Nonpharmacological interventions aimed at modifying health and behavioural outcomes for adults with asthma: a critical review.

Evidence suggests that living with asthma is linked with psychological and behavioural factors including self-management and treatment adherence, and therefore, there is a reasonable hypothesis that nonpharmacological treatments may improve health outcomes in people living with this condition. A systematic review of randomized controlled trials (RCTs) of nonpharmacological interventions for adults with asthma was designed. Databases searched included The Cochrane Airways Group Register of trials, CENTRAL and Psychinfo. The literature search was conducted until May 2014. Twenty-three studies met the inclusion criteria and were organized into four groups: relaxation-based therapies (n = 9); mindfulness (n = 1), biofeedback techniques (n = 3); cognitive behavioural therapies (CBT) (n = 5); and multicomponent interventions (n = 5). A variety of outcome measures were used, even when trials belonged to the same grouping, which limited the ability to conduct meaningful meta-analyses. Deficiencies in the current evidence base, notably trial heterogeneity, means that application to clinical practice is limited and clear guidelines regarding the use of nonpharmacological therapies in asthma is limited. Relaxation and CBT, however, appear to have a consistent positive effect on asthma-related quality of life and some psychological outcomes, and lung function (relaxation only). Future trials should be informed by previous work to harmonize the interventions under study and outcome measures used to determine their effectiveness; only then will meaningful meta-analyses inform clinical practice.

Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12.

RATIONALE: Dyspnoea is a debilitating and distressing symptom that is reflected in different verbal descriptors. Evidence suggests that dyspnoea, like pain perception, consists of sensory quality and affective components. The objective of this study was to develop an instrument that measures overall dyspnoea severity using descriptors that reflect its different aspects. METHODS: 81 dyspnoea descriptors were administered to 123 patients with chronic obstructive pulmonary disease (COPD), 129 with interstitial lung disease and 106 with chronic heart failure. These were reduced to 34 items using hierarchical methods. Rasch analysis informed decisions regarding further item removal and fit to the unidimensional model. Principal component analysis (PCA) explored the underlying structure of the final item set. Validity and reliability of the new instrument were further assessed in a separate group of 53 patients with COPD. RESULTS: After removal of items with hierarchical methods (n = 47) and items that failed to fit the Rasch model (n = 22), 12 were retained. The "Dyspnoea-12" had good internal reliability (Cronbach's alpha = 0.9) and fit to the Rasch model (chi(2) p = 0.08). Items patterned into two groups called "physical"(n = 7) and "affective"(n = 5). In the separate validation study, Dyspnoea-12 correlated with the Hospital Anxiety and Depression Scale (anxiety r = 0.51; depression r = 0.44, p<0.001, respectively), 6-minute walk distance (r = -0.38, p<0.01) and MRC (Medical Research Council) grade (r = 0.48, p<0.01), and had good stability over time (intraclass correlation coefficient = 0.9, p<0.001). CONCLUSION: Dyspnoea-12 fulfills modern psychometric requirements for measurement. It provides a global score of breathlessness severity that incorporates both "physical" and "affective" aspects, and can measure dyspnoea in a variety of diseases.

Psychological interventions for adults with asthma.

BACKGROUND: Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease. OBJECTIVES: To assess the effectiveness of psychological interventions for adults with asthma. SEARCH STRATEGY: The Cochrane Airways Group Specialised Register and PsycINFO were searched with pre-defined terms up until August 2005. SELECTION CRITERIA: Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a form of control in adult participants were included in the review. DATA COLLECTION AND ANALYSIS: Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted. MAIN RESULTS: Fourteen studies, involving 617 particpants, were included in the review, however study quality was poor and sample sizes were frequently small. However, some pooled effects were analysed. The use of 'as needed' medications was reduced in two studies, (47 patients), by relaxation therapy (OR 4.47, CI 1.22 to 16.44). There was no significant difference in FEV1 for relaxation therapy in four studies of 150 patients, (SMD -0.01, CI -0.41 to 0.40). Quality of life, measured using the Asthma Quality of Life Questionnaire in two studies, (48 patients), showed a positive effect following CBT (WMD 0.71, CI 0.23 to 1.19). Peak Expiratory Flow outcome data in two studies, (51 patients), indicated a significant difference in favour of bio-feedback therapy (SMD 0.66, CI 0.09 to 1.23). The remainder of the findings between studies were conflicting. This may have been due to the different types of interventions used and the deficiencies in trial design. AUTHORS' CONCLUSIONS: This review was unable to draw firm conclusions for the role of psychological interventions in asthma due to the absence of an adequate evidence base. Larger, well-conducted and reported randomised trials are required in this area, in order to determine the effects of these techniques in the treatment of asthma in adults.

