Personalizing Heart Failure Care to the Patient With Cancer.

PURPOSE OF REVIEW: The current review describes the role of the cardio-oncology nurse and the need for personalized heart failure care for the patient with cancer. RECENT FINDINGS: It is a new role whereby cardiology or heart failure nurses care for patients with cancer who develop cardiotoxicity or cardiovascular diseases, either during the cancer therapy or in a later stage. Inter-disciplinary approach is important for individualized early treatment, shortened interruptions to cancer therapy, and irreversible cardiovascular injury prevention. Nurses have a key role in early evaluation and quality control of the care provided. This is a quite new clinical area and not much evidence exists for the development of clinical guidelines and pathways to support clinicians. More trials are needed for the development of clinical recommendations.

A qualitative meta-synthesis of patients with heart failure perceived needs.

Supportive care may have significant input into the treatment of patients with heart failure (HF). Support, understanding and being treated as a whole and unique person are vital for patients with HF. In order to develop a person-centred program, it is important to know patients' needs from their perspectives. The aim of the current review and meta-synthesis was to explore the needs of patients with HF from their perspective. A qualitative review was conducted using the keywords: ("needs" OR "need") AND ("heart failure") AND ("qualitative") in four databases. Pre-defined inclusion and exclusion criteria were set. The 'Consolidated criteria for reporting qualitative studies' item checklist was used to assess the research methodologies of the included studies. A "thematic synthesis" methodological approach was used: (1) Line by line coding of the findings from primary studies. (2) The resulting codes were organized into related areas thus building descriptive themes. (3) Analytical themes were developed. Eleven articles were included in the present review. The results from the meta-synthesis extracted five different categories covering patents' needs: Self-management, palliative care, supportive care, social support and continuing person-centred care. The need for continuing empowerment and support to meet those needs was also identified, revealing the core theme: 'Wind beneath my wings'. The meta-synthesis quotations highlighted the necessity for dynamic and interactive continuing person-centred care focusing on the ongoing patients' needs through the HF trajectory. Giving more emphasis to the human dimension and holistic approach of patients with HF, along with cardiology medicine development might be a key factor in improving clinical outcomes and health related quality of life.

The association of breastfeeding self-efficacy with breastfeeding duration and exclusivity: longitudinal assessment of the predictive validity of the Greek version of the BSES-SF tool.

INTRODUCTION: While breastfeeding self-efficacy (BSES) is an important modifiable determinant of breastfeeding, a structured assessment is not standard practice in Cyprus. We assessed the Greek version of the Breastfeeding Self-Efficacy Scale (BSES-SF), including its predictive validity in terms of Breastfeeding (BF) and Exclusive Breastfeeding (EBF) up to the sixth month. METHODS: A methodological study with longitudinal design among 586 mother-infant dyads, as part of the "BrEaST Start in Life" project. BSES was assessed 24-48 h after birth and at the first month. Breastfeeding status was assessed at the clinic, the 1st, 4th and 6th month. The association between BSES and breastfeeding was estimated in logistic regression models and its diagnostic ability in ROC analysis. RESULTS: With Mean = 3.55 (SD = 0.85), BSES was moderate, and lower among Cypriot women, primiparas and those who delivered by Cesarean Section (C/S). There was good internal consistency across the 14 items (Cronbach's α = 0.94) while factor analysis revealed a two-factor structure. BSES scores were higher among mothers who initiated exclusive breastfeeding (M = 3.92, SD = 0.80) compared to breastfeeding not exclusively (M = 3.29, SD = 0.84) and not breastfeeding (M = 3.04, SD = 1.09; p-value < 0.001). There was a stepwise association with exclusivity (40.5% in the highest vs 7.9% lowest quartile of self-efficacy). The association between in-hospital BSES and long-term EBF persisted in multivariable models. Women in the upper quartile of BSES at 48 h were more likely to breastfeed exclusively by adjOR = 5.3 (95% CI 1.7-17.1) at the 1st and adjOR = 13.7 (95% CI 2.7-68.6) at the 4th month. Similar associations were observed between self-efficacy at the 1st month and BF at subsequent time-points. High first month BSES (> 3.96 as per ROC) had 58.9% positive and 79.6% negative predictive value for breastfeeding at 6 months which reflects higher sensitivity but lower specificity. CONCLUSIONS: The Greek version of BSES-SF showed good metric properties (construct, know-group, concurrent and predictive validity). In the absence of community support structures or programmes in Cyprus, prevalence of breastfeeding remains low. This suggests a need for policy, educational and community support interventions, including the systematic use of BSES scale as a screening tool to identify those at higher risk for premature BF discontinuation.

