential to provide good pain control in patients with hip fractures and especially important in patients with severely impaired cognitive status, as they receive less pain medication, have poorer mobility, poorer quality of life and higher mortality than patients with intact cognition. The purpose of this study was to examine the association between preoperative pain management with nerve blocks and cognitive status in patients with hip fractures during the perioperative period. METHODS: One hundred and twenty-seven patients with hip fractures participating in a double-blind, randomised, controlled trial were included in this study. At hospital admission, a low-dose fascia iliaca compartment block (FICB) was administered as a supplement to regular analgesia. Cognitive status was registered on arrival at hospital before FICB and on the first postoperative day using the Short Portable Mental Status Questionnaire. RESULTS: Changes in cognitive status from arrival at hospital to the first postoperative day showed a positive, albeit not significant, trend in favour of the intervention group. The results also showed that patients with no or a moderate cognitive impairment received 50% more prehospital pain medication than patients with a severe cognitive impairment. FICB was well tolerated in patients with hip fractures. CONCLUSION: Fascia iliaca compartment block given to patients with hip fractures did not affect cognitive status in this study. Patients with a cognitive impairment may receive inadequate pain relief after hip fracture and this discrimination needs to be addressed in further studies. TRIAL REGISTRATION: EudraCT number 2008-004303-59 date of registration: 2008-10-24.

The prognostic relevance of FOXA1 and Nestin expression in breast cancer metastases: a retrospective study of 164 cases during a 10-year period (2004-2014).

BACKGROUND: Current prognostic markers cannot adequately predict the clinical outcome of breast cancer patients. Therefore, additional biomarkers need to be included in routine immune panels. FOXA1 was a significant predictor of favorable outcome in primary breast cancer, while Nestin expression is preferentially found in triple-negative tumors with increased rate of nodal metastases, and reduced survival. No studies have investigated the prognostic value of FOXA1 and Nestin expression in breast cancer metastases. METHODS: Breast cancer metastases (n = 164) from various anatomical sites were retrospectively analyzed by immunohistochemistry for FOXA1, Nestin and GATA3 expression. Cox regression analysis assessed the prognostic value of FOXA1 and Nestin expression. RESULTS: In breast cancer metastases, FOXA1 expression was associated with Nestin-negativity, GATA3-positivity, ER-positivity, HER2-positivity and non-triple-negative status (P < 0.05). In contrast, Nestin expression was associated with FOXA1-negative, GATA3-negative, ER-negative, and triple-negative metastases (P < 0.05). Univariate Cox regression analysis showed FOXA1 expression was predictive of overall survival (OS, P = 0.00048) and metastasis-free survival (DMFS, P = 0.0011), as well as, distant metastasis-free survival in ER-positive patients (P = 0.036) and overall survival in ER-negative patients (P = 0.024). Multivariate analysis confirmed the significance of FOXA1 for both survival endpoints in metastatic breast cancer patients (OS, P = 0.0033; DMFS, P = 0.015). CONCLUSIONS: In our study, FOXA1 was expressed mostly in ER-positive breast cancer metastases. Expression of Nestin was related to triple-negative metastases, where brain was the most frequent metastatic site. These findings highlight the clinical utility of FOXA1 and Nestin expression and warrant their inclusion in routine immunohistochemical panels for breast carcinoma.

Exploration of dynamics in a complex person-centred intervention process based on health professionals' perspectives.

BACKGROUND: The assessment and evaluation of practical and sustainable development of health care has become a major focus of investigation in health services research. A key challenge for researchers as well as decision-makers in health care is to understand mechanisms influencing how complex interventions work and become embedded in practice, which is significant for both evaluation and later implementation. In this study, we explored nurses' and surgeons' perspectives on performing and participating in a complex multi-centre person-centred intervention process that aimed to support patients diagnosed with colorectal cancer to feel prepared for surgery, discharge and recovery. METHOD: Data consisted of retrospective interviews with 20 professionals after the intervention, supplemented with prospective conversational data and field notes from workshops and follow-up meetings (n = 51). The data were analysed to construct patterns in line with interpretive description. RESULTS: Although the participants highly valued components of the intervention, the results reveal influencing mechanisms underlying the functioning of the intervention, including multiple objectives, unclear mandates and competing professional logics. The results also reveal variations in processing the intervention focused on differences in using and talking about intervention components. CONCLUSIONS: The study indicates there are significant areas of ambiguity in understanding how theory-based complex clinical interventions work and in how interventions are socially constructed and co-created by professionals' experiences, assumptions about own professional practice, contextual conditions and the researchers' intentions. This process evaluation reveals insights into reasons for success or failure and contextual aspects associated with variations in outcomes. Thus, there is a need for further interpretive inquiry, and not only descriptive studies, of the multifaceted characters of complex clinical interventions and how the intervention components are actually shaped in constantly shifting contexts.

