Effect of an Oncology Nurse-Led Primary Palliative Care Intervention on Patients With Advanced Cancer: The CONNECT Cluster Randomized Clinical Trial.

Importance: Guidelines recommend early specialty palliative care for all patients with advanced cancer, but most patients lack access to such services. Objective: To assess the effect of CONNECT (Care Management by Oncology Nurses to Address Supportive Care Needs), a primary palliative care intervention delivered by oncology nurses, on patient outcomes. Design, Setting, and Participants: This cluster randomized clinical trial of the CONNECT intervention vs standard care was conducted from July 25, 2016, to October 6, 2020. Participants were adult patients with metastatic solid tumors who were undergoing oncological care and for whom an oncologist would agree with the statement "would not be surprised if the patient died in the next year." The trial was conducted at 17 community oncology practices in western Pennsylvania. Data analyses adhered to the intention-to-treat principle. Interventions: The CONNECT intervention included 3 monthly visits with an existing infusion room nurse who was trained to address symptoms, provide emotional support, engage in advance care planning, and coordinate care. Main Outcomes and Measures: The primary outcome was quality of life. At baseline and 3 months, participants completed assessments of quality of life (Functional Assessment of Chronic Illness Therapy-Palliative care: score range, 0-184, with higher scores indicating better quality of life), symptom burden (Edmonton Symptom Assessment Scale: score range, 0-90, with higher scores indicating greater symptom burden), and mood symptoms (Hospital Anxiety and Depression Scale [HADS]: score range, 0-21, with higher scores indicating substantial anxiety and depression). Linear mixed-effects models were used to estimate adjusted mean differences in 3-month outcomes. Preplanned, intensity-adjusted analyses were conducted. Results: A total of 672 patients were enrolled (mean [SD] age, 69.3 [10.2] years; 360 women [53.6%]). The mean (SD) number of CONNECT visits completed was 2.2 (1.0). At 3 months, no difference in mean (SD) quality-of-life score was found between the CONNECT and standard care groups (130.7 [28.2] vs 134.1 [28.1]; adjusted mean difference, 1.20; 95% CI, -2.75 to 5.15; P = .55). Similarly, there was no difference between groups in 3-month mean (SD) symptom burden (23.2 [16.6] vs 24.0 [16.1]; adjusted mean difference, -2.64; 95% CI, -5.85 to 0.58; P = .11) or mood symptoms (HADS depression subscale score: 5.1 [3.4] vs 4.8 [3.7], adjusted mean difference, -0.08 [95% CI, -0.71 to 0.57], P = .82; HADS anxiety subscale score: 5.7 [3.9] vs 5.4 [4.2], adjusted mean difference, -0.31 [95% CI, -0.96 to 0.33], P = .34). Intensity-adjusted analyses revealed a larger estimated treatment effect for patients who received a full dose (3 visits) of the CONNECT intervention. Conclusions and Relevance: This cluster randomized clinical trial found that a primary palliative care intervention that was delivered by oncology nurses did not improve patient-reported outcomes at 3 months. Primary palliative care interventions with a higher dose intensity may be beneficial for most patients with advanced cancer who lack access to palliative care specialists. Trial Registration: ClinicalTrials.gov Identifier: NCT02712229.

Identifying Symptom Information in Clinical Notes Using Natural Language Processing.

BACKGROUND: Symptoms are a core concept of nursing interest. Large-scale secondary data reuse of notes in electronic health records (EHRs) has the potential to increase the quantity and quality of symptom research. However, the symptom language used in clinical notes is complex. A need exists for methods designed specifically to identify and study symptom information from EHR notes. OBJECTIVES: We aim to describe a method that combines standardized vocabularies, clinical expertise, and natural language processing to generate comprehensive symptom vocabularies and identify symptom information in EHR notes. We piloted this method with five diverse symptom concepts: constipation, depressed mood, disturbed sleep, fatigue, and palpitations. METHODS: First, we obtained synonym lists for each pilot symptom concept from the Unified Medical Language System. Then, we used two large bodies of text (clinical notes from Columbia University Irving Medical Center and PubMed abstracts containing Medical Subject Headings or key words related to the pilot symptoms) to further expand our initial vocabulary of synonyms for each pilot symptom concept. We used NimbleMiner, an open-source natural language processing tool, to accomplish these tasks and evaluated NimbleMiner symptom identification performance by comparison to a manually annotated set of nurse- and physician-authored common EHR note types. RESULTS: Compared to the baseline Unified Medical Language System synonym lists, we identified up to 11 times more additional synonym words or expressions, including abbreviations, misspellings, and unique multiword combinations, for each symptom concept. Natural language processing system symptom identification performance was excellent. DISCUSSION: Using our comprehensive symptom vocabularies and NimbleMiner to label symptoms in clinical notes produced excellent performance metrics. The ability to extract symptom information from EHR notes in an accurate and scalable manner has the potential to greatly facilitate symptom science research.

