Perspectives on multidrug-resistant organisms at the end of life : A focus group study of staff members and institutional stakeholders.

BACKGROUND: There is a lack of research into how hospital staff and institutional stakeholders (i. e. institutional representatives from public health authorities, hospital hygiene, and the departments of microbiology, palliative care, and geriatrics) engage with patients who are carriers of multidrug-resistant organisms and receiving end-of-life care. Knowledge of their experiences, workload, and needs should be considered in dealing with hospitalized carriers of multidrug-resistant organisms as well as staff education. OBJECTIVE: This study explored and compared staff members' and stakeholders' perspectives on multidrug-resistant organisms and on provision of end-of-life care to carrier patients. METHODS: In this study four focus groups consisting of hospital staff members and institutional stakeholders were formed within a mixed-methods parent study in a palliative care unit at a university clinic and a geriatric ward of a Catholic and academic teaching hospital. Participants discussed results from staff and stakeholder interviews from a former study phase. Data were analyzed according to Grounded Theory and perspectives of staff members and institutional stakeholders were compared and contrasted. RESULTS: Key issues debated by staff members (N = 19) and institutional stakeholders (N = 10) were 1) the additional workload, 2) reasons for uncertainty about handling carrier patients, 3) the format of continuing education, and 4) the preferred management approach for dealing with multidrug-resistant organism carrier patients. Although similar barriers (e. g. colleagues' ambiguous opinions) were identified, both groups drew different conclusions concerning the management of these barriers. While institutional stakeholders recommended making decisions on hygiene measures under consideration of the specific patient situation, staff members preferred the use of standardized hygiene measures which should be applied uniformly to all patients. DISCUSSION: Staff members and institutional stakeholders perceived similar barriers to practice caused by multidrug-resistant organisms and similar needs for continuing education. The staff members' preferred management approach might originate from an uncertainty about the multidrug-resistant organism infection risk. Experiences and visions of both groups should be included in a specific recommendation for end-of-life care to ensure behavioral confidence.

Staff members' ambivalence on caring for patients with multidrug-resistant bacteria at their end of life: A qualitative study.

AIMS AND OBJECTIVES: To explore healthcare professionals' personal experiences, feelings and attitudes about caring for hospitalised patients with multidrug-resistant bacteria in palliative and geriatric care. BACKGROUND: Working in end-of-life care involves at times burdening demands that affect not only healthcare professionals personally but also their actions. It is suggested that multidrug-resistant bacteria and their consequences for colonised or infected patients in hospitals are among the challenges for all professionals in end-of-life care. Little is known about the feelings and experiences of staff members during healthcare activities with regard to these bacteria. DESIGN: A qualitative interview study in two German hospitals. METHODS: We interviewed 35 staff members from a German palliative care unit and a geriatric unit about their experiences with multidrug-resistant bacteria in end-of-life care and the management of colonised or infected patients. Semistructured interviews were transcribed verbatim and analysed using grounded theory. RESULTS: Interviewees represented two interdisciplinary teams with 40% nurses, 26% physicians and 34% other professionals. Salient themes that were identified included impact of multidrug-resistant bacteria on staff members' personal actions, feelings and attitudes towards the bacteria and the required isolation measures. Besides higher workload and consequences for working routines, the patients' palliative care needs were recognised, as well as the necessary protection measures to avoid contaminations in hospital. Healthcare professionals reported a dilemma that they experienced when facing these diverse demands. CONCLUSIONS: Findings point to emotional and behavioural ambivalence in end-of-life care among staff members because necessary isolation measures and particular situation in end-of-life care create unsolvable conflicts for healthcare professionals. Possible strategies to cope with ambivalence are discussed. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals in palliative and geriatric care have to deal with multidrug-resistant bacteria and have to face contradictory feelings while trying to fulfil patients' needs as well as isolation requirements.

Multidrug-resistant bacterial microorganisms (MDRO) in end-of-life care: development of recommendations for hospitalized patients using a mixed-methods approach.

