Measuring pain or discomfort during routine nursing care in lightly sedated mechanically ventilated intensive care patients: A prospective preliminary cohort study.

BACKGROUND: Pain is routinely measured on mechanically ventilated ICU patients. However, the tools used are not designed to discriminate between pain and non-pain discomfort, a distinction with therapeutic implications. OBJECTIVES: To evaluate whether clinical measurement tools can discern both pain and non-pain discomfort. METHODS: A prospective observational cohort study was conducted in a General ICU at a tertiary Medical Center in Israel. The Behavior Pain Scale (BPS) and Visual Analog Scale (VAS) of Discomfort were simultaneously assessed by a researcher and bedside nurse on thirteen lightly sedated patients during 71 routine nursing interventions in lightly sedated, mechanically ventilated, adult patients. Patients were asked whether they were in pain due to these interventions. RESULTS: Statistically significant increases from baseline during interventions were observed [median change: 1.00 (-1-5), 1.5(-4-8.5), p < 0.001] as measured by BPS and VAS Discomfort Scale, respectively. BPS scores ranged between 4 and 6 when the majority (53 %) of the patients replied that they had no pain but were interpreted by the clinicians as discomfort. Endotracheal suctioning caused the greatest increase in BPS and VAS, with no statistically significant differences in BPS and VAS Discomfort Scale scores whether patients reported or did not report pain. A BPS>6 had a higher sensitivity and specificity to reported pain (accuracy of 76 %) compared to a BPS of 4-6. CONCLUSIONS: Standard assessments are sensitive to pain caused by routine nursing care interventions. However, this study presents evidence that among lightly sedated ICU patients, moderate BPS scores could also measure non-pain discomfort. ICU nurses should be aware that signs of unpleasantness measured by a pain scale could reflect non-pain discomfort.

Acute palliative care models: scoping review.

OBJECTIVE: The goal of this scoping review is to identify the most commonly used models of palliative care delivery in acute care settings, their advantages and disadvantages, and to review existent research evidence in support of each model. METHODS: We conducted an extensive search using EMBASE, Medline, CINAHL and Pubmed, using various combinations of terms relating to models in palliative care and acute care settings. Data were analysed using tabular summaries and content analysis. RESULTS: 41 articles were analysed. Four models were identified: primary, consultative, integrative and hybrid models of palliative care. All four models have varying characteristics in terms of access to specialist palliative care; fragmentation of healthcare services; therapeutic relationships between patients and providers; optimal usage of scarce palliative care resources; timing of provision of palliative care; communication and collaboration between providers and clarity of provider roles. Moreover, all four models have different patient outcomes and healthcare utilisation. Gaps in research limit the ability to determine what model of care is more applicable in an acute care setting. CONCLUSION: No ideal model of care was identified. Each model had its advantages and disadvantages. Future work is needed to investigate which setting one model may be better than the other.

Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings.

Introduction: Palliative care (PC) delivery for persons with advanced dementia (AD) remains low, particularly in acute-care settings. Studies have shown that cognitive biases and moral characteristics can influence patient care through their effect on the thinking patterns of healthcare workers (HCWs). This study aimed to determine whether cognitive biases, including representativeness, availability, and anchoring, are associated with treatment approaches, ranging from palliative to aggressive care in acute medical situations, for persons with AD. Methods: Three hundred fifteen HCWs participated in this study: 159 physicians and 156 nurses from medical and surgical wards in two hospitals. The following questionnaires were administered: a socio-demographic questionnaire; the Moral Sensitivity Questionnaire; the Professional Moral Courage Scale; a case scenario of a person with AD presenting with pneumonia, with six possible interventions ranging from PC to aggressive care (referring to life-prolonging interventions), each given a score from (-1) (palliative) to 3 (aggressive), the sum of which is the "Treatment Approach Score;" and 12 items assessing perceptions regarding PC for dementia. Those items, the moral scores, and professional orientation (medical/surgical) were classified into the three cognitive biases. Results: The following aspects of cognitive biases were associated with the Treatment Approach Score: representativeness-agreement with the definition of dementia as a terminal disease and appropriateness of PC for dementia; availability-perceived organizational support for PC decisions, apprehension regarding response to PC decisions by seniors or family, and apprehension regarding a lawsuit following PC; and anchoring-perceived PC appropriateness by colleagues, comfort with end-of-life conversations, guilt feelings following the death of a patient, stress, and avoidance accompanying care. No association was found between moral characteristics and the treatment approach. In a multivariate analysis, the predictors of the care approach were: guilt feelings about the death of a patient, apprehension regarding senior-level response, and PC appropriateness for dementia. Conclusion: Cognitive biases were associated with the care decisions for persons with AD in acute medical conditions. These findings provide insight into the potential effects of cognitive biases on clinical decisions, which may explain the disparity between treatment guidelines and the deficiency in the implementation of palliation for this population.

