Dialysis Needle-Related Distress: Patient Perspectives on Identification, Prevention, and Management.

Introduction: Needle-related distress is common among people receiving hemodialysis and affects quality of life and treatment decisions, yet little evidence exists to guide management. This study explored patients' experiences of needle-related distress to inform the development of prevention, identification, and management strategies. Methods: Semistructured interviews concerning dialysis cannulation, needle-related distress, and potential solutions were conducted with people with current or recent experience of hemodialysis (N = 15) from a tertiary hospital-based service. Interviews ceased at thematic saturation. Transcripts were analyzed thematically. Results: There were 4 themes and 11 subthemes generated: (i) uncovering a hidden source of distress (dismissal and minimization by others; suffering in silence to stay alive; preparation, assessment, and education); (ii) coping with cannulation pain and trauma (interaction between physical damage, pain, and distress; operator dependency-the importance of nurse skill and technique); (iii) the environment created by dialysis nurses (emotional transference; communication during cannulation; valuing empathy and person-centered care; a psychosocially supportive dialysis unit); and (iv) supporting patient self-management of distress (accessing tools to help themselves; distraction to reduce distress). Conclusion: Needle-related distress is an often-hidden element of the hemodialysis experience. Patients learn to tolerate it as an inevitable part of dialysis for survival. Nurses' technical skills and the dialysis environment they create are key determinants of the patient cannulation experience. Proposed solutions include psychological screening, education for patients to self-manage distress, and training for nurses in communication and providing relevant psychological support.

Nephrology nurses' perspectives working with patients experiencing needle-related distress.

BACKGROUND: A key skill of nephrology nursing is cannulation of patients receiving haemodialysis. Traumatic and unsuccessful cannulation experiences, particularly in the initial weeks of haemodialysis, may contribute to the onset of needle distress for patients. OBJECTIVES: To identify the key knowledge, skills and attitudes of nephrology nurses working with haemodialysis patients and the competencies relevant to nephrology nursing working with patients with needle-related distress. DESIGN: A qualitative study involving semistructured interviews. Interviews were audio-recorded, transcribed and deductive, and inductive thematic analysis applied. PARTICIPANTS: Nephrology nurses (n = 17) were interviewed from a tertiary kidney service in South Australia. Nurses had varying roles and years of experience (range 1-30 years) working with dialysis patients within the service. RESULTS: Two overarching themes, (1) Flexibility in Practice and Care and (2) Responsibility of Nephrology Nursing, were identified as relevant across all knowledge, skills and attitudes of nephrology nurses working with patients with needle-related distress. Thirty-six knowledge, skills and attitudes were identified; 12 related to knowledge, 14 related to skills and 10 were identified as attitudes and were summarised under seven broad competencies. CONCLUSION: This study identifies potential knowledge, skills and attitudes and competencies required for nephrology nurses working with patients with needle-related distress. It highlights strategies that may prevent the onset and worsening of needle-related distress, as well as reduce it. It also brings to light that nurses desire additional education regarding strategies to improve the patient experience of cannulation and nurse confidence and skill in this area.

Suggestions in Hypnosis to Aid Pain Education (SHAPE) in People with Chronic Low-Back Pain: A Pilot Feasibility Randomized, Controlled Trial.

Chronic low back pain (CLBP) is a debilitating and burdensome condition, and new treatment strategies are needed. This study aimed to evaluate (1) the feasibility of undertaking a controlled clinical trial investigating a novel intervention for people with CLBP: hypnotically reinforced pain science education, and (2) the acceptability of the intervention as rated by participants. A priori feasibility and intervention acceptability criteria were set. Twenty participants with CLBP were recruited and randomized to receive: (1) hypnotically delivered pain science education that utilizes hypnotic suggestions to enhance uptake of pain science concepts; or (2) pain science education with progressive muscle relaxation as an attention control. Twenty participants were recruited, however, not solely from the hospital waitlist as intended; community sampling was required (13 hospital, 7 community). Most criteria were met in the community sample but not the hospital sample. Protocol modifications are needed before progressing to a full scale randomized controlled trial for hypnotically reinforced pain science education. Improvements in relevant secondary outcomes paired with moderate-high treatment acceptability ratings are promising.