Psychological interventions for children with asthma.

BACKGROUND: Asthma is a chronic disease of inflammation and smooth muscle dysfunction, including bronchoconstriction. These symptoms are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. Psychological factors may influence the symptoms and management of asthma in children in many ways, for example, evidence suggests that emotional stress can either precipitate or exacerbate both acute and chronic asthma. OBJECTIVES: To assess the efficacy of psychological interventions in improving health and behavioural outcomes for children with asthma. SEARCH STRATEGY: The Cochrane Airways Group Specialised Register and PsycINFO were searched with pre-defined terms up until March 2005. SELECTION CRITERIA: Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a control intervention in children and adolescents with asthma were included in the review. Cross-over trials were considered inappropriate for studies using psychological interventions and were therefore excluded from this systematic review. DATA COLLECTION AND ANALYSIS: Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted. MAIN RESULTS: Twelve studies (588 children) were included in the review. Study quality was poor and sample sizes were frequently small. A meta-analysis was possible on two studies only examining the effects of relaxation therapy on PEFR which favoured the treatment group (32 L/min, 95% CI 13 to 50 L/min). No other meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. In addition, many studies reported insufficient data. AUTHORS' CONCLUSIONS: This review was unable to draw firm conclusions for the role of psychological interventions for children with asthma. This review demonstrates the absence of an adequate evidence base and highlights the need for well-conducted and reported randomised trials in this area.

Family therapy for chronic asthma in children.

BACKGROUND: Psychosocial and emotional factors are important in childhood asthma. Nevertheless, drug therapy alone continues to be the main treatment. Treatment programmes that include behavioural or psychological interventions have been developed to improve disturbed family relations in the families of children with severe asthma. These approaches have been extended to examine the efficacy of family therapy to treat childhood asthma in a wider group of patients. This review systematically examines these studies. OBJECTIVES: Recognition that asthma can be associated with emotional disturbances has led to the investigation of the role of family therapy in reducing the symptoms and impact of asthma in children. The objective of this review was to assess the effects of family therapy as an adjunct to medication for the treatment of asthma in children. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register, Psychlit and Psychinfo. Searches are current as of January 2005. SELECTION CRITERIA: Randomised trials comparing children undergoing systematic therapy focusing on the family in conjunction with asthma medication, with children taking asthma medication only. DATA COLLECTION AND ANALYSIS: Two reviewers assessed the studies for inclusion in the review. MAIN RESULTS: Two trials with a total of 55 children were included. It was not possible to combine the findings of these two studies because of differences in outcome measures used. In one study, gas volume, peak expiratory flow rate and daytime wheeze showed improvement in family therapy patients compared to controls. In the other study, there was an improvement in overall clinical assessment and number of functionally impaired days in the patients receiving family therapy. There was no difference in forced expiratory volume or medication use in both studies. AUTHORS' CONCLUSIONS: There is some indication that family therapy may be a useful adjunct to medication for children with asthma. This conclusion is limited by small study sizes and lack of standardisation in the choice of outcome measures.

Psychotherapeutic interventions for adults with asthma.

BACKGROUND: Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease. OBJECTIVES: To assess the effectiveness of psychological interventions for adults with asthma. SEARCH STRATEGY: The Cochrane Airways Group specialised register and PsycINFO were searched with pre-defined terms until September 2003. SELECTION CRITERIA: Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a form of control in adult participants were included in the review. DATA COLLECTION AND ANALYSIS: Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted. MAIN RESULTS: Twelve studies were included in the review, however study quality was poor and sample sizes were frequently small. No meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. Findings between studies were conflicting. This may have been due to the different types of interventions used and the deficiencies in trial design. REVIEWER'S CONCLUSIONS: This review was unable to draw firm conclusions for the role of psychological interventions in asthma due to the absence of an adequate evidence base. Large, well-conducted and reported randomised trials are required in this area, in order to determine the effects of these techniques in the treatment of asthma in adults.

The impact of pre-operative education on recovery following coronary artery bypass surgery. A randomized controlled clinical trial.