Nursing quality indicators for adult intensive care: A consensus study.

BACKGROUND: The selection of quality indicators demonstrating the efficiency and relevance of nursing practice in patient outcomes in the intensive care unit remains a challenge. AIM: The aim of this study was to develop a set of potential quality indicators to quantify nursing care provided to critically ill patients through a consensus method. DESIGN: This was a three-phase study including a European survey of intensive care unit (ICU) nurses (phase one) followed by a two-phase face-to-face consensus meeting of experts from Cyprus. METHOD: Two distinct panels of experts were asked to rate each quality indicator using a 4-point Likert scale in phases one and two. The level of consensus was set at 60%. In phase three, scores of the content validity index for items and scales were considered for the final selection of quality indicators. RESULTS: The phase one survey included 139 ICU nurses from 13 European countries, and phases two and three included seven ICU experts from Cyprus. "Consensus in" was achieved for 12 items at the end of phase two. Three of the quality indicators were significantly different by country: (a) falls (P = .006), (b) accidental removal of nasogastric tube (P < .001), and (c) accidental removal of intravascular catheters (P < .001). Only falls was significantly correlated with higher academic qualifications of the participants (P = .002). CONCLUSIONS: Fifteen items have been identified as potential indicators for adult ICU nursing quality. These need to be prospectively studied to determine the extent to which they can accurately capture nursing care quality in this setting. RELEVANCE TO CLINICAL PRACTICE: The study provides a set of relevant quality indicators. A nursing set for the ICU may serve as the basis for nursing management and facilitate the strategy dedicated to the vision of health care quality assurance.

The Greek versions of the TeamSTEPPS teamwork perceptions questionnaire and Minnesota satisfaction questionnaire "short form".

BACKGROUND: Teamwork and job satisfaction are important among the multidisciplinary team who care patients with chronic illnesses such as heart failure (HF) patients. TeamSTEPPS teamwork perceptions questionnaire (T-TPQ) and Minnesota Satisfaction Questionnaire "short form" (MSQ-short) are both self-report questionnaires which examine multiple dimensions of perceptions of teamwork and job satisfaction within healthcare settings, respectively. The aim of the study was to examine the psychometric properties of the Greek versions of the TeamSTEPPS Teamwork perceptions questionnaire (Gr-T-TPQ) and Minnesota Satisfaction Questionnaire "short form" (Gr-MSQ-short). METHODS: A methodological study was contacted in order to assess the construct validity and reliability of the Gr-T-TPQ and Gr-MSQ-short. For that reason, 292 questionnaires were administrated to Greek-Cypriot health care professionals (HCPs). Confirmatory factor analysis (CFA) was conducted for the data collected with the GrT-TPQ and Exploratory factor analysis (EFA) and CFA were also conducted for the data collected with the GrMSQ-short questionnaire. Cronbach's a was calculated as well. RESULTS: CFA of the data collected with Gr-T-TPQ confirmed the initial scale structure with excellent fit indices (× 2 (df) 1124.75 (550), p < 0.0001, AGFI = 0.986, TLI = 0.994, CFI = 0.994, RMSEA = 0.06, 90%, C.I.[0.055-0.065]). Furthermore, all dimensions were found to be correlated (r = 0.65 to r = 0.88) and internal consistency was found adequate (Cronbach's α = 0.96). Subscales also, demonstrated high internal consistency (α = 0.87-0.95). CFA for the data collected with Gr-MSQ-short, did not confirm the initial scale's dimensions. In EFA items 1, 5, 6, 12 and 18 were eliminated from the analysis due to low communalities and multiple components loading. The oblimin rotation with two factors was explaining 58% of the variance. These two factors identified were Supervisor/Autonomy and Task Enrichment. CONCLUSIONS: In general, the Gr-T-TPQ and Gr-MSQ-short are construct-valid instruments for measuring perceptions of teamwork and job satisfaction in Greek speaking HCPs' population.

Supportive Care Interventions to Promote Health-Related Quality of Life in Patients Living With Heart Failure: A Systematic Review and Meta-Analysis.