The effect of cognitive behavioral stress management on perceived stress, biological stress markers and weight loss/regain, from a diet-induced weight loss program: A randomized controlled trial.

Obesity and psychosocial stress are inter-related chronic conditions which lead to increased cardiovascular morbidity and mortality. The aim of this parallel randomized controlled trial was to determine whether the addition of a structured cognitive behavioral stress management (CBSM) on to a commercial online weight loss program, resulted in greater weight loss than the standard weight loss program in isolation. Eligible participants were adults between the ages 18-65, BMI 30-45 kg/m2, with no major systemic or psychiatric conditions. Seventy-four participants were assigned according to simple randomization using computer generated random numbers to either a 3-month online Weight Watchers® program (n = 36), or Weight Watchers® plus 10 weekly sessions of CBSM (n = 38). The primary outcome was weight at 3 months compared to baseline. Secondary outcomes were weight at 12 months and subjective/objective stress system measures and metabolic markers at 3 and 12 months. The study was powered at 90% to detect a 5 kg difference in weight between the two groups at 3 months. Independent sample t-tests were used to analyze the difference in weight (in kg) between the groups and paired sample t-tests were used to analyze the difference within group at different time intervals. At follow-up, there was no significant difference in weight loss between the groups (1.8 kg, 2.1 kg). However, CBSM was effective in reducing psychological measures of stress (p < 0.05) and salivary cortisol (waking, 20-min post-waking) at 3-months; with the effect on stress persisting at 12-months within the CBSM group. The reduction in PSS at 3 months was significantly greater in the CBSM group (3.84, p = 0.028) compared to WW only group at 3 months. Addition of CBSM to a standard weight loss intervention did not improve the weight loss over the standard approach on its own, but the CBSM intervention improved psychological stress parameters and cortisol secretion in participants living with obesity.

The prevalence and evidence-based management of needle fear in adults with chronic disease: A scoping review.

BACKGROUND: Little is known about the prevalence and best management of needle fear in adults with chronic disease, who may experience frequent and long-term exposure to needles for lifesaving therapies such as renal dialysis and cancer treatment. Identifying interventions that assist in management of needle fear and associated distress is essential to support these patients with repeated needle and cannula exposure. METHOD: We followed the PRISMA methodology for scoping reviews and systematically searched PsychINFO, PubMed (MEDLINE), ProQuest, Embase and grey literature and reference lists between 1989 and October 2020 for articles related to needle discomfort, distress, anxiety, fear or phobia. The following chronic diseases were included: arthritis, asthma, chronic back pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and mental illness, or kidney failure. Literature concerning dentistry, vaccination, intravenous drug users and paediatric populations were excluded. RESULTS: We identified 32 papers reporting prevalence (n = 24), management (n = 5) or both (n = 3). Needle fear prevalence varied in disease cohorts: 17-52% (cancer), 25-47% (chronic kidney disease) and 0.2-80% (diabetes). Assessment methods varied across studies. Management strategies had poor evidence-base, but included needle-specific education, decorated devices, cognitive-behavioural stress management techniques, distraction, and changing the therapy environment or modality. CONCLUSION: Although needle fear is common there is a paucity of evidence regarding interventions to address it among adults living with chronic disease. This scoping review has highlighted the need for improved identification of needle fear in adults and development of interventions are required for these cohorts.

Integrated Psychological Care Reduces Health Care Costs at a Hospital-Based Inflammatory Bowel Disease Service.