AIMS: Research has demonstrated the beneficial impact that pre-operative education exerts on the postoperative recovery of patients having surgery but little work has focused specifically on cardiac surgery. Therefore a randomized controlled trial was designed to elucidate the consequences of pre-operative education, given before admission, on postoperative pain, anxiety, depression and wellbeing in the 6 months following a first episode of coronary artery surgery. METHOD AND RESULTS: Three hundred and fifty-six people were randomized into the study, with 188 in the experimental and 168 in the control arms. Patients in the experimental group received the intervention, a day of education by members of the multidisciplinary team, prior to admission for surgery. Experimental and control subjects had the usual care, which involved education on admission and throughout their stay in hospital. Measurement was conducted on entry to the study, before randomization, and at 3 days, 6 weeks, 3 months and 6 months following operation. A variety of tools were used: the SF-36 Health Status questionnaire, the Hospital Anxiety and Depression scale, the General Well-Being questionnaire and a pain measurement tool. Analysis was done using the intention-totreat principle and non-parametric statistics. There were no significant differences between groups in the primary outcomes namely anxiety (P=0.09) and pain (P=0.48), or in depression (P=0.62) and wellbeing ('worn out' P=0.11; 'tense and uptight' P=0.29) 6 months after operation. This was also the case 3 days after coronary artery surgery. There was a significant difference in length of hospital stay (P=0.01) with the experimental group having the longer stay. These findings contrast with much of the existing evidence. CONCLUSION: The findings demonstrate that there is no benefit to be gained from this form of pre-operative education and that there is an associated increase in length of hospital stay. Future research could examine an ongoing programme of education and support, and might use alternative methods such as CD-ROM or the Internet.

Pre-operative education for the patient having coronary artery bypass surgery.

Patient education is an important element of care for people having a range of investigations and treatments. The potentially beneficial effect on outcomes has been explored. In particular research, and meta-analyses of the studies, have demonstrated the positive effect of pre-operative education on post-operative outcomes in patients having a variety of surgical procedures. However, application of the findings to defined groups of specialist patients may be difficult. This paper seeks to establish whether pre-operative education benefits patients following coronary artery bypass surgery and to identify the outcomes affected. A broad search strategy revealed 10 studies which examined pre-operative education and measured post-operative outcomes. Data were extracted which revealed there is limited evidence to suggest that pre-operative education benefits patient's recovery from coronary artery bypass surgery. However, this finding should be considered with caution as this body of research suffered from weak design and there was limited available data.

Anxiety, depression and functional capacity in older women with mitral valve stenosis.

Mitral valve stenosis can lead to a range of symptoms that affect daily life. As many of the people with this problem are elderly, the difficulties resulting from age can be exacerbated by illness. A pilot descriptive study was designed to examine the differences in anxiety, depression and functional capacity in women with mitral valve stenosis who were aged over 60 years when compared to a similar group of volunteers who did not have any cardiac disease. Measurement was undertaken using the Hospital Anxiety and Depression scale, the SF-36 Health Status questionnaire and the Functional Limitations Profile. Forty women were recruited to the study: 20 women with mitral valve stenosis and 20 volunteers. Each person was asked to complete the three questionnaires on one occasion only. Non-parametric statistics were used for analysis. Patients fared worse than volunteers with significant differences between groups in respect of anxiety (P = 0.03), depression (P = 0.02) and overall function (P < 0.001), but not in physical (P = 0.52) or mental health (P = 0.32). Future research could focus on strategies that would help alleviate anxiety and depression and improve functional capacity in older women with mitral valve stenosis.

A review of the impact of pre-operative education on recovery from surgery.

Seminal research by Boore (Boore, J., 1978. Prescription for Recovery. RCN, London) and Hayward (Hayward, J., 1975. Information--a Prescription against Pain, RCN, London) demonstrated that pre-operative information reduces post-operative stress, pain and anxiety in general surgical patients. Both studies used experimental designs and the results are frequently cited in the UK nursing literature. However, they are now more than twenty years old and surgical practices, patterns of hospitalisation and nursing as well as patients' knowledge and expectations have changed enormously. Other more recent studies have sought to evaluate the impact of pre-operative education on post-operative recovery. This paper reviews the research published in this field since 1985. It focuses on studies in which an experimental design was used and considers the types of educational intervention employed and the impact on patient outcomes. A sequel paper will evaluate the research methods used in the light of current practice in the design and reporting of randomised controlled clinical trials.

Pre-operative education--a review of the research design.

Trials on the effectiveness of providing people with education before surgery have suggested a beneficial effect. Although this has been demonstrated through meta-analyses, the results from individual studies have not always shown significant differences between control and experimental groups. This could be a product of the design of the studies. Hence this paper examines the research literature on pre-operative education in the light of modern standards in design and reporting of randomised controlled trials. Patient assignment, blinding of participants and researchers, follow-up procedures and statistical analyses are considered. The theoretical framework underpinning this body of research and ethical issues are discussed. Although there are a relatively large number of studies on pre-operative education the conclusion is that there is considerable room for improvement in trial design as a basis for promoting evidence based nursing.

Case mix type as a predictor of nursing workload.

