Understanding of empathetic communication in acute hospital settings: a scoping review.

OBJECTIVE: Empathy and empathy education have been reviewed a number of times through systematic reviews and meta-analyses; however, the topic of 'empathetic communication' remains poorly understood when considering engaging in hospital-based research. Therefore, this scoping review aimed to explore the existing literature concerning empathetic communication in hospital settings and to evaluate the definitions presented. DESIGN: Scoping review. DATA SOURCES: Systematic searches of the PubMed, CINAHL, Cochrane, PsycINFO, and PsycArticles databases were conducted. STUDY SELECTION: All English studies in which empathetic communication in hospital settings were explored. The search terms used included empathy, communication, hospital settings, providers, and consumers. DATA EXTRACTION: Data were assessed through the use of a pre-set analysis tool. RESULTS: After conducting the searches, 419 articles were identified, of which 26 were included in this review. No single article specifically defined the term 'empathetic communication'; however, 33 unique definitions of 'empathy' were identified, of which 23 considered communication to be a component of empathy. There was a considerable lack of consistency between the empathy definitions, with some classifying communication in empathy as an ability and others classifying it as a dynamic process. CONCLUSION: Future and contextually focused research is needed to develop a consistent and clear definition of empathetic communication and empathy within a hospital setting to better build positive healthcare cultures. PRACTICE IMPLICATIONS: Inconsistencies between definitions of empathy in empathetic communication research could reduce the efficacy of future research gains and impact the translation of research findings into clinical practice.

Improving health services for patients with extreme obesity requiring bariatric level care at Wellington Regional Hospital: a clinical audit.

AIM: To benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards, and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital requiring bariatric level care. METHODS: A clinical audit consisting of retrospective case-note review and cross-sectional survey was conducted and benchmarked against Accident Compensation Corporation (ACC) national standards. Information recorded included patient demographics, admission planning, patient anthropometric and risk assessments, provider communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations, discharge planning and reportable events. RESULTS: A total of 574 patients were included. The prevalence of hospitalised patients requiring bariatric services was 6.4%. One third of patients (34.3%) were not identified by clinical teams as requiring bariatric support. Most bed (80%) and bathroom (83%) spaces failed to achieve the facility design standard. The majority of patient focused moving and handling hazards were documented whereas environmental hazards or equipment limitations were poorly reported. Only 26.1% of patients had a documented discharge plan. CONCLUSION: Inadequate identification of patients requiring bariatric support and insufficient documentation of bariatric service delivery were identified. Improving policy adherence will address shortcomings in the provision of a safe environment and high quality care for bariatric patients.

Obesity, leptin and host defence of Streptococcus pneumoniae: the case for more human research.

Pneumococcal pneumonia is the leading cause of community-acquired pneumonia. Obesity is a risk factor for pneumonia. Host factors play a critical role in susceptibility to pulmonary pathogens and outcome from pulmonary infections. Obesity impairs innate and adaptive immune responses, important in the host defence against pneumococcal disease. One area of emerging interest in understanding the complex relationship between obesity and pulmonary infections is the role of the hormone leptin. There is a substantive evidence base supporting the associations between obesity, leptin, pulmonary infections and host defence mechanisms. Despite this, there is a paucity of research that specifically focuses on Streptococcus pneumoniae (pneumococcal) infections, which are the leading cause of community-acquired pneumonia hospitalisations and mortality worldwide. Much of the evidence examining the role of leptin in relation to S. pneumoniae infections has used genetically mutated mice. The purpose of this mini review is to explore the role leptin plays in the host defence of S. pneumoniae in subjects with obesity and posit an argument for the need for more human research.

Healthcare Service Interventions to Improve the Healthcare Outcomes of Hospitalised Patients with Extreme Obesity: Protocol for an Evidence and Gap Map.