BACKGROUND & AIMS: Inflammatory bowel diseases (IBD) are associated with high psychosocial burden and economic cost. Integrating psychological care into routine management might lead to savings. We performed a 2-year investigation of the effects of integrated psychological care in reducing healthcare use and costs. METHODS: We performed a prospective study of 335 adult patients treated at a hospital-based IBD service in Australia. Participants were recruited between September 2015 and August 2016 and completed screening instruments to evaluate mental health and quality of life. Data on healthcare use and costs for the previous 12 months were also collected. Patients found to be at risk for mental health issues were offered psychological intervention. Patients were followed up 12 months after screening (between September 2016 and August 2017). RESULTS: A significantly higher proportion of subjects at risk for mental health issues had presented to an emergency department in the 12 months before screening (51/182; 28%) compared to psychologically healthy subjects (28/152; 18%; X2(1) = 4.23; P = .040). Higher levels of depression and general distress (but not anxiety) were related to increased odds of hospital admission (adjusted odds ratios, 1.07 and 1.05, respectively). Among the patients who accepted psychological intervention, the number who presented to emergency departments was reduced significantly in the 12 months after screening (follow-up) compared to the 12 months before screening (P = .047), resulting in a cost saving of AU$30,140 ($20,816 USD). A cost-benefit analysis of the integrated psychological care model revealed a net saving of AU$84,905 ($58,647 USD) over a 2-year period. CONCLUSIONS: Risk for mental health issues is associated with higher healthcare costs in people with IBD. Providing integrated psychological care to individuals at risk for mental health issues can reduce costs, particularly by decreasing visits to emergency departments. Further studies are required to determine the best care to provide to reduce costs.

Waiting in Pain II: An Updated Review of the Provision of Persistent Pain Services in Australia.

OBJECTIVE: To provide an update on Australian persistent pain services (number, structure, funding, wait times, activity). METHODS: An updated national search was conducted. Of those identified, 74 persistent pain services provided detailed responses between July 2016 and February 2018 (64 adult, seven pediatric, two pelvic pain, and one cancer pain). A similar structure to the original Waiting in Pain (WIP) survey was used, and participants chose online or telephone completion. RESULTS: Pediatric pain services had more than doubled but remained limited. Adult services had also increased, with a concurrent decrease in median wait times and an increase in the number of new referrals seen each year. Despite this, some lengthy wait times (≥3 years) persisted. Wait times were longest at clinics using public or combined funding models and offering pain management group programs (PMGPs). Although clinical activity had increased, medical staffing had not, suggesting that clinics were operating differently. Privately funded clinics performed more procedures than publicly funded services. Use of PMGPs had increased, but program structure remained diverse. CONCLUSIONS: Specialist pain services have expanded since the original WIP survey, facilitating treatment access for many. However, wait time range suggested that the most disadvantaged individuals still experienced the longest wait times, often far exceeding the recommended 6-month maximum wait. More needs to be done. Numerous developments (e.g., National Strategic Action Plan for Pain Management, health system changes as a result of the COVID-19 pandemic) will continue to influence the delivery of pain services in Australia, and repeated analysis of service structures and wait times will optimize our health system response to the management of this condition.

Integrated Psychological Care is Needed, Welcomed and Effective in Ambulatory Inflammatory Bowel Disease Management: Evaluation of a New Initiative.

BACKGROUND AND AIMS: Inflammatory bowel disease is associated with psychosocial issues which reduce quality of life and impair medical management. However, these issues are rarely addressed in routine care. A model of integrated psychological screening and intervention was trialled to measure prevalence, patient participation, and potential benefits to mental health and/or quality of life. METHODS: During a 12-month period, 490 adult patients at an established hospital-based service were approached to complete screening instruments for anxiety, depression, general distress, quality of life and medication adherence. Disease-specific and demographic data were also collected. Patients who scored highly on screening questionnaires were offered psychological intervention (in-service or externally referred). Participants were reassessed after 12 months. RESULTS: Psychological screening was well accepted with 68% (N = 335) participating. Psychological care was 'needed', with 55% (N = 183) scoring highly for anxiety, depression and/or general distress. Half of those 'in need' (N = 91) accepted intervention. In those who accepted, levels of anxiety (mean at intake [M1] = 12.11 vs mean at follow-up [M2] = 9.59, p < 0.001), depression (M1 = 8.38 vs M2 = 6.42, p < 0.001), general distress (M1 = 17.99 vs M2 = 13.96, p < 0.001), mental health quality of life (M1 = 54.64 vs M2 = 59.70, p < 0.001) and overall quality of life (M1 = 57.60 vs M2 = 64.10, p < 0.001) each improved between intake and follow-up. Engagement in psychological intervention was six times greater for those treated in-service vs externally referred (χ2[1] = 13.06, p < 0.001, odds ratio = 6.47). CONCLUSIONS: Mental health issues are highly prevalent in people with inflammatory bowel disease. Patients are open to psychological screening and treatment. Psychological care can improve patient mental health and quality of life, and works best when integrated into routine management.

