A systematic review of interventional studies on oral care of palliative patients.

BACKGROUND: To study and review the effectiveness of oral care interventions for palliative patients for amelioration of clinical conditions affecting oral cavity. METHODS: Following PRISMA standard, a systematic evaluation of articles published between 2000 and 2021 was undertaken utilising five databases on interventions studies. This comprehensive review consists of randomised controlled trials (RCTs) and specific types of non-randomised studies (NRS) examining oral care interventions for palliative patients. Three independent authors screened search records, identified related studies, extracted data and evaluated risk of bias. The key findings of each study were summarised according to the research questions and data that generated during the data extraction procedure. RESULTS: Out of the 67 identified studies, seven were included in this review (five RCTs and two NRSs) involving head-and-neck cancer, oral cancer, oral mucositis, xerostomia and individuals with malignant disease. Interventions studied were: Ziziphus honey, artificial saliva, CAM2028-Benzydamine, morphine mouthwash, ketamine mouthwash, bethanechol tablets and caphosol with regular oral-care. The durations of interventions in the included studies were largely short-term (six weeks or less). Overall, six studies revealed good results in support of the intervention, with magnitudes of effect ranging from 13.2-10,110.0%. However, just four researches found significant changes, with magnitudes of effect ranging from 50.0-10,110.0%. Although two of the trials have not revealed significant changes in the results, investigations have indicated a reduction in oral conditions in the group with interventions. Only one trial has not indicated an improvement in oral conditions in the groups which received the interventions. DISCUSSION: By assessing the efficacy of available oral hygiene interventions for palliative patients, this systematic review can help palliative team finds the viable strategies to apply in controlling oral problems among hospice patients. Even though only four of the seven research found a statistically significant difference, most studies found great effectiveness in favour of intervention.

Effect of nurse-led home-based biofeedback intervention on the blood pressure levels among patients with hypertension: Pretest-posttest study.

AIM: To investigate the effect of nurse-led home-based biofeedback intervention on the blood pressure levels among patients with hypertension. BACKGROUND: Nurse-led interventions are emerging as cost-effective as well as clinically proven in chronic illness management. Hypertension, a leading long-term cardiovascular condition, has autonomic dysregulation and increased sympathetic tone as its pathophysiological background. Complementary interventions evidenced to interplay hypertension pathophysiology. DESIGN: A pretest-posttest design. MATERIALS AND METHODS: Uncomplicated primary hypertension outpatients were randomly assigned as study group (n = 173) and control group (n = 173) at a tertiary care hospital. Sociodemographic, clinical, and outcome variables [the baseline blood pressure and galvanic skin response (GSR)] were collected. Study group patients were given four teaching sessions of abdominal breathing-assisted relaxation facilitated by GSR biofeedback. Daily home practice was encouraged and monitored to measure the effects on blood pressure and GSR at the end of the 1st, 2nd, and 3rd month of intervention. RESULTS: The study group participants showed significant decrease in mean (SD) systolic [140.77 (8.31) to 136.93 (7.96), F = 469.08] and diastolic blood pressure [88.24 (5.42) to 85.77 (4.66), F = 208.21]. In contrast, control group participants had a mild increase in the mean systolic (F = 6.02) and diastolic blood pressure (F = 4.70) values from pretest to posttests. GSR showed a significant increase from 559.63 (226.33) to 615.03 (232.24), (F = 80.21) from pretest to posttest III. CONCLUSIONS: Use of home-based biofeedback-centered behavioral interventions enabled BP reduction among hypertensive patients. Further studies should use biochemical markers of sympathetic nervous system activity to endorse this home-based chronic illness intervention.

Why oral palliative care takes a backseat? A national focus group study on experiences of palliative doctors, nurses and dentists.