Hospitalised patients with extreme obesity have poorer healthcare outcomes compared to normal weight patients. How hospital services are coordinated and delivered to meet the care needs of patients with extreme obesity is not well understood. The aim of the proposed evidence gap map (EGM) is to identify and assess the available evidence on healthcare interventions to improve healthcare outcomes for hospitalised patients with extreme obesity. This research will use standardised evidence gap map methods to undertake a five-stage process to develop an intervention-outcome framework; identify the current evidence; critically appraise the quality of the evidence, extract, code, and summarise the data in relation to the EGM objectives; and create a visualisation map to present findings. This EGM will provide a means of determining the nature and quality of health service initiatives available, identify the components of the services delivered and the outcome measures used for evaluation, and will identify areas where there is a lack of research that validates the funding of new research studies.

Association between body mass index, multi-morbidity and activities of daily living among New Zealand nursing home older adults: a retrospective analysis of nationwide InterRAI data.

BACKGROUND: Obesity is a well-established risk factor for multi-morbidity and disability among older adults in the community and acute care settings. However, nursing home residents with body mass index (BMI) below 18.5 kg/m2 and above 25.0 kg/m2 have been understudied. We examined the prevalence of multi-morbidity and disability in activities of daily living (ADL) by BMI category and further investigated the association between BMI, multi-morbidity, and disability of ADL in a large cohort of older adults in nursing homes in New Zealand. METHODS: A retrospective review of nursing home residents' data obtained from the New Zealand International Resident Assessment Instrument national dataset from 2015 to 2018. One hundred ninety-eight thousand seven hundred ninety older adults (≥60 years) living in nursing homes were included. BMI was calculated as weight in kilograms (kg) divided by height in meters squared (m2). Multimorbidity was defined as the presence of ≥2 health conditions. The risk of disability was measured by a 4-item ADL self-performance scale. The prevalence ratio (PR) of the association between BMI and multi-morbidity and between BMI and disability in ADL was assessed using Poisson regression with robust variance. RESULTS: Of the 198,790 residents, 10.6, 26.6, 11.3 and 5.4% were underweight, overweight, obese, and extremely obese, respectively. 26.4, 31.3 and 21.3% had one, two and three disease conditions, respectively, while 14.3% had four or more conditions. 24.1% could perform only one ADL, and 16.1% could perform none. The prevalence of multi-morbidity increased with increasing BMI, whereas mean disability in ADL decreased with increasing BMI. The risk of multi-morbidity was higher for the overweight (PR, 95%CI: 1.03, 1.02-1.03) and obese (PR, 95% CI: 1.07, 1.06-1.08) compared to normal weight after controlling for age, sex, ethnicity, and region. BMI was inversely associated with mean ADL; ß, 95% CI for overweight (- 0.30, - 0.32, - 0.28) and obese - 0.43, - 0.45, - 0.40 compared to normal weight. CONCLUSION: Being underweight was associated with a decline in the performance of ADL in nursing home residents. In contrast, being overweight and obese positively affected functional performance, demonstrating that the obesity paradox plays an important role in this population. The observed associations highlight areas where detection and management of underweight and healthy aging initiatives may be merited.

Improving the Quality of Patient Care and Healthcare Staff Well-Being through an Empathy Immersion Educational Programme in New Zealand: Protocol of a Feasibility and Pilot Study.

Empathy is positively related to healthcare workers and patients' wellbeing. There is, however, limited research on the effects of empathy education delivered in acute clinical settings and its impact on healthcare consumers. This research tests the feasibility and the potential efficacy outcomes of an immersive education programme developed by the research team in collaboration with clinical partners and a multidisciplinary advisory group. Healthcare worker participants in the intervention ward will receive an 8-week immersive empathy education. The primary outcome (feasibility) will be assessed by evaluating the acceptability of the intervention and the estimated resources. The secondary outcome (efficacy) will be assessed using a quasi-experimental study design. Non-parametric tests will be used to test healthcare worker participants' empathy, burnout, and organisational satisfaction (within-group and across groups), and healthcare consumer participants' satisfaction (between-group) over time. Despite growing interest in the importance of empathy in professional relationships, to our knowledge, the present pilot study is the first to explore the feasibility and efficacy of an immersive empathy education in New Zealand. Our findings will provide critical evidence to support the development of a randomised cluster trial and potentially provide preliminary evidence for the effectiveness of this type of empathy education.