Metachronous and Synchronous Occurrence of 5 Primary Malignancies in a Female Patient between 1997 and 2013: A Case Report with Germline and Somatic Genetic Analysis.

The number of patients with multiple primary malignancies has been increasing steadily in recent years. In the present study, we describe a unique case of an 81-year-old woman with 5 metachronous and synchronous primary malignant neoplasms. The patient was first diagnosed with an endometrium adenocarcinoma in 1997 and a colon adenocarcinoma in 2002. Eleven years after her colon surgery, in 2013, the patient presented with 3 other primary malignancies within a 4-month time span: an invasive malignant melanoma on the lower leg, an invasive mucinous breast carcinoma in the right breast, and a pleomorphic spindle cell sarcoma on the left upper arm. Subsequent routine medical checkups in 2013-2017 revealed no metastases of the primary malignancies. The patient mentioned a familial aggregation of malignant tumors, including 2 sisters with breast cancer and a brother with lung cancer. Interestingly, next-generation sequencing analysis of the patient's blood sample detected no mutations in the BRCA1, BRCA2, TP53, PTEN, CDH1, PALB2, RAD51C, RAD51D, MLH1, MSH2, MSH6, PMS2, EPCAM, APC, MUTYH, STK11, BMPR1A, SMAD4, PTEN, POLE, POLD1, GREM1, and GALNT12 genes. Therefore, whole genome sequencing is warranted to identify cancer-related genetic alterations in this patient with quintuple primary malignancies.

Mindfulness and its efficacy for psychological and biological responses in women with breast cancer.

Many breast cancer survivors have to deal with a variety of psychological and physiological sequelae including impaired immune responses. The primary purpose of this randomized controlled trial was to determine the efficacy of a mindfulness-based stress reduction (MBSR) intervention for mood disorders in women with breast cancer. Secondary outcomes were symptom experience, health status, coping capacity, mindfulness, posttraumatic growth, and immune status. This RTC assigned 166 women with breast cancer to one of three groups: MBSR (8 weekly group sessions of MBSR), active controls (self-instructing MBSR) and non-MBSR. The primary outcome measure was the Hospital Anxiety and Depression Scale. Secondary outcome measures were: Memorial Symptom Assessment Scale, SF-36, Sense of Coherence, Five Facets of Mindfulness Questionnaire, and Posttraumatic Growth Index. Blood samples were analyzed using flow cytometry for NK-cell activity (FANKIA) and lymphocyte phenotyping; concentrations of cytokines were determined in sera using commercial high sensitivity IL-6 and IL-8 ELISA (enzyme-linked immunosorbent assay) kits. Results provide evidence for beneficial effects of MBSR on psychological and biological responses. Women in the MBSR group experienced significant improvements in depression scores, with a mean pre-MBSR HAD-score of 4.3 and post-MBSR score of 3.3 (P = 0.001), and compared to non-MBSR (P = 0.015). Significant improvements on scores for distress, symptom burden, and mental health were also observed. Furthermore, MBSR facilitated coping capacity as well as mindfulness and posttraumatic growth. Significant benefits in immune response within the MBSR group and between groups were observed. MBSR have potential for alleviating depression, symptom experience, and for enhancing coping capacity, mindfulness and posttraumatic growth, which may improve breast cancer survivorship. MBSR also led to beneficial effect on immune function; the clinical implications of this finding merit further research.

Designing quality of care--contributions from parents: Parents' experiences of care processes in paediatric care and their contribution to improvements of the care process in collaboration with healthcare professionals.