Supportive care (physical, psychosocial, and spiritual) may be beneficial as a coping resource in the care of patients with heart failure (HF). Nurses may provide individualised supportive care to offer positive emotional support, enhance the patients' knowledge of self-management, and meet the physical and psychosocial needs of patients with HF. The aim of this study was to examine the potential effectiveness of supportive care interventions in improving the health- related quality of life (HRQoL) of patients with HF. Related outcomes of depression and anxiety were also examined. A systematic search of PubMed, CINAHL, and the Cochrane Library was performed to locate randomised controlled trials (RCTs) that implemented any supportive care interventions in patients with HF published in the English language. Identified articles were further screened for additional studies. Ten (10) RCTs were selected for the meta-analysis. Effect sizes were estimated between the comparison groups over the overall follow-up period, and presented along with confidence intervals (CIs). Statistical heterogeneity for each comparison was estimated using Q (chi square test) and I2 statistics with 95% CIs. Statistical heterogeneity was observed in all study variables (i.e., HRQoL and dimensions). There was a positive, but not statistically significant, effect of social support on HRQoL (mean difference [MD], 5.31; 95% CI, -8.93 to 19.55 [p=0.46]). The results of the two dimensions suggested a positive and statistically significant effect of the supportive care interventions (physical: MD, 7.90; 95% CI, 11.31-4.50 [p=0.00]; emotional dimension: MD, 4.10; 95% CI, 6.14-2.06; [p=0.00]). The findings of the current study highlight the need to incorporate supportive care to meet the needs of patients with HF. Patients with HF have care needs that change continuously and rapidly, and there is a need of a continuous process in order to address the holistic needs of patients with HF at all times and not just in a cardiology department or an acute care setting. Patients with HF have multiple needs, which remain unmet. Supportive care is a holistic, ongoing approach that may be effective in identifying and meeting the care needs of patients with HF along with the patient. This review includes all interventions provided in individuals with HF, giving clinicians the opportunity to choose the most suitable ones in improving the clinical outcomes of their patients with HF.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial.

BACKGROUND: Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes. OBJECTIVES: To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients. METHODS: Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed. RESULTS: A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47). CONCLUSION: Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

Evaluation of the psychometric properties of the Greek version of the Active Life with Asthma (Gr-ALMA) review: a descriptive methodological study.

BACKGROUND: Regular asthma reviews are recommended by international guidelines to improve the quality of life of asthma patients. To facilitate these reviews in primary care practice, there is a need for structured asthma review tools. AIM: The aim of this study was to assess the metric properties of the Greek-translated version of the Active Life with Asthma (ALMA) review. METHODS: A convenience sample of 156 asthmatic patients from three public hospitals participated in this methodological study with a descriptive cross-sectional correlation design. Participants responded to the 19-item ALMA questionnaire and provided socio-demographic and clinical information. The construct validity of the tool was explored in exploratory factor analysis and the internal consistency of scale and sub-scales was estimated using Cronbach's α. Convergence validity was assessed using the Asthma Control Questionnaire (ACQ), a commonly used asthma control measure, and concurrent criterion validity was assessed using the MiniAQoL, an asthma-specific quality of life questionnaire. Known-group validity was assessed based on observed differences in terms of frequency of hospitalizations or emergency visits in the past year. RESULTS: Amongst 156 participants, 95 (60.9%) were women and the median age was 50-65 years old. Exploratory factor analysis (KMO = 0.83 and Bartlett test < 0.001) with principal component extraction and orthogonal rotation revealed a clear structure of three factors with little cross-loading: physical, environmental and mental domains, as in the original study. Cronbach's alpha coefficient for internal consistency for the whole scale was 0.85, while for the sub-scales, these were: environmental a = 0.69, mental a = 0.76 and physical a = 0.85. Test-retest reliability based on the correlation between scores of 20 participants responding twice two weeks apart was r = 0.92. There was stong correlation in the expected direction between ALMA and ACQ (r = - 0.70) as well as miniAQoL (r = 0.71). Finally, there were statistically significant higher ALMA scores in participants who reported emergency visits and hospital admissions in the past year. CONCLUSION: In general, the ALMA showed good metric properties. It appears to be a reliable and valid tool which can be used as a measure for asthma control and self-management in clinical practice as well as future descriptive or intervention research studies.