Interprofessional palliative and end-of-life education: short-term and long-term outcomes - mixed-methods analysis.

ObjectiveInterprofessional care is integral to end-of-life (EOL) and palliative care (PC) and may be suited for EOL and PC education.We evaluate the impact of an interprofessional EOL care curriculum on participants, during the course, on completion and 4 years laterusing quantitative (questionnaires) and qualitative (open-ended questions and interviews) methods.The course included 14 fifth and sixth-year medical students, 9 social work students and 7 nursing students enrolled in master's degree programmes. Seventeen participants completed questionnaires 4 years later and eight participated in interviews.On postcourse questionnaires, participants attributed high value to interprofessional education (IPE) (4.77/5±0.50 on a Likert scale). Four years later, participants reported that IPE impacted their professional (3.65/5±1.11) and personal lives (3.94/5±1.09) and found PC IPE important (4.88/5±0.33).Conventional content analysis showed that the course enabled discussion of death and dying and provided an opportunity for a personal-emotional journey. It offered an approach to EOL care and an opportunity to experience interprofessional teamwork at the EOL resulting in behavioural change.Interprofessional EOL education resulted in meaningful and lasting self-reported personal and professional behavioural outcomes.

Intensive Care Unit Caregivers Perception of Patient Discomfort: A Qualitative Study.

BACKGROUND: Being hospitalized in an intensive care unit ICU often involves pain and discomfort. While pain is commonly alleviated with analgesics, discomfort is more difficult to diagnose and treat, thus potentially leading to incorrect analgesic administration. AIM: To describe intensive care unit practitioners' perceptions of discomfort in the ICU, and their methods to discern between pain and non-pain discomfort. METHODS: Twenty-five intensive care unit practitioners (7 doctors and 18 nurses) were interviewed from medical and general intensive care units at one institution in Jerusalem, Israel. Data collection was performed using semi-structured interviews. Interviews were audio-recorded and transcribed. Transcriptions were coded and categorized by two researchers independently. Content analysis identified common themes. RESULTS: Two main discomfort themes were identified: unpleasant physical sensations and unpleasant psychologic feelings, with further subcategories. Physiologic and non-physiologic signs such as facial expression and motor activity helped to diagnose discomfort. Trial and error and cause and effect were used to differentiate pain from other sources of discomfort. CONCLUSIONS: Practitioners saw pain as a dominant source of discomfort. Treating overall discomfort should focus on improving the quality of the total intensive care unit experience. Strategies to diagnose non-pain discomfort and pain were similar. Differentiating pain from non-pain discomfort is essential in order to provide appropriate treatment for pain and non-pain-related discomfort.

Do Perceptions about Palliative Care Affect Emergency Decisions of Health Personnel for Patients with Advanced Dementia?