AIMS AND OBJECTIVES: The aim of this article was to explore whether current quality dimensions for health care services are sufficient to capture how parents perceive and contribute to quality of health care. BACKGROUND: New quality improvement initiatives that actively involve patients must be examined with a critical view on established quality dimensions to ensure that these measures support patient involvement. DESIGN: This paper used a qualitative and descriptive design. METHODS: This paper is based on interviews with parents participating in two experience-based co-design projects in a Swedish hospital that included qualitative content analysis of data from 12 parent interviews in paediatric care. RESULTS: Health care professionals often overemphasize their own significance for value creation in care processes and underappreciate parents' ability to influence and contribute to better quality. However, quality is not based solely on how professionals accomplish their task, but is co-created by health care professionals and parents. Consequently, assessment of quality outcomes also must include parents' ability and context. CONCLUSIONS: This paper questions current models of quality dimensions in health care, and suggests additional sub-dimensions, such as family quality and involvement quality. RELEVANCE TO CLINICAL PRACTICE: This paper underscores the importance of involving parents in health care improvements with health care professionals to capture as many dimensions of quality as possible.

Providing Palliative Care in a Swedish Support Home for People Who Are Homeless.

Despite high frequencies of multiple, life-limiting conditions relating to palliative care needs, people who are homeless are one of the most underserved and rarely encountered groups in palliative care settings. Instead, they often die in care places where palliative competence is not available. In this qualitative single-case study, we explored the conditions and practices of palliative care from the perspective of staff at a Swedish support home for homeless people. Interpretive description guided the research process, and data were generated from repeated reflective conversations with staff in groups, individually, and in pairs. The findings disclose a person-centered approach to palliative care, grounded in the understanding of the person's health/illness and health literacy, and how this is related to and determinant on life as a homeless individual. Four patterns shape this approach: building trustful and family-like relationships, re-dignifying the person, re-considering communication about illness and dying, and re-defining flexible and pragmatic care solutions.

Extensive human suffering: a point prevalence survey of patients' most distressing concerns during inpatient care.

AIM: To explore patients' most distressing concerns during a hospital stay. BACKGROUND: The characteristics of hospitalised patients have changed. Care is provided at a higher age, lengths of stay have fallen and the nursing workload is increasing. It is presumed that hospitalised patients are more seriously ill and have more palliative needs than previously. Studies show that inpatients suffer from more distress than similar outpatients although there is a lack of overall knowledge about inpatients' distress and major concerns, regardless of age, diagnosis or care setting. METHODS: This study was part of a point prevalence survey (PPS) concerning symptom prevalence. Of the 710 patients who participated in the PPS, 678 (95%) answered an open-ended question in a questionnaire: What is your main concern or what is most distressing or troublesome for you at present? Using a life-world approach, the text was analysed qualitatively and patients' concerns were interpreted in two main dimensions, an intersubjective dimension and a temporal dimension. FINDINGS: The patients reported extensive suffering due to illness, symptoms and failing health. Patients were concerned about family members, existential issues and the future. Three aspects of the patients' most distressing concerns were interpreted: The suffering self, The suffering person in close relations and The suffering person in a threatening world. CONCLUSION: Hospitalised patients are affected by severe illness, distressing symptoms and existential quandaries, revealing extensive human suffering in the midst of the demanding activities that take place during an ordinary day in a hospital. To support patients and alleviate suffering, hospital staff need to be more sensitive to patients' most distressing concerns. This presupposes a hospital environment in which the value system supports caring and comforting behaviour.

Symptom burden clusters: a challenge for targeted symptom management. A longitudinal study examining symptom burden clusters in breast cancer.

CONTEXT: Although there has been a growing interest in cancer symptom clusters, less is known about symptom burden clusters. OBJECTIVES: To explore clusters of burdensome symptoms over time, the impact on health status and quality of life, and coping capacity in patients with breast cancer. METHODS: In this longitudinal study, a sample of 206 patients completed the Memorial Symptom Assessment Scale, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Sense of Coherence scale, at diagnosis of primary or recurrent breast cancer, and at one-, three-, and six-month follow-ups. RESULTS: Three clusters of burdensome symptoms were identified: emotional symptom burden, gastrointestinal symptom burden, and unwellness symptom burden. Most burdensome were emotional symptoms, with worrying, feeling sad, and feeling nervous as the core or defining symptoms. Over time, additional symptoms escalated the emotional symptom burden. The gastrointestinal symptom burden, with "change in the way food tastes" as a core symptom, was more often associated with chemotherapy. Less stable over time, the unwellness symptom burden could be interpreted as short- and long-term side effects of hormonal therapy. Of these clusters, only the emotional symptom burden cluster significantly diminished health status and quality of life. Patients reporting lower coping capacity experienced higher levels of symptom burden. CONCLUSION: This study provides insights into symptom burden clusters over time. A challenging approach toward symptom management in clinical oncology is to target the burden of a symptom cluster and to recognize the need for individually designed interventions to ameliorate symptom burden in cancer patients.