Aim: Poor oral care among frail older people at the end of life endangers quality of life. However, only few dying people have access to oral palliative care services. Therefore, this study aimed to investigate oral palliative care practices and referral patterns for palliative patients in the Brunei healthcare settings. Design: An exploratory qualitative study. Methods: Five focus groups were conducted among palliative care nurses (N = 7), palliative medicine doctors (N = 4), dentists (N = 6), oncologists (N = 4) and oncology nurses (N = 4). Verbatim was analysed using qualitative thematic analysis. Results: Analyses revealed four distinct themes emerging as current oral palliative care assessment and referral practice in the Brunei healthcare settings: "taking a back seat," "opportunistic oral care," "they refused and refused" and "challenging healthcare resources and oral palliative care."

Oral health problems among palliative and terminally ill patients: an integrated systematic review.

BACKGROUND: High incidence of treatable oral conditions has been reported among palliative patients. However, a large proportion of palliative patients lose their ability to communicate their sufferings. Therefore, it may lead to under-reporting of oral conditions among these patients. This review systematically synthesized the published evidence on the presence of oral conditions among palliative patients, the impact, management, and challenges in treating these conditions. METHODS: An integrative review was undertaken with defined search strategy from five databases and manual search through key journals and reference list. Studies which focused on oral conditions of palliative patients and published between years 2000 to 2017 were included. RESULTS: Xerostomia, oral candidiasis and dysphagia were the three most common oral conditions among palliative patients, followed by mucositis, orofacial pain, taste change and ulceration. We also found social and functional impact of having certain oral conditions among these patients. In terms of management, complementary therapies such as acupuncture has been used but not well explored. The lack of knowledge among healthcare providers also posed as a challenge in treating oral conditions among palliative patients. CONCLUSIONS: This review is first in its kind to systematically synthesize the published evidence regarding the impact, management and challenges in managing oral conditions among palliative patients. Although there is still lack of study investigating palliative oral care among specific group of patients such as patients with dementia, geriatric or pediatric advanced cancer patients, this review has however provided baseline knowledge that may guide health care professionals in palliative settings.

Oral Microbiological Evidence among Palliative Patients: An Integrated Systematic Review.

Life-limiting diseases such as cancers and its related treatments often compromise normal oral microbial flora and predispose a palliative patient to diverse oral infections. Knowledge on microbial flora in the oral cavity of patients with life-limiting diseases is essential to develop treatment options for clinical practitioners. This review aimed to systematically synthesize the published evidence on the oral microbiology of palliative patients. An integrative review was undertaken with defined search strategy from five databases with manual search through key journals and reference list. Studies included were published during the year 2000-2017 focusing on microbiological evidence associated with oral conditions among palliative patients. Candida presence was reported in the oral cavity of terminally ill patients in seven of nine articles, with Candida albicans being the predominant species. The majority of the included studies used oral swabs as a technique for isolation of the organism. This review is first to systematically synthesize the published evidence on the oral microbial flora of palliative patients, taking into account the techniques for identification of the microbiota. Larger multicenter studies may help in developing standardized clinical guidelines for the oral care of these patients.

Barriers and Solutions for Improving Pain Management Practices in Acute Hospital Settings: Perspectives of Healthcare Practitioners for a Pain-Free Hospital Initiative.

BACKGROUND: Effective pain management is a fundamental human right. However, global disparities in pain management practices exist across health settings. This study explored healthcare practitioners' views on pain management in the acute care hospital setting. METHODS: The focus groups included clinical specialties most likely to encounter patients with 'difficult to manage pain', namely those in the Geriatrics and Palliative Care Unit (2 doctors and 3 nurses), Critical Care Unit (7 doctors), and the Pain Management Team (3 doctors and 2 nurses). The transcripts were analyzed using a qualitative thematic analysis. RESULTS: The data analysis revealed four themes. Theme 1, 'Being too safe' described the presence of apprehensive attitudes among patients and healthcare practitioners that limits the appropriate use of diverse and tailored pain medications in acute care hospital settings. Theme 2, 'Working as a team' described the need for collaborative approaches to achieve hospital-wide evidence-based pain management. Theme 3, 'Adaptation for local and cultural preferences' explored how pain was perceived through cultural lenses and suggested strategies to tailor pain management to local and cultural preferences. Finally, Theme 4, 'Driving acute pain management forward' listed clinician solutions for improving pain management in acute care hospital settings toward a pain-free hospital initiative. CONCLUSION: Despite advances in pain medicine and pain teaching strategies, effective pain management is proportionate to both clinical and cultural preferences. Future studies should investigate the standardization of global pain management tools and guidelines to fit the local culture and context.

