Inclusion of informal caregivers in the palliative and end-of-life care of older adults: a scoping review protocol.

INTRODUCTION: Palliative and end-of-life (EOL) care will increasingly be required in years to come as a result of an ageing population. An important component of this type of care is the inclusion of informal caregivers, who are family members or friends offering unpaid assistance to older adults with a terminal illness. Although systematic reviews were conducted on topics related to the inclusion of informal caregivers in the palliative and EOL care of older adults, several gaps remain as they were specific to a health condition and/or setting. The purpose of our scoping review is to map the extent of knowledge on this subject. METHODS AND ANALYSIS: We will conduct our scoping review following Levac's methodology. We will gather publications of various types through nine databases, manual searches in journals and search engines and reference lists. The selection process will be conducted by two independent reviewers and consist of screening by title and abstract, followed by reading the full text to confirm eligibility. An independent reviewer will then extract data and assess quality from included publications. Data extracted from different publication types will be synthesised together in the Excel software using a content analysis method, with quantitative data transformed into a qualitative description. Results will be presented through descriptive statistics and themes. During different steps of the review, we will also consult informal caregivers and health professionals for feedback as stakeholders. ETHICS AND DISSEMINATION: The conduction of this scoping review requires no ethical approval. Results will provide an overview of the state of knowledge on the inclusion of informal caregivers in palliative and EOL of older adults, which could help guide clinical practice, the development of interventions and policy and further research. We will disseminate these results by publishing an article, presenting in conferences, and discussing findings with stakeholders.

The development of the MENTOR_D nursing intervention: Supporting family involvement in delirium management.

BACKGROUND: Although families are increasingly seen as allies to improve delirium management and reduce its consequences, their involvement in the postcardiac surgery setting is challenging considering patients' critical state and short hospital stay. To our knowledge, no theory-based nursing intervention exists that optimally supports the involvement of families in delirium management in the context of postcardiac surgery. OBJECTIVES: We aimed to develop MENTOR_D, a nursing intervention to support the involvement of families in delirium management. METHODS: MENTOR_D was developed based on Sidani and Braden's (2011) intervention development framework. Narrative literature reviews paired with the clinical experience of an expert committee were used to inform these three steps: (1) develop an understanding of the problem under study; (2) define the objectives of the intervention and identify a theoretical framework for highlighting strategies to be used in the intervention; and (3) operationalize the intervention and identify its anticipated outcomes. RESULTS: As a result of the three steps, the MENTOR_D nursing intervention relies on a caring-mentoring relationship between a nurse and the family. The aim of MENTOR_D is to increase the presence of the family at their relative's bedside and their involvement in delirium management. MENTOR_D's content is delivered over three phases that are organised around the visits of the family at the patient's bedside. During these phases, families used their knowledge of the patient to tailor the delirium management actions. These actions include orientation and reminiscence and were aimed at diminishing anxiety and increasing sense of self-efficacy in families and diminishing delirium severity and improving recovery in patients. CONCLUSIONS: A deep understanding of the underlying mechanisms of an intervention is key in its success to reach the targeted goals of effectiveness in practice. This understanding can be achieved through the careful development of a theory of the intervention before the operationalisation of its components and its testing. The proposed paper presents the theory of the MENTOR_D intervention, that is, its conceptualization and proposed mechanisms of action. IMPLICATIONS FOR PRACTICE: As delirium continues to be a major complication, this intervention is a promising solution to increase families' involvement in delirium management and highlights the support that nurses can offer to facilitate this involvement. With its use in future studies and practice, it can be further refined.

A post cardiac surgery intervention to manage delirium involving families: a randomized pilot study.

BACKGROUND: As many delirium manifestations (e.g., hallucinations or fears) are linked to patients' experiences and personality traits, it is suggested that interventions should be tailored to optimize its management. The inclusion of family members, as part of an intervention, has recently emerged as a solution to developing individualised patient care, but has never been assessed in post-cardiac surgery intensive care unit where almost half of patients will present with delirium. AIMS: To assess the feasibility, acceptability and preliminary efficacy of an nursing intervention involving family caregivers (FC) in delirium management following cardiac surgery. DESIGN: A randomized pilot study. METHODS: A total of 30 patient/FC dyads were recruited and randomized to usual care (n = 14) or intervention (n = 16). The intervention was based on the Human Caring Theory, a mentoring model, and sources informing self-efficacy. It comprised seven planned encounters spread over 3 days between an intervention nurse and the FC, each including a 30-min visit at the patient's bedside. During this bedside visit, the FC used delirium management strategies, e.g. reorient the person with delirium. The primary indicator of acceptability was to obtain consent from 75% of approached FCs. The preliminary effect of the intervention on patient outcomes was assessed on (1) delirium severity using the Delirium Index, (2) occurrence of complications, such as falls, (3) length of postoperative hospital stay and (4) psycho-functional recovery using the Sickness Impact Profile. The preliminary effect on FC outcomes was assessed on FC anxiety and self-efficacy. Data were analysed using descriptive statistics, ANCOVAs and logistic regressions. RESULTS: The primary indicator of obtaining consent from FC was achieved (77%). Of the 14 dyads, thirteen (93%) dyads received all seven encounters planned in the experimental intervention. Intervention group patients presented better psycho-functional recovery scores when compared with control group patients (p = 0·01). Mean delirium severity scores showed similar trajectories on days 1, 2 and 3 in both groups. CONCLUSION: The mentoring intervention was acceptable and feasible and shows promising results in improving patients and FC outcomes. RELEVANCE TO CLINICAL PRACTICE: Nurses should involve, if willing, FC to participate in activities that optimise patient well-being FC to use recognized delirium management strategies like reorientation and reassurance.