Advancing Oncology Nursing Practice Through the Adoption of Patient Monitoring Digital Tools.

OBJECTIVE: The objective of this paper is to describe the use of oncology digital symptom monitoring and patient self-management coaching tools, how nurses and nurse practitioners (NPs) can optimize their use as an adjunct in improving oncology care and discuss issues and strategies needed for adoption within a variety of clinical settings. DATA SOURCES: A review of the research literature regarding digital health in oncology symptom management in PubMed provided the foundation for this paper. CONCLUSION: Digital symptom monitoring technology provides a variety of opportunities for oncology nurses and NPs to efficiently extend and improve symptom management in multiple settings including cancer patients at home between clinic visits, at clinic visits, and during inpatient stays. Digital monitoring and patient engagement make possible frequent symptom assessments, just-in-time personalized self-management reinforcement, and judiciously alert nurses and NPs about key times for follow-up with patients supported with evidenced-based guidelines. Oncology nurses at all levels have the opportunity to be leaders in the adoption and expansion of digital tools to enhance their practice. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses and NPs can lead practice changes that improve patient outcomes through understanding and shaping the use of digital tools.

Navigating Symptom Management in Heart Failure: The Crucial Role of the Critical Care Nurse.

High-acuity, progressive care, and critical care nurses often provide care for patients with heart failure during an exacerbation of acute disease or at the end of life. Identifying and managing heart failure symptoms is complex and requires early recognition and early intervention. Because symptoms of heart failure are not disease specific, patients may not respond to them appropriately, resulting in treatment delays. This article reviews the complexities and issues surrounding the patient's ability to recognize heart failure symptoms and the critical care nurse's role in facilitating early intervention. It outlines the many barriers to symptom recognition and response, including multimorbidities, age, symptom intensity, symptom escalation, and health literacy. The influence of self-care on heart failure management is also described. The critical care nurse plays a crucial role in teaching heart failure patients to identify and respond appropriately to their symptoms, thus promoting early intervention.

How visiting nurses detect symptoms of disease progression in patients with chronic heart failure.

Purpose: Chronic heart failure patients are often rehospitalized because they fail to seek appropriate, timely care. However, both patients and nurses experience difficulties in detecting signs of heart failure exacerbation. We aimed to qualitatively investigate how visiting nurses detect symptoms of disease progression in chronic heart failure patients in their homes.Methods: Participants were three experienced home-visit chronic heart failure nurses who completed one-to-one interviews. Data were analysed using the qualitative synthesis method (KJ method).Results: Six themes were identified that reflected detection of disease exacerbation and nursing support to prevent disease progression: difficulty of judging deterioration in patients with comorbidities; ascertaining conditions needing immediate intervention; detection of illness progression from changes in the patient's appearance; inferring instability in physical condition from patients' concerns and questions; arranging to ensure continued management of the patient post discharge; and instructing patients to ensure they never return to their old habits.Conclusions: The findings indicate that nurses experience challenges in detecting illness progression and judging when outpatient or hospital care is needed. However, nurses use a range of signs and symptoms to determine deterioration. Home-visit nurses thus play a crucial role in the post-hospital care of chronic heart failure patients.

Perspectives of Childhood Cancer Symptom-Related Distress: Results of the State of the Science Survey.

Management of symptom-related distress is an important area of pediatric oncology nursing. Participants who attended the Children's Oncology Group (COG) State of the Science Symposium on symptom distress completed an anonymous survey. The purpose was to explore participant perceptions of symptom distress experienced by children receiving cancer treatment on clinical trials, determine how symptom distress is currently assessed at COG institutions, and to identify what interventions are used to reduce symptom distress for these children. Among the 90 symposium attendees, 72% completed the survey, the majority (92%) of whom were nurses. The five most distressing symptoms in children with cancer enrolled on clinical trials identified by survey respondents were nausea/vomiting, fatigue, pain, anxiety, and sleep disturbances. Results from our survey also suggest that symptom distress may differ by disease type. For example, symptoms associated with leukemia/lymphoma included steroid side effects, procedural pain, and neuropathy. The majority of respondents (90%) also reported that symptoms go unrecognized by health care providers. The most commonly described unrecognized symptoms were behavioral (i.e., sadness, anxiety, fear, depression, and emotional needs; 45%) and fatigue (19%). Key focus areas reported by respondents included informal and inconsistent symptom assessment, the need for uniform measurement tools, and improved documentation of symptom-related distress. Management of symptom-related distress is an important aspect of pediatric oncology nursing. Further exploration of symptom distress experienced by children with specific types of cancers, and the development of standardized symptom assessment processes, will provide a foundation for developing future interventions aimed at alleviating symptom-related distress.