Nursing students' experiences of involvement in clinical research: an exploratory study.

BACKGROUND: Nursing education can positively affect nurses' attitudes toward nursing research, resulting in better patient outcomes. Experiential learning theory was the basis for this study. OBJECTIVES: To explore nursing students' experiences of involvement in clinical research, their approach to learning and their interest in nursing research. DESIGN: Cross-sectional. METHODS: One hundred and twenty-six nursing students were invited to be involved as data collectors in a research project as part of their training in research methodology. The students completed an evaluation form and the Revised Study Process Questionnaire. The questionnaires were analyzed quantitatively and one open-ended question was analyzed qualitatively. RESULTS: On the whole, the students were happy to be involved in the data collection although a minority felt uncertain and exposed. Students with a deeper approach to learning felt that their involvement had increased their interest in nursing research and they stated that data collection should be a regular feature of the course. CONCLUSIONS: Participation as data collectors in research has the potential to increase interest in nursing research among students with higher levels of deep learning. Further studies are needed to examine ways to increase interest in research among students with lower levels of deep learning.

Mindfulness based stress reduction study design of a longitudinal randomized controlled complementary intervention in women with breast cancer.

BACKGROUND: The stress of a breast cancer diagnosis and its treatment can produce a variety of psychosocial sequelae including impaired immune responses. Mindfulness Based Stress Reduction (MBSR) is a structured complementary program that incorporates meditation, yoga and mind-body exercises. Despite promising empirical evidence for the efficacy of MBSR, there is a need for randomized controlled trials (RCT). There is also a need for RCTs investigating the efficacy of psychosocial interventions on mood disorder and immune response in women with breast cancer. Therefore, the overall aim is to determine the efficacy of a Mindfulness Based Stress Reduction (MBSR) intervention on well-being and immune response in women with breast cancer. METHODS AND DESIGN: In this RCT, patients diagnosed with breast cancer, will consecutively be recruited to participate. Participants will be randomized into one of three groups: MBSR Intervention I (weekly group sessions + self-instructing program), MBSR Intervention II (self-instructing program), and Controls (non-MBSR). Data will be collected before start of intervention, and 3, 6, and 12 months and thereafter yearly up to 5 years. This study may contribute to evidence-based knowledge concerning the efficacy of MBSR to support patient empowerment to regain health in breast cancer disease. DISCUSSION: The present study may contribute to evidence-based knowledge concerning the efficacy of mindfulness training to support patient empowerment to regain health in a breast cancer disease. If MBSR is effective for symptom relief and quality of life, the method will have significant clinical relevance that may generate standard of care for patients with breast cancer. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01591915.

Relationship of sense of coherence to stressful events, coping strategies, health status, and quality of life in women with breast cancer.

OBJECTIVE: To test the hypothesis that Antonovsky's concept of sense of coherence (SOC) predicts stressful events, coping strategies, health status, and quality of life (QoL) in a cohort of postmenopausal women (n = 131) with newly diagnosed primary or recurrent breast cancer. METHODS: Regression analyses of longitudinal data at baseline through 6 months following breast cancer diagnosis examined the relationships between SOC (13-item version), daily assessment of coping with stressful events, health status, and QoL (EORTC QLQ-30). RESULTS: The findings support Antonovsky's concept of SOC. Women with strong SOC reported fewer stressful events and more days without stressful events. They used more coping strategies and more frequently used distraction, situation redefinition, direct action, and relaxation, but seldom religion, to cope with stressful events, and reported better health status and QoL. Women with weak SOC experienced more distress and used fewer coping strategies, and they more frequently used coping strategies such as catharsis and seeking social and spiritual support, but seldom acceptance of the situation. They reported worse health status and QoL, regardless of disease stage or treatment. The relationships between SOC and health status and QoL were linear. CONCLUSIONS: Sense of coherence significantly predicts distress, number and type of coping strategies such as direct action and relaxation, health status, and QoL in women with breast cancer. Our data suggest that the SOC scale may be a useful screening tool to identify individuals particularly vulnerable to distress and unable to cope adequately. Assessing SOC strength may assist health care providers to provide individualized patient interventions.