In the current health care service, the need to measure nursing workload has become the subject of major debate. Attempts have been made to relate workload and nurse staffing, however, despite there being systems for this there appears to be no single recognized formula. Case mix groups have been advocated as a useful tool for measuring nursing workload, particularly in Canada where work continues. Case mix groups work on the basis that patients who are clinically similar and use equivalent resources are grouped using procedure and diagnostic codes. The retrospective study examines the relationship between case mix, resource utilization and nursing effort to determine whether future workload could be predicted using these parameters. The sample included 798 patients and 30 nurses over the period 1993-1994 with analysis of data from the Patient Administration System (PAS) and TEAMWORK, which purports to measure nurse workload. Results showed that there was little relationship between nursing workload and case mix grouping and recommendations are made for future research.

Introducing an integrated nursing research programme.

The move towards evidence-based medicine, the standards being set by purchasers and the greater involvement of nurses in higher education have all led to an increasing interest in research among nurses. This paper describes how one NHS trust sought to develop a clinical nursing research programme and integrate this within its overall research strategy.

Quality improvement and critical care nursing.

Within the field of quality in health care there is a move away from quality assurance to a process of Continuous Quality Improvement. This change needs to be considered when designing a program to ensure quality within a critical care environment. There are several approaches available, one of which is the Dynamic Quality Improvement program. This involves solving problems and improving everyday practice whilst focusing on the recipients of the service. It utilises the Dynamic Standard Setting System (DySSSy) to define a professionally agreed level of performance for a chosen population. The standard must be achievable, observable, desirable and measurable. Patient focused nursing activities such as eye care and the prevention of pressure sores can be the basis for standard setting, audit and action to improve the care of the critically ill patient in a comprehensive program of quality initiatives.

Assessment of anxiety in hospital patients.

There has been research in North America to validate the nursing diagnosis of anxiety. As part of this work, Young used the defining characteristics and developed a tool to measure anxiety. The present research sought to extend that study in the United Kingdom, assess the anxiety-defining characteristics tool and identify key indicators of anxiety that might be useful in clinical practice. Four anxiety measurement tools, drawn from the literature, were used. These were the state trait anxiety inventory, the graphic anxiety scale, the hospital anxiety and depression scale, and the anxiety-defining characteristics tool. A random sample of 79 hospitalized patients were interviewed and their anxiety rated using all four measures. Calculation of Spearman's correlation co-efficients revealed convergent validity between the anxiety-defining characteristics tool and the state trait anxiety inventory and the anxiety score on the hospital anxiety and depression scale. Anxiety levels were found not to be affected by the age or sex of the respondent, or the length of stay or number of previous admissions. Discriminant analysis suggested that six characteristics adequately discriminated anxious subjects: sweating, faintness, tendency to blame others, continual review of things in their mind, focus on self and a lack of self-confidence. The study concluded that there is a scope for further research into these characteristics and their use in clinical practice.

An exploratory study of students' perceptions of the benefits of regular small group tutorials in a 2-year day release course.

This study was undertaken with the intention of improving the effectiveness of small group tutorials in a diploma in nursing course. There was concern to avoid some of the less valuable aspects of tutorials highlighted in the literature. An investigation was conducted to elicit students' perceptions of the benefits of group tutorials at a comparatively early stage in their 2-year course, at the end of the second term. A qualitative approach was taken to explore the views of four students through individual semi-structured interviews. Additional data were gathered through personal field notes to add the tutor's perspective of the group process. Data were analysed inductively using a phenomenological approach in an attempt to elucidate the essence of each participant's experience of the tutorials. While the findings suggested that students valued their involvement in small group tutorials, some questions were raised which point to the need for further investigation. Themes were revealed which drew attention to the value students place on the experience of small group tutorials, thus endorsing the strategies employed. Benefits to students include the opportunity to get to know a small group of people when part of a larger learning group, support when coping with the pressures of course work and being able to share ideas about issues relevant to nursing. The report concludes that there is scope for further investigation and reflection in order to develop educational practice.

Nurse education in a specialist environment.

The curricula discussed here have been designed to promote and support the practice of registered nurses in cardiorespiratory nursing. Drawing on Benner's (1984) work, levels of practice from novice to expert have been identified and descriptors for each determined. These reflect Benner's (1984) ideas combined with Bloom's (1956) taxonomy as well as our own work in current nursing issues such as accountability and research in practice. Practice is underpinned by an academically validated theoretical programme ensuring that theory and practice are intrinsic to each course. There is a reciprocal relationship between progression in practice from novice through advanced beginner to expert and increasing intellectual enquiry and the evaluation of research. In this way a continuum of theory and practice has been recognised and an education programme from Certificate to Masters Degree level developed to promote this.