Pre COVID-19 emergency department nurses' perspectives of the preparedness to safely manage influenza pandemics: A descriptive exploratory qualitative study.

BACKGROUND: Pandemics pose significant challenges to healthcare systems worldwide and emergency departments are a crucial component in any pandemic response. This study was designed to explore what New Zealand emergency nurses perceive as the major challenges to nursing care and staff safety during a pandemic, and to identify strategies nurses feel are important in mitigating these challenges. METHODS: A descriptive exploratory qualitative design using semi-structured interviews was conducted in March 2019. Participants were 16 triage nurses from two New Zealand emergency departments. Qualitative content and thematic data analysis techniques were used. RESULTS: Emergency nurses highlighted existing safety issues in their practice, and their concerns about how a pandemic might exacerbate these issues. These themes were identified as: safety of self and family, safety of patients, and safety of organisational systems. Nurses also shared their perspectives on how to mitigate these safety issues. CONCLUSIONS: This study provides a detailed understanding of the concerns emergency nurses hold about working during pandemics. Similar fears for staff and patient safety have been voiced globally during the current COVID-19 pandemic, and it is crucial that emergency departments worldwide develop pandemic plans that address the safety concerns to which fear was attributed.

Experimental Human Challenge Defines Distinct Pneumococcal Kinetic Profiles and Mucosal Responses between Colonized and Non-Colonized Adults.

Colonization of the upper respiratory tract with Streptococcus pneumoniae is the precursor of pneumococcal pneumonia and invasive disease. Following exposure, however, it is unclear which human immune mechanisms determine whether a pathogen will colonize. We used a human challenge model to investigate host-pathogen interactions in the first hours and days following intranasal exposure to Streptococcus pneumoniae Using a novel home sampling method, we measured early immune responses and bacterial density dynamics in the nose and saliva after volunteers were experimentally exposed to pneumococcus. Here, we show that nasal colonization can take up to 24 h to become established. Also, the following two distinct bacterial clearance profiles were associated with protection: nasal clearers with immediate clearance of bacteria in the nose by the activity of pre-existent mucosal neutrophils and saliva clearers with detectable pneumococcus in saliva at 1 h post challenge and delayed clearance mediated by an inflammatory response and increased neutrophil activity 24 h post bacterial encounter. This study describes, for the first time, how colonization with a bacterium is established in humans, signifying that the correlates of protection against pneumococcal colonization, which can be used to inform design and testing of novel vaccine candidates, could be valid for subsets of protected individuals.IMPORTANCE Occurrence of lower respiratory tract infections requires prior colonization of the upper respiratory tract with a pathogen. Most bacterial infection and colonization studies have been performed in murine and in vitro models due to the current invasive sampling methodology of the upper respiratory tract, both of which poorly reflect the complexity of host-pathogen interactions in the human nose. Self-collecting saliva and nasal lining fluid at home is a fast, low-cost, noninvasive, high-frequency sampling platform for continuous monitoring of bacterial encounter at defined time points relative to exposure. Our study demonstrates for the first time that, in humans, there are distinct profiles of pneumococcal colonization kinetics, distinguished by speed of appearance in saliva, local phagocytic function, and acute mucosal inflammatory responses, which may either recruit or activate neutrophils. These data are important for the design and testing of novel vaccine candidates.

Experimental Human Pneumococcal Colonization in Older Adults Is Feasible and Safe, Not Immunogenic.