Does a Brief Educational Session Produce Positive Change for Individuals Waiting for Tertiary Chronic Pain Services?

OBJECTIVES: To examine: 1) whether a single brief pre-clinic educational session improved the well-being and quality of life of individuals entering the wait-list for a tertiary chronic pain (CP) service; and 2) the impact of waiting for services on these outcomes. METHODS: Participants were 346 adults, with basic English skills and non-urgent triage codes, who were recruited on referral to a tertiary Australian metropolitan CP unit. Participants were randomized across two conditions: "treatment as usual" (normal wait-list) and "experimental" (normal wait-list plus a 3-hour CP educational session). The educational session encouraged self-management and life engagement despite pain. Multiple outcomes (pain acceptance, pain-related interference, psychological distress, health care utilization [frequency, types], quality of life, health knowledge/beliefs), as well as pain severity and symptom exaggeration, were assessed at intake and again at 2 weeks and 6 months post-educational session (or equivalent for the wait-list group). RESULTS: Satisfaction with the educational session was moderate-to-high, but attendance was not associated with improved outcomes. At 2 weeks, all study participants reported significant improvements in pain acceptance (willingness, overall acceptance), health care utilization (frequency) and quality of life (physical), which were maintained/enhanced at 6 months. Use of psychological and physical therapies increased significantly by 6 months. There was no functional deterioration while wait-listed. CONCLUSIONS: Attending a brief pre-clinic education session did not improve function. There was no deterioration in wait-listed participants who agreed to be involved in research and who completed study measures at 2 and 6 months, but referral was associated with short-term functional improvements. This is the first study to link positive change with referral to, rather than treatment by, a tertiary CP service.

Changes in Acceptance in a Low-Intensity, Group-Based Acceptance and Commitment Therapy (ACT) Chronic Pain Intervention.

BACKGROUND: Acceptance and commitment therapy has shown to be effective in chronic pain rehabilitation, and acceptance has been shown to be a key process of change. The influence of treatment dose on acceptance is not clear, and in particular, the effectiveness of a non-intensive treatment (<20 h) in a tertiary pain clinic is required. PURPOSE: The purpose of the study was to assess the effectiveness of a low-intensity, acceptance and commitment therapy (ACT) group program for chronic pain. The study sought to compare, at both groups and individual patient levels, changes in acceptance with changes observed in previous ACT studies. METHODS: Seventy-one individuals with chronic pain commenced a 9-week ACT-based group program at an outpatient chronic pain service. In addition to acceptance, outcomes included the following: pain catastrophizing, depression, anxiety, quality of life, and pain-related anxiety. To compare the current findings with previous research, effect sizes from seven studies were aggregated using the random-effects model to calculate benchmarks. Reliable change indices (RCIs) were applied to assess change on an individual patient-level. RESULTS: The ACT intervention achieved a statistically significant increase in acceptance and medium effect size (d = 0.54) at a group level. Change in acceptance was of a similar magnitude to that found in previous ACT studies that examined interventions with similar treatment hours (<20 h). Results across other outcome measures demonstrated small to medium effect sizes (d = 0.01 to 0.48, mean = 0.26). Reliable improvement in acceptance occurred in approximately one-third (37.2, 90% CI) of patients. Approximately three-quarters (74.3, 90% CI) demonstrated reliable change in at least one of the outcome measures. CONCLUSIONS: The low-intensity, group-based ACT intervention was effective at a group level and showed a similar magnitude of change in acceptance to previous ACT studies employing low-intensity interventions. Three-quarters of patients reported reliable change on at least one outcome measure.