Prevalence of breast-feeding and exclusive breast-feeding at 48 h after birth and up to the sixth month in Cyprus: the BrEaST start in life project.

OBJECTIVE: To assess the prevalence and sociodemographic determinants of breast-feeding (BF) and exclusive breast-feeding (EBF) in Cyprus up to the sixth month. DESIGN: Cross-sectional and longitudinal descriptive study. BF and EBF were estimated based on mothers' self-reported BF status in line with Step 7 of the WHO/UNICEF Baby-Friendly Hospital Initiative questionnaire and based on 24 h recall. SETTING: Maternity wards in all public hospitals and twenty-nine (of thirty-five) private maternity clinics nationwide. SUBJECTS: Consecutive sample of 586 mothers recruited within 48 h from birth, followed up by telephone interview at the first, fourth and sixth month. RESULTS: Although 84·3 % of mothers initiated BF before discharge, prevalence of BF at the sixth month was 32·4 %, with the highest reduction observed between the first and fourth months. Prevalence of EBF at 48 h was 18·8 % and fell gradually to 5·0 % at the sixth month. Mothers with higher educational attainment or higher family income were more likely to breast-feed until the sixth month. In terms of EBF, an association was observed only with education, which persisted until the sixth month. Other than social gradient, mode of delivery was the strongest determinant of BF initiation, exclusivity and continuation. Mothers who gave birth vaginally were three to four times more likely to initiate BF (OR=3·1; 95 % CI 1·7, 5·4) and EBF (OR=4·3; 95 % CI 2·7, 6·8). CONCLUSIONS: The low prevalence of BF and EBF in Cyprus, together with the fact that caesarean section rates are currently among the highest in Europe, suggest the need for further research to understand this multidimensional phenomenon and for interdisciplinary policy action to protect, promote and support BF.

A Meta-ethnography of Out-of-Hospital Cardiac Arrest Survivors' Meanings on Life and Death.

BACKGROUND: Although out-of-hospital cardiac arrest (OHCA) survivors' physiological outcomes have been addressed, less is known on the holistic needs of individuals after OHCA, which hinders our ability to prioritize care around what really matters to survivors. AIM: The aim of this study was to interpretatively synthesize qualitative findings on OHCA survivors' perceptions and meanings of life and death and existential issues. METHODS: We used a meta-ethnographic synthesis of published qualitative studies addressing the experiences of OHCA survivors based on a systematic literature search (CINAHL, PsycINFO, Scopus, PubMed). Studies were selected based on predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on the Critical Appraisal Skills Programme. RESULTS: Based on eligibility criteria, 6 phenomenological studies were included, of overall medium to high quality. One core theme, "the reality of death," and 4 main themes were identified: "redefining existence"; "revaluing death"; "being familiar with, yet oblivious of death"; and "living consciously." Emerging from the realization of death, the themes appeared to describe a gradual progression toward living consciously. CONCLUSIONS: An existential trajectory and a need for meaning are central in the experience of OHCA survivors. When existential issues are not addressed, the ongoing suffering may interfere with survivors' recovery and quality of life. Future research needs to address specific needs and ways to support survivors' meaning-making.

The effect of guided imagery on physiological and psychological outcomes of adult ICU patients: A systematic literature review and methodological implications.

OBJECTIVES: Guided imagery (GI) is a relaxation technique that is being increasingly explored in various patients' populations. We systematically reviewed evidence on the effects of GI on physiological and psychological outcomes of adult critically ill patients and extracted implications for future research. REVIEW METHOD USED: Systematic literature review of published studies based on the Cochrane Guidelines. DATA SOURCES: Studies were located through literature searches of CINAHL, PubMed, Embase, Cochrane Database of Systematic Reviews and Psych-Info. REVIEW METHODS: We explored effects of GI in critically illness. The outcome measures included pain, anxiety, hemodynamic measurements, stress neuropeptides, length of stay, sleep quality, inflammatory markers, patient satisfaction and cost of care. The Cochrane Collaboration's tool for assessing risk of bias was employed. Extracted data included pathophysiological framework, sample, diagnoses of participants, specifics of intervention, design, experimental groups, analyses and main outcomes. RESULTS: Based on the selection criteria, 10 studies were identified, involving N=1391 critically ill patients. The main limitations include incomplete outcome data and selective reporting, incomplete blinding and lack of experimental group allocation concealment. Due to heterogeneity and incomplete reporting, a meta-analysis was not feasible. Our findings included: (a) favourable effects of the intervention with regard to decrease of pain, anxiety and LOS; (b) many studies employing randomised controlled trial designs; (c) a predominant focus on patients with cardiac surgery; (d) large heterogeneity in measurement of outcomes. Moreover, the evidence suggests that improvements in sleep quality, patient satisfaction and cost of care merit further investigation. Methodological implications include the need to clarify the underlying physiological framework, the use of repeated measure designs and the adjustment for confounders. CONCLUSIONS: On the basis of these results, and of the absence of reported side-effects, we conclude that GI is a promising patient-centered approach for the improvement of a number of patients' outcomes that merits further investigation in critical care.