Decision analysis regarding emergency medical treatment in patients with advanced dementia has seldom been investigated. We aimed to examine the preferred medical treatment in emergency situations for patients with advanced dementia and its association with perceptions of palliative care. We conducted a survey of 159 physicians and 156 nurses from medical and surgical wards in two tertiary hospitals. The questionnaire included two case scenarios of patients with advanced dementia presenting gastrointestinal bleeding (scenario I) or pneumonia (scenario II) with a list of possible interventions and 11 items probing perceptions towards palliative care. Low burden interventions such as laboratory tests and intravenous administration of antibiotics/blood were preferred. Palliative measures such as analgesia/sedation were chosen by about half of the participants and invasive intervention by 41.6% (gastroscopy in scenario I) and 37.1% (intubation/mechanical ventilation in scenario II). Medical ward staff had a more palliative approach than surgical ward staff in scenario I, and senior staff had a more palliative approach than junior staff in scenario II. Most participants (90.4%) agreed that palliative care was appropriate for patients with advanced dementia. Stress in caring for patients with advanced dementia was reported by 24.5% of participants; 33.1% admitted fear of lawsuit, 33.8% were concerned about senior-level responses, and 69.7% were apprehensive of family members' reaction to palliative care. Perceptions of health care workers towards palliative care were associated with preferred treatment choice for patients with advanced dementia, mainly in scenario II. Attitudes and apprehensions regarding palliative care in these situations may explain the gap between positive attitudes towards palliative care and the chosen treatment approach. Acquainting emergency care practitioners with the benefits of palliative care may impact their decisions when treating this population.

Practice of end-of-life care for patients with advanced dementia by hospital physicians and nurses: Comparison between medical and surgical wards.

BACKGROUND: Patients with advanced dementia are commonly hospitalized in acute care wards, yet there is limited data regarding the end-of-life (EOL) care delivered to this population. The aim of the study was to examine EOL care delivered to patients with advanced dementia hospitalized on acute wards as reported by physicians and nurses. METHODS: Participants were physicians and nurses from medical and surgical wards of two tertiary hospitals in Israel. Participants completed a self-report questionnaire evaluating EOL care experiences, knowledge, performance, assessment, communication, and perceived futile care regarding patients with dementia. RESULTS: The questionnaire was completed by 315 providers. There were 190 medical ward respondents and 125 from general surgical wards. Of them, 48.6% recognized dementia as a terminal disease, while 26.0% of the participants reported that they knew the end-of-life preferences for less than 10% of their patients. Among the providers, 53.3% reported that end-of-life ward discussions took place only when there was a life-threatening situation and 11.1%-16.5% never engaged in end-of-life communication regarding EOL patient's preferences, appointing an attorney for the patient, disease trajectory or the essence of palliative care, with patients or their representatives. Only 17.1% reported "never" performing care they considered to be futile for patients with advanced dementia. Controlling for gender, age, role, position (senior/junior), and exposure to patients with advanced dementia, surgical ward respondents reported performing less EOL care than medical ward respondents in almost all aspects of palliative care. CONCLUSIONS: Despite growing attention, a significant portion of staff in acute care wards do not report applying EOL care to patients with advanced dementia in clinical practice, especially surgical ward staff.

Practitioner Bias as an Explanation for Low Rates of Palliative Care Among Patients with Advanced Dementia.

Patients with advanced dementia are less likely than those with other terminal illnesses to receive palliative care. Due to the nature and course of dementia, there may be a failure to recognize the terminal stage of the disease. A possible and under-investigated explanation for this healthcare disparity is the healthcare practitioner who plays a primary role in end-of-life decision-making. Two potential areas that might impact provider decision-making are cognitive biases and moral considerations. In this analysis, we demonstrate how the cognitive biases and moral considerations of practitioners related to clinical decision-making are inherent in clinical practice and may impact on providers' accuracy related to diagnostic and treatment related decision-making associated with patients with advanced dementia. Anchoring, default, availability, representativeness and framing biases are cognitive biases based on the "Two System Model" that relate to decision-making in end-of-life care. In patients with advanced dementia, those biases may result in a tendency to adhere to traditional mandatory care, involving an aggressive approach to care, which values saving lives at all costs, without taking into account the possible suffering and long-term consequences. Aspects such as moral sensitivity and moral courage play an important role in ethical decision-making related to advanced dementia. Investigations of clinical decision-making that include the cognitive biases and ethical considerations of practitioners might advance the comprehensive understanding of the clinical decision-making process related to care of patients with advanced dementia and promote the quality of care given to this population.