Rationale: Pneumococcal colonization is key to the pathogenesis of invasive disease but is also immunogenic in young adults, protecting against recolonization. Colonization is rarely detected in older adults, despite high rates of pneumococcal disease.Objectives: To establish experimental human pneumococcal colonization in healthy adults aged 50-84 years, to measure the immune response to pneumococcal challenge, and to assess the protective effect of prior colonization against autologous strain rechallenge.Methods: Sixty-four participants were inoculated with Streptococcus pneumoniae (serotype 6B; 80,000 cfu in each nostril). Colonization was determined by bacterial culture of nasal wash, and humoral immune responses were assessed by anticapsular and antiprotein IgG concentrations.Measurements and Main Results: Experimental colonization was established in 39% of participants (25/64) with no adverse events. Colonization occurred in 47% (9/19) of participants aged 50-59 compared with 21% (3/14) in those aged ≥70 years. Previous pneumococcal polysaccharide vaccination did not protect against colonization. Colonization did not confer serotype-specific immune boosting, with a geometric mean titer (95% confidence interval) of 2.7 µg/ml (1.9-3.8) before the challenge versus 3.0 (1.9-4.7) 4 weeks after colonization (P = 0.53). Furthermore, pneumococcal challenge without colonization led to a drop in specific antibody concentrations from 2.8 µg/ml (2.0-3.9) to 2.2 µg/ml (1.6-3.0) after the challenge (P = 0.006). Antiprotein antibody concentrations increased after successful colonization. Rechallenge with the same strain after a median of 8.5 months (interquartile range, 6.7-10.1) led to recolonization in 5/16 (31%).Conclusions: In older adults, experimental pneumococcal colonization is feasible and safe but demonstrates different immunological outcomes compared with younger adults in previous studies.

Symptoms associated with influenza vaccination and experimental human pneumococcal colonisation of the nasopharynx.

BACKGROUND: Nasopharyngeal colonisation by S. pneumoniae is a prerequisite for invasive pneumococcal infections. Influenza co-infection leads to increased susceptibility to secondary pneumonia and mortality during influenza epidemics. Increased bacterial load and impaired immune responses to pneumococcus caused by influenza play a role in this increased susceptibility. Using an Experimental Human Challenge Model and influenza vaccines, we examined symptoms experienced by healthy adults during nasal co-infection with S. pneumoniae and live attenuated influenza virus. METHODS: Randomised, blinded administration of Live Attenuated Influenza Vaccine (LAIV) or Tetravalent Inactivated Influenza Vaccine (TIV) either preceded bacterial inoculation or followed it, separated by a 3-day interval. The presence and density of S. pneumoniae was determined from nasal washes. Participants completed a symptom questionnaire from the first intervention until 6 days post second intervention. RESULTS: The timing and type of influenza vaccination and presence of S. pneumoniae in the nasopharynx significantly affected symptom reporting. In the study where influenza vaccination preceded bacterial inoculation: nasal symptoms were less common in the LAIV group than the TIV group (OR 0.57, p < 0.01); with colonisation status only affecting the TIV group where more symptoms were reported by colonised participants compared to non-colonised participants following inoculation (n = 12/23 [52.17%] vs n = 13/38 [34.21%], respectively; p < 0.05). In the study where influenza vaccination followed bacterial inoculation: no difference was seen in the symptoms reported between the LAIV and TIV groups following inoculation and subsequent vaccination; and symptoms were unaffected by colonisation status. CONCLUSION: Symptoms experienced during live viral vaccination and bacterial co-infection in the nasopharynx are directly affected by the precedence of the pathogen acquisition. Symptoms were directly affected by nasal pneumococcal colonisation but only when TIV was given prior to bacterial exposure.

Dissonance in naming adiposity: a quantitative survey of naming preferences from a convenience sample of health professional and lay population in Aotearoa New Zealand.

BACKGROUND: Communication has an essential role in the therapeutic relationship between a patient and healthcare professionals (HCPs) with terminology playing an important role. The terminology used by HCPs can significantly impact on an individual's perceptions of weight and experience of stigma. This is the first quantitative research study in Aotearoa New Zealand to explore weight-related terminology. METHOD: A self-completion questionnaire was administered to a convenience sample of adults aged 18 years and over, residing in New Zealand across four different geographical regions (Auckland, Wellington, Christchurch and Dunedin) in 2016. RESULTS: Seven hundred and seventy-five participants completed questionnaires, with 330 identifying as HCPs or HCP students, 440 as lay persons and five not specified. 'Weight' or 'high BMI' were the most preferred terms for describing excess adiposity for participants. The term 'bariatric' is poorly understood in New Zealand. There was dissonance in responses relating to the terms considered most blaming and those considered to be motivating terms to lose weight. CONCLUSION: The terms 'weight' or 'high BMI' are the terms most commonly preferred across this and other surveys, although neither term is meaningful in describing accurately the clinical relevance of the person's size during the HCP-patient interaction. Whichever term is selected, HCP-patient conversations need to be respectful, appropriate and support meaningful non-stigmatising dialogue.