Educational challenges to the health care professional in heart failure care.

The purpose of this review is to discuss the educational challenges faced by health care professionals in the care and management of patients with heart failure (HF). Self-care is a vital component in HF management, and promotion of self-care through education is a fundamental aspect of patient-centered care and supports patients' right to autonomy. The ultimate goal is not simply to convey knowledge, but to promote patients' understanding and to enhance their self-care skills by assuming an active role in their care. As such, health care professionals are confronted with a number of patient-related issues as they strive to provide high-quality education. Beyond assessing patients' individual information needs and preferences, they are tasked with addressing several obstacles that impede patients' ability to engage in self-care. Factors such as cognitive impairment and low health literacy have a major impact on patients' ability to understand, absorb, and recall information. Moreover, the existence of negative beliefs, which are strong determinants of patients' attitudes towards their disease and treatment, may also influence their response to educational messages. Health care professionals must not only identify and overcome these obstacles, but they must act effectively within the limitations of their working environment and of the health care system.

Differences in presentation, diagnosis and management of heart failure in women. A scientific statement of the Heart Failure Association of the ESC.

Despite the progress in the care of individuals with heart failure (HF), important sex disparities in knowledge and management remain, covering all the aspects of the syndrome, from aetiology and pathophysiology to treatment. Important distinctions in phenotypic presentation are widely known, but the mechanisms behind these differences are only partially defined. The impact of sex-specific conditions in the predisposition to HF has gained progressive interest in the HF community. Under-recruitment of women in large randomized clinical trials has continued in the more recent studies despite epidemiological data no longer reporting any substantial difference in the lifetime risk and prognosis between sexes. Target dose of medications and criteria for device eligibility are derived from studies with a large predominance of men, whereas specific information in women is lacking. The present scientific statement encompasses the whole scenario of available evidence on sex-disparities in HF and aims to define the most challenging and urgent residual gaps in the evidence for the scientific and clinical HF communities.

Risk and Management of Patients with Cancer and Heart Disease.

Cancer and cardiovascular disease are two of the leading causes of global mortality and morbidity. Medical research has generated powerful lifesaving treatments for patients with cancer; however, such treatments may sometimes be at the expense of the patient's myocardium, leading to heart failure. Anti-cancer drugs, including anthracyclines, can result in deleterious cardiac effects, significantly impacting patients' functional capacity, mental well-being, and quality of life. Recognizing this, recent international guidelines and expert papers published recommendations on risk stratification and care delivery, including that of cardio-oncology services. This review will summarize key evidence with a focus on anthracycline therapy, providing clinical guidance for the non-oncology professional caring for a patient with cancer and heart failure.

A randomized trial of a nurse-led educational intervention in patients with heart failure and their caregivers: impact on caregiver outcomes.