Nurses' perceptions of social rejection, resilience and well-being during COVID-19: A national comparative study.

AIMS AND OBJECTIVES: To determine the level of social rejection and well-being of nurses, whether resilience is a mediator between them and to compare nurses who worked versus did not work on COVID-19 wards. BACKGROUND: During the COVID-19 pandemic health care workers reported psychological distress and social rejection. METHODS: An online survey was sent to nursing social media groups in Israel. Respondents completed a Demographic, Social Rejection, Resilience and General Well-being questionnaire. RESULTS: Two hundred and forty-seven nurses responded. The majority were female with a mean age of 43.6 years Approximately one-third were worried about infecting their family members and many agreed that their family fears that the nurse will infect them. Nurses reported their partner, family members, neighbours and the public physically distanced themselves from them. Approximately one quarter reported feeling lonely. Statistically significant differences were found between those who worked versus not work on a COVID-19 unit on general well-being, and social rejection. No differences were found in resilience scores. CONCLUSIONS: Social rejection was felt by many nurses as shown by an inverse relationship between the closeness of the relationship and the sense of social rejection and a high level of loneliness and depression. A higher level of social rejection and lower well-being were found among nurses working on COVID-19 wards as opposed to those who did not. General well-being was found to be exceptionally low during COVID-19. Resilience did not mediate the relationship between social rejection and general well-being. RELEVANCE TO CLINICAL PRACTICE: Perceived social rejection might be associated with decreased well-being. The level of resilience is related to the level of well-being among nurses in general. Nurses not working in COVID-19 wards have higher levels of well-being and less social rejection compared with nurses working in these wards.

Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study.

BACKGROUND: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING: None.

Perception of discomfort by mechanical ventilation patients in the Intensive Care Unit: A qualitative study.

BACKGROUND: Routine care in intensive care units (ICU) results in patient pain and discomfort. While pain is treated with analgesics, discomfort is generally not well characterised or addressed. Since many ICU patients communicate only non-verbally, practitioners often cannot discern between pain or discomfort when treating such patients, potentially leading to inappropriate analgesic administration. A first step in discriminating between pain and discomfort is understanding how patients perceive their discomfort. OBJECTIVE: To describe mechanically ventilated ICU patients' perceptions of discomfort and how they differentiate discomfort from pain. METHOD: A qualitative descriptive study using semi-structured interviews conducted with 13 patients in a Medical and General ICU who survived mechanical ventilation. Transcripts were analysed using content analysis. FINDINGS: Two main discomfort themes were identified: unpleasant physical sensations and unpleasant psychological feelings. Each theme was further divided into subcategories. Most patients did not describe high levels of pain and did not associate physical discomfort with pain. CONCLUSIONS: Discomfort, as described by patients, stems from both physical sensations and psychological feelings. Pain was less often described as a negative ICU experience, while other non-pain sources of discomfort were more likely to be recalled. Therefore, practitioners should not only focus on treating pain but also on treating overall comfort to improve the quality of the ICU experience and potentially decrease post-ICU psychological sequela.

Hospital nurses' intention to report near misses, patient safety culture and professional seniority.