Adaptación cultural y validez de la "Memorial Symptom Assessment Scale (MSAS) 10­18" para Pediatría Oncológica en Colombia / Cultural adaptation and validity of the "Memorial Symptom Assessment Scale (MSAS) 10­18" for Pediatric Oncology in Colombia

Los niños y adolescentes con cáncer se enfrentan a una serie de cambios en su dinámica familiar, actividad social, experimentan síntomas físicos y psicoemocionales como consecuencia de la enfermedad y el tratamiento. La comprensión de la prevalencia y características de los síntomas en niños con cáncer se ha visto obstaculizada por la falta de herramientas de evaluación validadas en esta población. Para los enfermeros de la práctica en oncología pediátrica es determinante reconocer y manejar los síntomas, en tanto que tienen contacto directo con su sujeto de cuidado. Objetivo: Adaptar culturalmente y validar la escala de evaluación de síntomas Memorial para adolescentes entre 10- 18 años de edad en pediatría oncológica en el contexto colombiano en el año 2018. Método: Estudio de validación de escalas que se desarrolló en dos fases; la primera fue la adaptación cultural del MSAS 10-18 al contexto colombiano en donde participaron adolescentes sanos y la segunda fase de validación facial y de contenido con participantes expertos en el fenómeno, adolescentes con cáncer entre las edades descritas. Resultados: Se obtuvo versión adaptada de la Memorial Symptom Assessment Scale 10-18 al contexto colombiano para escenarios de oncología pediátrica, con una comprensibilidad global de los ítems mayores al 85% y un índice de validez de contenido de 0.71.

Children and adolescents with cancer face a series of changes in their family dynamics, social activity, they experience physical and psycho-emotional symptoms as a result of the disease and treatment. Understanding the prevalence and characteristics of symptoms in children with cancer has been hampered by the lack of validated assessment tools in this population. For nurses practice in pediatric oncology, it is crucial to recognize and manage the symptoms, as long as they have direct contact with the patients. Objective: To adapt culturally and validate the Memorial symptom assessment scale for children between 10-18 years of age in pediatric oncology in the Colombian context in 2018. Method: Study of validation scale that was developed in two phases; the first was the cultural adaptation of MSAS 10-18 to the Colombian context and the second phase of facial and content validation with expert in the phenomenon and adolescents with cancer between the ages described. Results: An adapted version of the Memorial Symptom Assessment Scale 10-18 was obtained in the Colombian context for pediatric oncology with a global comprehensibility of the items greater than 85% and a content validity index of 0.71

Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department.

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

[The latest best practice guidelines relating to seclusion and restraint]. / Les dernières recommandations de bonnes pratiques sur l'isolement et la contention.

Several measures relating to seclusion and restraint are included in the French public health code. The best practice guidelines of the French National Health Authority, published in 2017, define these two notions and advise on the behaviour to adopt with regard to their implementation and monitoring. Likewise, informing and supporting the patient when these measures are lifted are critical moments which the teams must also be able to manage correctly.

A qualitative study of nurse observations of symptoms in infants at end-of-life in the neonatal intensive care unit.

OBJECTIVES: Assessment and management of symptoms exhibited by infants can be challenging, especially at the end-of-life, because of immature physiology, non-verbal status, and limited symptoms assessment tools for staff nurses to utilize. This study explored how nurses observed and managed infant symptoms at the end-of-life in a neonatal intensive care unit. METHODOLOGY/DESIGNMETHODS: This was a qualitative, exploratory study utilizing semi-structured face-to-face interviews, which were tape-recorded, transcribed verbatim, and then analyzed using the Framework Approach. SETTING: The sample included 14 staff nurses who cared for 20 infants who died at a large children's hospital in the Midwestern United States. MAIN OUTCOME MEASURES: Nurses had difficulty recalling and identifying infant symptoms. Barriers to symptom identification were discovered based on the nursing tasks associated with the level of care provided. RESULTS: Three core concepts emerged from analyses of the transcripts: Uncertainty, Discomfort, and Chaos. Nurses struggled with difficulties related to infant prognosis, time of transition to end-of-life care, symptom recognition and treatment, lack of knowledge related to various cultural and religious customs, and limited formal end-of-life education. CONCLUSION: Continued research is needed to improve symptom assessment of infants and increase nurse comfort with the provision of end-of-life care in the neonatal intensive care unit.

Adverse reactions to whole blood donation, basic human needs and nursing diagnoses: a reflection.