An analysis of multidisciplinary staffing levels and clinical activity in Australian tertiary persistent pain services.

OBJECTIVE: To document staffing (medical, nursing, allied health [AH], administrative) in Australian multidisciplinary persistent pain services and relate them to clinical activity levels. METHODS: Of the 68 adult outpatient persistent pain services approached (Dec'08-Jan'10), 45 agreed to participate, received over 100 referrals/year, and met the contemporaneous International Association for the Study of Pain criteria for Level 1 or 2 multidisciplinary services. Structured interviews with Clinical Directors collected quantitative data regarding staff resources (disciplines, amount), services provided, funding models, and activity levels. RESULTS: Compared with Level 2 clinics, Level 1 centers reported higher annual demand (referrals), clinical activity (patient numbers) and absolute numbers of medical, nursing and administrative staff, but comparable numbers of AH staff. When staffing was assessed against activity levels, medical and nursing resources were consistent across services, but Level 1 clinics had relatively fewer AH and administrative staff. Metropolitan and rural services reported comparable activity levels and discipline-specific staff ratios (except occupational therapy). The mean annual AH staffing for pain management group programs was 0.03 full-time equivalent staff per patient. CONCLUSIONS: Reasonable consistency was demonstrated in the range and mix of most disciplines employed, suggesting they represented workable clinical structures. The greater number of medical and nursing staff within Level 1 clinics may indicate a lower multidisciplinary focus, but this needs further exploration. As the first multidisciplinary staffing data for persistent pain clinics, this provides critical information for designing and implementing clinical services. Mapping against clinical outcomes to demonstrate the impact of staffing patterns on safe and efficacious treatment delivery is required.

Psychological functioning of people living with chronic pain: a meta-analytic review.

OBJECTIVES: Chronic pain (CP; >3 months) is a common condition that is associated with significant psychological problems. Many people with CP do not fit into discrete diagnostic categories, limiting the applicability of research that is specific to a particular pain diagnosis. This meta-analysis synthesized the large extant literature from a general CP, rather than diagnosis-specific, perspective to systematically identify and compare the psychological problems most commonly associated with CP. METHODS: Four databases were searched from inception to December 2013 (PsychINFO, The Cochrane Library, Scopus, and PubMed) for studies comparing the psychological functioning of adults with CP to healthy controls. Data from 110 studies were meta-analysed and Cohen's d effect sizes calculated. RESULTS: The CP group reported experiencing significant problems in a range of psychological domains (depression, anxiety, somatization, anger/hostility, self-efficacy, self-esteem and general emotional functioning), with the largest effects observed for pain anxiety/concern and somatization; followed by anxiety and self-efficacy; and then depression, anger/hostility, self-esteem and general emotional functioning. CONCLUSIONS: This study demonstrates, for the first time, that individuals with CP are more likely to experience physically focussed psychological problems than other psychological problems and that, unlike self-efficacy, fear of pain is intrinsically tied to the CP experience. This challenges the prevailing view that, for individuals with CP, problems with depression are either equal to, or greater than, problems with anxiety, thereby providing important information to guide therapeutic targets. PRACTITIONER POINTS: Positive clinical implications: This is the first time that the CP literature has been synthesized from a general perspective to examine psychological functioning in the presence of CP and provide practical recommendations for assessment and therapy. Individuals with CP were most likely to experience psychological problems in physically focussed areas - namely pain anxiety/concern and somatization. Although fear of pain was intrinsically tied to the CP experience, self-efficacy was not. CP was more strongly associated with anxiety than with depression. Limitations The study focuses on the general CP literature, adults and research-utilizing self-report measures. Meta-analyses are limited by the empirical literature on which they are based.