OBJECTIVES: To determine the extent nurses reported near miss events; to describe the relationship between patient safety culture, professional seniority and intention to report near misses; and to determine predictors of intention to report near miss events. DESIGN: This was a descriptive cross-sectional correlational study.The sampling method was cluster convenience sampling. Surveys were based on the Hospital Survey on Patient Safety (HSOPS). SETTING: Three general Hospitals (a small, large and a tertiary center) located in the north and center of Israel. PARTICIPANTS: ICU and inpatient ward nurses working in general hospitals. MAIN OUTCOME MEASURES: Patient safety culture, reporting medical errors and near miss events, intention to report near miss events, professional seniority. RESULTS: The sample included 227 nurses. Most nurses rated the patient safety culture components as moderately positive. Approximately 80% stated their intention to report a near miss, however 52.4% indicated that they did not report a near miss event in the past year. A positive correlation was found between all components of the patient safety culture and the intention to report a near miss event. Professional seniority was not related to any safety culture components or intention to report a near-miss event. Three variables predicted intention to report: team work, feedback and communication about errors, and the amount of near misses reported in the last year. CONCLUSIONS: There is a discrepancy between what nurses describe as their intent to report a near miss event and their actual reporting of an event. Components of safety culture, especially communication openness, teamwork and reported near misses in the last year are significant predictors of the intent to report. Therefore, reinforcement of these components should be encouraged at the policy level to enable nurses to report near misses and thus improve patient safety.

The Differentiation Between Pain and Discomfort: A Concept Analysis of Discomfort.

BACKGROUND: Discomfort is a concept found in the literature, usually related to pain. Some sources do not distinguish between pain and discomfort. Others refer to different sources of discomfort, thereby leading to a lack of conceptual clarity. AIMS: The objective of this paper was to present a concept analysis of discomfort. Full-text articles published between 1970 and 2016 in English were used to inform the concept analysis. DESIGN: Articles were taken from CINAHL, Medline and PsycNET databases. METHODS: A total of 7,406 articles and 120 abstracts were identified for evaluation. After initial review, 42 articles were further analyzed. Two reviewers independently evaluated the selected publications using the Walker and Avant approach to concept analysis. RESULTS: Discomfort can be physical or psychological and is characterized by an unpleasant feeling resulting in a natural response of avoidance or reduction of the source of the discomfort. Pain is one of the causes for discomfort, but not every discomfort can be attributed to pain. It is identified by self-report or observation. Discomfort in noncommunicative patients is assessed and measured via behavioral expression, also used to describe pain and agitation, leading to discomfort being interpreted as pain in some conditions. CONCLUSIONS: A clarification of the concept of discomfort leads to a more accurate theoretical and operational definition. This clarification can help nurses to make more accurate nursing diagnoses and develop methods to measure discomfort in order to provide optimal quality of nursing care.

Interprofessional Shared Decision-Making in the ICU: A Systematic Review and Recommendations From an Expert Panel.

OBJECTIVES: There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation. DATA SOURCES: We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making. STUDY SELECTION: Three authors screened titles and abstracts in duplicate. DATA SYNTHESIS: Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs. CONCLUSIONS: Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Barriers to palliative care for advanced dementia: a scoping review.

People with dementia often fail to receive palliative care, despite increased recognition of their need and eligibility for such care. The aims of this study were to assess the barriers associated with a lack of implementation of palliative care for people with dementia and to explore whether there is a gap in knowledge necessitating further study. We reviewed the English literature published from 2000 to 2016, related to barriers to palliative care for people with dementia. Twenty-two articles met inclusion criteria for the review. Most originated in Europe or North America and were qualitative in nature. Four key themes were identified: administrative/policy issues, education, communication, and staff personal characteristics. Barriers to the delivery of palliative care for people with dementia have been studied for more than a decade, yet at present, there is a lack of consensus in practice. More research is needed related to barriers associated with personal characteristics. Such investigations have the potential to improve and better understand the complex nature of palliative care in this population.

Patient-Specific Tailored Intervention Improves INR Time in Therapeutic Range and INR Variability in Heart Failure Patients.