Pneumococcal Colonization in Healthy Adult Research Participants in the Conjugate Vaccine Era, United Kingdom, 2010-2017.

Pneumococcal colonization is rarely studied in adults, except as part of family surveys. We report the outcomes of colonization screening in healthy adults (all were nonsmokers without major comorbidities or contact with children aged <5 years) who had volunteered to take part in clinical research. Using nasal wash culture, we detected colonization in 6.5% of volunteers (52 of 795). Serotype 3 was the commonest serotype (10 of 52 isolates). The majority of the remaining serotypes (35 of 52 isolates) were nonvaccine serotypes, but we also identified persistent circulation of serotypes 19A and 19F. Resistance to at least 1 of 6 antibiotics tested was found in 8 of 52 isolates.

Inflammation induced by influenza virus impairs human innate immune control of pneumococcus.

Colonization of the upper respiratory tract by pneumococcus is important both as a determinant of disease and for transmission into the population. The immunological mechanisms that contain pneumococcus during colonization are well studied in mice but remain unclear in humans. Loss of this control of pneumococcus following infection with influenza virus is associated with secondary bacterial pneumonia. We used a human challenge model with type 6B pneumococcus to show that acquisition of pneumococcus induced early degranulation of resident neutrophils and recruitment of monocytes to the nose. Monocyte function was associated with the clearance of pneumococcus. Prior nasal infection with live attenuated influenza virus induced inflammation, impaired innate immune function and altered genome-wide nasal gene responses to the carriage of pneumococcus. Levels of the cytokine CXCL10, promoted by viral infection, at the time pneumococcus was encountered were positively associated with bacterial load.

A Qualitative Study to Explore the Impact of Simulating Extreme Obesity on Health Care Professionals' Attitudes and Perceptions.

Extremely obese patients pose significant challenges for those who strive to provide care. The prevalence and consequences of weight bias and stigma in health care have been well documented, but research on how to reduce weight bias and stigma is limited. To assess the impact of simulating obesity on the attitudes and perceptions of health professionals toward extreme obesity, a qualitative study involving 6 registered nurses and 1 registered physiotherapist was conducted between November 2015 and May 2016. Health professionals who had regular contact with persons with obesity were recruited through poster advertisement in 1 hospital and 2 universities. Participants completed a demographic survey that included their physical measurements (height, weight, and waist circumference). They then wore a suit simulating the shape and size of a person with extreme obesity for approximately 2 hours and engaged in activities such as taking public transport or visiting a café. Audiotaped, semistructured interviews were conducted before and after the suit exercise and transcribed verbatim for conventional content analysis that identified 3 main categories: 1) insights into the physical challenges facing people with extreme obesity; 2) awareness of social consequences for people with extreme obesity; and 3) changes in participants' attitudes toward people with extreme obesity. Following the exercise, personal attitudes were found to be less judgmental and more empathetic. Using a simulation suit may increase awareness among health professionals regarding issues facing persons with obesity and may be a positive influence on diffusing weight stigma and bias in health care settings, particularly in the area of wound prevention and management where excess weight often requires additional nursing care that may exacerbate existing biases. Ethical guidance needs to be developed in conjunction with further research to explore the risks and benefits of using simulation suits in clinical practice and education.

The challenges in caring for morbidly obese patients in Intensive Care: A focused ethnographic study.