PURPOSE: Palliative care professionals are frequently confronted with patients colonized or infected with MDRO. One major challenge is how to balance necessary isolation measures and social inclusion as one of the main principles of palliative and end-of-life care. To date, MDRO-specific policies and protocols vary widely between institutions. AIM: provide empirical recommendations on how to deal with hospitalized MDRO patients in end-of-life care. METHODS: Recommendations were developed based on (i) initial results of face-to-face interviews and focus groups, (ii) impartial experts' comments and consensus on the draft via online survey and (iii) a face-to-face meeting with consortium members to finalize recommendations. Findings of 158 interviews and six focus groups (39 participants) with patients, family caregivers, staff members and institutional stakeholders contributed to the recommendations. The assessments of 17 experts were considered. RESULTS: In total, 21 recommendations were approved. The recommended strategy in dealing with MDRO at the end of life allows case-based application of protection and isolation measures. MDRO diagnostics and therapy involve screening at admission. The recommendations suggest consideration of required accommodation facilities, provided material as well as staff and time resources. The recommendations further highlight the importance of providing for strategies enabling the patient's social inclusion and provision of verbal and written information about MDRO for patients and family caregivers, transparent medical documentation, and staff member training. CONCLUSION: The recommendations summarize the perspectives of individuals and groups affected by MDRO at the end of life and provide practical guidance for clinical routine. Further dissemination and implementation requirements are discussed and should contain the evaluation of the knowledge, views, worries, and anxieties of the target groups.

Understanding institutional stakeholders' perspectives on multidrug-resistant bacterial organism at the end of life: a qualitative study.

BACKGROUND: Information lacks about institutional stakeholders' perspectives on management approaches of multidrug-resistant bacterial organism in end-of-life situations. The term "institutional stakeholder" includes persons in leading positions with responsibility in hospitals' multidrug-resistant bacterial organism management. They have great influence on how strategies on multidrug-resistant bacterial organism management approaches in institutions of the public health system are designed. This study targeted institutional stakeholders' individual perspectives on multidrug-resistant bacterial organism colonization or infection and isolation measures at the end of life. METHODS: Between March and December 2014, institutional stakeholders of two study centers, a German palliative care unit and a geriatric ward, were queried in semistructured interviews. Interviews were audiotaped, transcribed verbatim, and analyzed qualitatively with the aid of the software MAXQDA for qualitative data analysis using principles of Grounded Theory. In addition, two external stakeholders were interviewed to enrich data. RESULTS: Key issues addressed by institutional stakeholders (N=18) were the relevance of multidrug-resistant bacterial organism in palliative and geriatric care, contradictions between hygiene principles and patients' and family caregivers' needs and divergence from standards, frame conditions, and reflections on standardization of multidrug-resistant bacterial organism end-of-life care procedures. Results show that institutional stakeholders face a dilemma between their responsibility in protecting third persons and ensuring patients' quality of life. Until further empirical evidence establishes a clear multidrug-resistant bacterial organism management approach in end-of-life care, stakeholders suggest a case-based approach. CONCLUSION: The institutional stakeholders' perspectives and their suggestion of a case-based approach advance the development process of a patient-, family-, staff-, and institutional-centered approach of how to deal with multidrug-resistant bacterial organism-positive patients in end-of-life care. Institutional stakeholders play an important role in the implementation of recommendations following this approach.

Endocrine and aggressive responses to competition are moderated by contest outcome, gender, individual versus team competition, and implicit motives.

This study examined hormonal responses to competition in relation to gender, social context, and implicit motives. Participants (N = 326) were randomly assigned to win or lose in a 10-round, virtual face-to-face competition, in same-sex individual- and team-competition contexts. Saliva samples, taken before and twice after the competition, were assayed for testosterone (T), estradiol (E), progesterone (P), and cortisol (C). Implicit needs for power (nPower) and affiliation (nAffiliation) were assessed with a picture-story exercise before the competition. Aggression was measured via the volume at which participants set noise blasts for their opponents. Men competing individually and women competing as teams showed similar T increases after winning. C was differentially associated with outcome in the team matches, with higher post-match cortisol for winning women, and an opposite effect for male teams. Analyses including implicit motives indicated that situational variables interacted with motivational needs in shaping hormonal responses to competition: in naturally cycling women, nPower predicted T increases after winning and T and E decreases after losing. In men, nPower predicted T increases after losing and decreases after winning. In male teams, nPower predicted C increases after losing, but not after winning, whereas in individual competitions, nPower was a general negative predictor of C changes in women. nAffiliation predicted P increases for women competing as teams, and P decreases for women competing individually. Aggression was higher in men, losers, and teams than in women, winners, and individuals. High aggression was associated with high baseline C in women competing individually and with low baseline C and C decreases in women competing as teams and in men generally. Our findings suggest that while situational and gender factors play a role in hormonal responses to competition, they also depend on their interplay with motivational factors. They also suggest that while aggression is strongly affected by situational factors in the context of a competition, it has no direct association with motivational and hormonal correlates of dominance (nPower, T, E) and instead is associated with (mostly) low levels of C.