BACKGROUND: Many patients with heart failure need anticoagulants, including warfarin. Good control is particularly challenging in heart failure patients, with <60% of international normalized ratio (INR) measurements in the therapeutic range, thereby increasing the risk of complications. This study aimed to evaluate the effect of a patient-specific tailored intervention on anticoagulation control in patients with heart failure. METHODS: Patients with heart failure taking warfarin therapy (n = 145) were randomized to either standard care or a 1-time intervention assessing potential risk factors for lability of INR, in which they received patient-specific instructions. Time in therapeutic range (TTR) using Rosendaal's linear model was assessed 3 months before and after the intervention. RESULTS: The patient-tailored intervention significantly increased anticoagulation control. The median TTR levels before intervention were suboptimal in the interventional and control groups (53% vs 45%, P = .14). After intervention the median TTR increased significantly in the interventional group compared with the control group (80% [interquartile range, 62%-93%] vs 44% [29%-61%], P <.0001). The intervention resulted in a significant improvement in the interventional group before versus after intervention (53% vs 80%, P <.0001) but not in the control group (45% vs 44%, P = .95). The percentage of patients with a TTR ≥60%, considered therapeutic, was substantially higher in the interventional group: 79% versus 25% (P <.0001). The INR variability (standard deviation of each patient's INR measurements) decreased significantly in the interventional group, from 0.53 to 0.32 (P <.0001) after intervention but not in the control group. CONCLUSIONS: Patient-specific tailored intervention significantly improves anticoagulation therapy in patients with heart failure.

Health Promoting Lifestyle Among Israeli Adult Survivors of Childhood Cancer.

BACKGROUND: Childhood cancer survivors are at risk for recurrence of their primary cancer as well as other secondary site cancers. The survivors are also at increased risk for long-term effects such as chronic illnesses. Health promoting lifestyles are therefore especially important for childhood cancer survivors. The purpose of the study was to describe the health promoting behaviors of childhood cancer survivors and to determine whether these behaviors are associated with demographic and clinical characteristics. This is a descriptive-comparative study that took place in an oncology follow-up clinic in Israel. SAMPLE: Seventy-seven childhood cancer survivors. TOOLS: Health Promoting Lifestyle Profile 2, questionnaire (interpersonal relationships, spiritual growth, physical activity, nutrition, health responsibility, and stress management), and smoking and alcohol consumption and a demographic-clinical questionnaire. The mean item score was moderate-high. Survivors scored highest on interpersonal relationships and spiritual growth while the lowest scoring activities were physical activity and nutrition. About 30% of the survivors abstained from smoking and alcohol consumption. Women, as opposed to men, were more likely to have higher scores related to nutrition and interpersonal relationships while singles as opposed to those who were married were found to have higher scores related to spiritual growth. CONCLUSIONS: Health behaviors associated with interpersonal relationships and spiritual growth were more likely to be performed compared to physical activity, good nutrition, and decreased smoking and alcohol consumption. Special attention should be placed on promoting physical activity and good nutrition among survivors of childhood cancer.

Development of a Model of Interprofessional Shared Clinical Decision Making in the ICU: A Mixed-Methods Study.

OBJECTIVES: To develop a model to describe ICU interprofessional shared clinical decision making and the factors associated with its implementation. DESIGN: Ethnographic (observations and interviews) and survey designs. SETTING: Three ICUs (two in Israel and one in the United States). SUBJECTS: A convenience sample of nurses and physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Observations and interviews were analyzed using ethnographic and grounded theory methodologies. Questionnaires included a demographic information sheet and the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration. From observations and interviews, we developed a conceptual model of the process of shared clinical decision making that involves four stepped levels, proceeding from the lowest to the highest levels of collaboration: individual decision, information exchange, deliberation, and shared decision. This process is influenced by individual, dyadic, and system factors. Most decisions were made at the lower two levels. Levels of perceived collaboration were moderate with no statistically significant differences between physicians and nurses or between units. CONCLUSIONS: Both qualitative and quantitative data corroborated that physicians and nurses from all units were similarly and moderately satisfied with their level of collaboration and shared decision making. However, most ICU clinical decision making continues to take place independently, where there is some sharing of information but rarely are decisions made collectively. System factors, such as interdisciplinary rounds and unit culture, seem to have a strong impact on this process. This study provides a model for further study and improvement of interprofessional shared decision making.

Inappropriate care in European ICUs: confronting views from nurses and junior and senior physicians.

BACKGROUND: ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power. METHODS: We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations. RESULTS: By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups. CONCLUSIONS: ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.