BACKGROUND: Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges. However little is known about the care of these patients in intensive care. OBJECTIVE: To explore medical and nursing practices and attitudes in intensive care when caring for critically ill morbidly obese patients. METHODS: A focused ethnographic approach was adopted. Participant observation of care practices and interviews with intensive care doctors and nurses were undertaken over a four month period. Qualitative analysis was conducted using constant comparison. SETTING: An 18 bedded tertiary intensive care unit in New Zealand. PARTICIPANTS: Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m2. FINDINGS: Morbidly obese patients present significant physical and language challenges for intensive care practice. The physical shape of morbidly obese patients did not appropriately fit the different equipment used. Staff used specific knowledge of the patient's body size and shape to adapt care practices and keep patients safe and comfortable. There were also specific language challenges where staff expressed concern about what words were most appropriate to use to describe body mass when in the presence of morbidly obese patients. CONCLUSIONS: Bariatric care pathways need to be developed that use more suitable body measurements to inform the use of bariatric equipment. Intensive care staff need to engage in debate about what is acceptable, respectful, and appropriate language in the delivery of bariatric patient care.

Glimpses into the transition world: New graduate nurses' written reflections.

BACKGROUND: This study was born out of our reflections as educators responsible for helping new graduate nurses transition into their first year of professional practice through a formal education programme. Finding ourselves wondering about many of the questions the students raised with us, we set about looking more closely at what could be gleaned from the students' experience, captured in their written work over the course of a year. OBJECTIVES: To identify the challenges and learning experiences revealed in reflective assignments written by new graduate nurses undertaking a postgraduate course as part of their transition to registered nurse practice. STUDY DESIGN, SETTING AND PARTICIPANTS: Data consisted of the written work of two cohorts of students who had completed a postgraduate university course as part of their transition to new graduate practice in New Zealand. Fifty four reflective essays completed by twenty seven participating students were collected and their contents analysed thematically. RESULTS: Five key themes were identified. The students' reflections noted individual attributes - personal and professional strengths and weaknesses; professional behaviour - actions such as engaging help and support, advocating for patients' needs and safety and putting their own feelings aside; situational challenges such as communication difficulties, both systemic and interpersonal, and the pressure of competing demands. Students also identified rewards - results they experienced such as achieving the nursing outcomes they desired, and commented on reflection as a useful tool. CONCLUSIONS: The findings shed light on the experiences of new graduates, and how they fare through this critical phase of career development. Challenges relating to the emotional labour of nursing work are particularly evident. In addition the reflective essay is shown to be a powerful tool for assisting both new graduate nurses and their lecturers to reflect on the learning opportunities inherent in current clinical practice environments.

Managing social awkwardness when caring for morbidly obese patients in intensive care: A focused ethnography.

BACKGROUND: Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges in the intensive care setting. These are resultant from specific physiological responses to critical illness in this population and the nature of the interventional therapies used in the intensive care environment. An additional challenge arises for this population when considering the social stigma that is attached to being obese. Intensive care staff therefore not only attend to the physical and care needs of the critically ill morbidly obese patient but also navigate, both personally and professionally, the social terrain of stigma when providing care. AIM: To explore the culture and influences on doctors and nurses within the intensive care setting when caring for critically ill morbidly obese patients. DESIGN AND METHODS: A focused ethnographic approach was adopted to elicit the 'situated' experiences of caring for critically ill morbidly obese patients from the perspectives of intensive care staff. Participant observation of care practices and interviews with intensive care staff were undertaken over a four month period. Analysis was conducted using constant comparison technique to compare incidents applicable to each theme. SETTING: An 18 bedded tertiary intensive care unit in New Zealand. PARTICIPANTS: Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m(2). FINDINGS: Interactions between intensive care staff and morbidly obese patients were challenging due to the social stigma surrounding obesity. Social awkwardness and managing socially awkward moments were evident when caring for morbidly obese patients. Intensive care staff used strategies of face-work and mutual pretence to alleviate feelings of discomfort when engaged in aspects of care and caring. This was a strategy used to prevent embarrassment and distress for both the patients and staff. CONCLUSIONS: This study has brought new understandings about intensive care situations where social awkwardness occurs in the context of obesity and care practices, and of the performances and behaviours of staff in managing the social awkwardness of fat-stigma during care situations.