A theoretical-Reflective study with the objective to reflect on human needs regarding the imbalance of whole blood donors considering adverse reactions to the donation, and the existing nursing diagnoses that best meet the imbalance needs. The following needs were pointed out according to the signs and symptoms of adverse reactions and based on the Theory of Basic Human Needs: skin and tissue integrity, emotional security, pain perception, body mechanics, oxygenation, physical integrity, physical comfort, elimination, neurological, electrolytic and vascular regulation. By observing NANDA International's Definitions and Classifications, adaptations to the existing nursing diagnoses and suggestions for new headings have been proposed. We conclude that some of the needs are interrelated, such as vascular regulation, oxygenation and physical integrity. Thus, more contextualized nursing diagnoses related to the needs of whole blood donors are needed, given the specific nature of the situation generating imbalances such as: ineffective systemic vascular regulation characterized by self-reported dizziness, cutaneous pallor and arterial hypotension related to vasovagal reaction.

Symptom assessment in pediatric oncology: how should concordance between children's and parents' reports be evaluated?

BACKGROUND: Clinical evaluations in pediatric oncology are often triadic, involving children or adolescents, parents, and clinicians. However, few studies have evaluated the concordance between children's and parents' reports of symptom occurrence. OBJECTIVES: The purposes of this study were to evaluate the concordance between children's and parents' symptom reports during the week of chemotherapy administration using 5 statistical approaches and determine which factors are associated with higher levels of dyadic concordance. METHODS: Independent assessments of symptom occurrence were obtained from children and adolescents with cancer (n = 107) and their parents using the Memorial Symptom Assessment Scale 10-18. Concordance was assessed using (1) percentage of overall agreement, (2) Cohen κ coefficients, (3) McNemar tests, (4) positive percentage agreement, and (5) negative percentage agreement. RESULTS: For each dyad, an average of 20 of the 31 symptom reports were concordant. Using children's reports as the "gold standard," parents rarely underestimated the children's symptoms. However, compared with children's reports, parents overestimated 7 symptoms. Advantages and disadvantages of each of the statistical approaches used to evaluate concordance are described in this article. CONCLUSIONS: A variety of statistical approaches are needed to obtain a thorough evaluation of the concordance between symptom reports. Discordance was most common for symptoms that children refuted, particularly psychosocial symptoms. IMPLICATIONS FOR PRACTICE: Clinicians need to interview children and adolescents along with their parents about the occurrence of symptoms and evaluate discrepant reports. Effective approaches are needed to improve communication between children and parents to improve symptom assessment and management.

Symptom burden in chronic kidney disease: a review of recent literature.

BACKGROUND: People living with chronic kidney disease (CKD) experience multiple symptoms due to both the disease and its treatment. However, these symptoms are often underrecognised. In addition, the majority of studies have focused on an individual symptom; however, these symptoms rarely occur in isolation and may instead occur in clusters. AIM OF REVIEW: To investigate the total symptom burden in advanced CKD (Stages 4 and 5) and to identify the key instruments that are used to assess multiple symptoms. METHODS: A literature search from 2006 to 2012 was undertaken and a total of 19 articles were included. RESULTS: The most common CKD symptoms were fatigue or lack of energy, feeling drowsy, pain and pruritus. However, symptom assessment instruments varied between studies, often with inconsistent or inadequate symptom dimensions. CONCLUSION: People with CKD experience a high symptom burden, although little is known about the burden for people with CKD Stage 4 and for those with CKD Stage 5 receiving peritoneal dialysis. This review recommends that a full range of symptoms be assessed for those at different stages of CKD. Improved understanding of the burden of symptoms can be used as the basis for treatment choices and for identifying priorities which are likely to contribute to a better quality of life and improve the quality of care.

[The French version of Symptom Management Theory and its application]. / Version Française de la Théorie de Gestion des Symptômes (TGS) et son application.

Patients with chronic diseases remain a challenge for patient centered care in terms of symptom management. In advancing the nursing profession in this respect, organizing and providing such care in a structured and systematic way benefits from being grounded in a sound theoretical framework. Since 1994, University of California in San Francisco's Symptom Management Theory (SMT) holds promise to provide such theoretical foundation. This paper aims at presenting a French version of the SMT, the "théorie de gestion des symptômes (TGS)" as well as at discussing its application in research and practice. The paper illustrates how different concepts of SMT interrelate for different symptoms or symptom clusters in light of the current state of knowledge. Furthermore, a selection of symptom assessment scales available in French are presented to inform practice, education and research. We believe that providing a French version of the SMT will foster a systematic and structured development of symptom management in nursing practice and research in francophone regions or countries.