Evaluation of a Web-Based Tailored Nursing Intervention (TAVIE en m@rche) Aimed at Increasing Walking After an Acute Coronary Syndrome: A Multicenter Randomized Controlled Trial Protocol.

BACKGROUND: Despite the health benefits of increasing physical activity in the secondary prevention of acute coronary syndrome (ACS), up to 60% of ACS patients are insufficiently active. Evidence supporting the effect of Web-based interventions on increasing physical activity outcomes in ACS patients is growing. However, randomized controlled trials (RCTs) using Web-based technologies that measured objective physical activity outcomes are sparse. OBJECTIVE: Our aim is to evaluate in insufficiently active ACS patients, the effect of a fully automated, Web-based tailored nursing intervention (TAVIE en m@rche) on increasing steps per day. METHODS: A parallel two-group multicenter RCT (target N=148) is being conducted in four major teaching hospitals in Montréal, Canada. An experimental group receiving the 4-week TAVIE en m@rche intervention plus a brief "booster" at 8 weeks, is compared with the control group receiving hyperlinks to publicly available websites. TAVIE en m@rche is based on the Strengths-Based Nursing Care orientation to nursing practice and the Self-Determination Theory of human motivation. The intervention is centered on videos of a nurse who delivers the content tailored to baseline levels of self-reported autonomous motivation, perceived competence, and walking behavior. Participants are recruited in hospital and are eligible if they report access to a computer and report less than recommended physical activity levels 6 months before hospitalization. Most outcome data are collected online at baseline, and 5 and 12 weeks postrandomization. The primary outcome is change in accelerometer-measured steps per day between randomization and 12 weeks. The secondary outcomes include change in steps per day between randomization and 5 weeks, and change in self-reported energy expenditure for walking and moderate to vigorous physical activity between randomization, and 5 and 12 weeks. Theoretical outcomes are the mediating role of self-reported perceived autonomy support, autonomous and controlled motivations, perceived competence, and barrier self-efficacy on steps per day. Clinical outcomes are quality of life, smoking, medication adherence, secondary prevention program attendance, health care utilization, and angina frequency. The potential moderating role of sex will also be explored. Analysis of covariance models will be used with covariates such as sex, age, fatigue, and depression symptoms. Allocation sequence is concealed, and blinding will be implemented during data analysis. RESULTS: Recruitment started March 30, 2016. Data analysis is planned for November 2017. CONCLUSIONS: Finding alternative interventions aimed at increasing the adoption of health behavior changes such as physical activity in the secondary prevention of ACS is clearly needed. Our RCT is expected to help support the potential efficacy of a fully automated, Web-based tailored nursing intervention on the objective outcome of steps per day in an ACS population. If this RCT is successful, and after its implementation as part of usual care, TAVIE en m@rche could help improve the health of ACS patients at large. TRIAL REGISTRATION: ClinicalTrials.gov NCT02617641; https://clinicaltrials.gov/ct2/show/NCT02617641 (Archived by WebCite at http://www.webcitation.org/6pNNGndRa).

Evaluation of a nurse mentoring intervention to family caregivers in the management of delirium after cardiac surgery (MENTOR_D): a study protocol for a randomized controlled pilot trial.

BACKGROUND: Despite the use of evidence-based preventive measures, delirium affects about 40% of patients following cardiac surgery with the potential for serious clinical complications and anxiety for caregivers. There is some evidence that family involvement as a core component of delirium management may be beneficial since familiarity helps patients stay in contact with reality, however, this merits further investigation. There is also currently a gap in the scientific literature regarding objective indicators that could enhance early detection and monitoring of delirium. Therefore, this randomized pilot trial examines the acceptability, feasibility, and preliminary efficacy of an experimental nursing intervention to help family caregivers manage post-cardiac surgery delirium in their relatives. It also explores the validity of a new and innovative measure that has potential as an indicator for delirium. METHODS/DESIGN: In this two-group randomized pilot study (n = 30), the control group will receive usual care and the intervention group will receive the experimental intervention aimed at reducing delirium severity. The intervention nurse's objective will be to foster the family caregiver's self-efficacy in behaving in a supportive manner during delirium episodes. Data will be collected from standard delirium assessment scales and a novel measure of delirium, i.e., cerebral oximetry obtained using near infrared spectroscopy, as well as medical records and participants' responses to questionnaires. DISCUSSION: New strategies for early detection, monitoring, and management of delirium are needed in order to improve outcomes for both patients and families. The present article exposes feasibility issues based on the first few months of the empirical phase of the study that may be useful to the scientific community interested in improving the care of patients with delirium. Another potentially important contribution is in the exploration of cerebral oximetry, a promising measure as an objective indicator for early detection and continuous monitoring of delirium. The proposed pilot study will build towards a larger trial with the potential to improve knowledge about delirium management and monitoring. TRIAL REGISTRATION: This pilot study was registered at Controlled Trials on March 27th 2013 and was assigned #ISRCTN95736036.