AIMS: Psychoeducational interventions focusing on self-management of heart failure (HF) patients may improve patient health knowledge and reduce hospitalizations, but data regarding the effects on caregiver outcomes are inconclusive. METHODS AND RESULTS: We conducted a single-centre, randomized controlled study to evaluate the effect of a nurse-led educational intervention in dyads of recently hospitalized HF patients and their caregivers on caregiver burden, feelings of guilt and health-related quality of life (HR-QoL). Dyads were randomized to usual care plus intervention group 1 (IG-1) or 2 (IG-2) or usual care only (control group, CG). Educational sessions in IG-1 and IG-2 were initiated before hospital discharge and continued with combination of home visits and telephone sessions in IG-1, or telephone sessions only in IG-2, delivered on regular intervals for 6 months. Caregiver burden was assessed by Heart Failure Caregiver Questionnaire (HF-CQ v5.0), guilt by Caregiver Guilt Questionnaire (CGQ), and QOL by EuroQol EQ-5D. Fifty-seven patient/caregiver dyads were included: 12 in IG-1, 18 in IG-2, and 27 in CG, of whom 11, 16, and 20, respectively, completed the study. All domains of HF-CQ and CGQ improved in IG-1 and IG-2 at 6 months, whereas deteriorated in CG (all P < 0.01). EQ-5D improved in IG-1 and IG-2 only in visual analogue scale part (P = 0.002), but not in the descriptive part. CONCLUSION: A nurse-led, 6-month educational intervention on recently hospitalized HF patients/caregiver dyads, delivered through either combined home visits and telephone sessions or telephone sessions only, reduced caregiver burden and feelings of guilt, with lesser effect on HR-QoL. REGISTRATION: ClinicalTrials.gov: NCT05480969.

An Interactive E-learning Platform-Based Training to Improve Intensive Care Professionals' Knowledge Regarding Central Venous Catheter-Related Infections.

Introduction The presence of a central venous catheter (CVC) leads to a high risk for blood infections, which are associated with increases in morbidity, mortality, and costs. This study aims to assess intensive care unit (ICU) nurses' and physicians' knowledge regarding the Centers for Disease Control and Prevention (CDC) guidelines for preventing CVC-related infections before and after an interactive distance education delivered through the e-learning platform Teleprometheus. Materials and methods The study was conducted among 85 nurses and physicians in Nicosia's General Hospital Intensive Care Unit (NGH-ICU) and high dependency unit (HDU). A validated questionnaire was used to assess nurses' and physicians' knowledge. Results Prior to the online interactive distance education, the mean total knowledge score was x̄ = 4.8 (SD = 2.46), while after, the mean total knowledge score increased to x̄ = 8.9 (SD = 2.38) (p<0.001). ICU physicians had a higher mean total knowledge score (x̄ = 10.20) than ICU nurses (x̄ = 8.75) after the intervention. There was no correlation between years of experience in the ICU and the level of knowledge (r = 0.048). The interactive distance education was positively evaluated by the participants, through a questionnaire, specially designed for this study. Discussion The most important findings were that (a) the level of knowledge of the participants improved with a statistically significant difference after the completion of the e-course, (b) the level of knowledge of the participants, after the completion of the e-course, was much higher from other studies, (c) there was no correlation between the years of experience of ICU health professionals and their level of knowledge, and (d) the interactive distance e-course was positively evaluated and satisfied the participants. Conclusion The current study demonstrates that in high-intensity work environments, such as ICUs, adopting e-learning approaches seems more necessary than ever.

The living experience of surviving out-of-hospital cardiac arrest and spiritual meaning making.

AIM: To understand the meaning of surviving out of hospital cardiac arrest and its aftereffects among Greek-speaking survivors. DESIGN: Hermeneutical phenomenological method based on Martin Heidegger's philosophy. METHODS: Eight Greek-speaking out of hospital cardiac arrest survivors were recruited using purposive sampling method. Data collection and analysis using the seven stages of hermeneutic analysis described by Diekelman. Data were collected through semi-structured personal interviews with open-ended questions. RESULTS: Analysis revealed five themes: 'The unexpected attack', 'Experiencing a different world: Transformation of Body, Time, Emotion and Sensation', 'Restoration of the re-embodied self', 'Life transformation' and 'Personal transformation'. The themes are commensurate with transcultural components of Near-Death Experiences. Surviving out of hospital cardiac arrest was perceived as a 'divine gift' and a chance to continue 'living in a more conscious and meaningful way'. Despite participants' physical and psychosocial challenges, the narratives highlighted a newly acquired deep appreciation for the joy of life, living and others. Construction of meaning and a heightened spirituality seem central in reconstructing life after out of hospital cardiac arrest survivors. PATIENT OR PUBLIC CONTRIBUTION: Out of hospital cardiac arrest survivors reflected and described in-depth on their lived experiences of out of hospital cardiac arrest through a 60- to 90-min interview. In addition, the participants provided their feedback on the interpretation of the findings, confirmed the study findings, and ensured that the analysis reflected aspects of their individual experiences and were true to them.