Predictors for nurses and midwives' readiness towards self-directed learning: An integrated review.

AIM: To systematically review the existing evidence on predictors for nurses and midwives' readiness towards Self-directed Learning (SDL). BACKGROUND: Increased complexities in healthcare settings demand that nurses and midwives become involved in lifelong learning by means of self-directed learning (SDL) for delivering quality healthcare. More evidence is available for the self-directed learning readiness (SDLR) of nursing and midwifery students, less is systematically derived on predictors for nurses and midwives' readiness to SDL. DESIGN: An integrative systematic review. METHODS: Systematic searches were carried out using the following five electronic databases: PubMed, Science Direct, Google Scholar, Ovid Medline and Embase. Studies published in English language from 2000 to 2017 were included. The integrative systematic review framework developed by Whittemore and Knafl (2005) was used to analyse and summarise the key themes. RESULTS: Of 804 initial screening papers, in total of eight eligible studies (six quantitative and two qualitative) were found. Integrative analysis resulted in four themes as predictors for nurses and midwives' readiness towards SDL: 1) personal characteristics, 2) working environment, 3) online learning and SDLR, and 4) process of SDL. Review found that, although demographic characteristics of nurses and midwives do not influence their SDLR, work environment often influences their SDLR. Furthermore, nurses and midwives have a positive interest in online learning that is often used to improve their knowledge acquisition. CONCLUSION: The review concludes that qualified nurses and midwives have a unique SDL predictors and process; hence, a personalized SDL programme should be prescribed based on personality traits so as to achieve better SDL outcomes. Future research should address the facilitating factors for SDLR, barriers to SDLR and strategies to improve SDLR among nurses and more importantly midwives, as limited evidence is available with respect to the latter.

Let him not be alone: perspectives of older British South Asian minority ethnic patients on dying in acute hospitals.

AIM: To investigate older British South Asians' views on dying at acute hospitals. BACKGROUND: Older people, including those from ethnic minorities prefer 'home as a haven' for their last days of life; however, they are more likely to die in hospital. METHODS: Constructive grounded theory was used as a methodological approach that informed data collection to data analysis. Open meetings with 11 local South Asian community organisations enabled the researchers to recruit a total of 55 older South Asians in this study. Data were collected using gender-based focus groups (n=5) and in-depth, semi-structured interviews (n=29). Transcripts were analysed using Nvivo 9. RESULTS: Three key themes were identified: 'mistrust', 'let him not be alone' and 'family as a protective shield'. The theme 'mistrust' is explored through examination of beliefs, attitudes and expectations about 'hospital' as a place in the care of the dying. The theme of 'let him not be alone' draws the family's preferences and concerns in relation to leaving their older dying relative alone in the hospital. The final theme of 'family as a protective shield' describes the element of family care as a protective shield for their older one to have peaceful end-of-life care moments in the hospital. CONCLUSIONS: Allowing older relatives to die in hospital seems to evoke feelings of missed filial responsibilities and guilt among family carers among older ethnic minorities. The presence of cultural paranoia and mistrust often led minorities to experience sub-standard end-of-life care in acute hospitals.

Reported clinical outcomes of high-fidelity simulation versus classroom-based end-of-life care education.

BACKGROUND: Nursing students often experience increased anxiety, lack of clinical skills and poor coping mechanisms when dealing with death and dying for the first time. AIMS: To design, use and assess the effectiveness of high-fidelity simulation teaching versus classroom-based end-of-life care (EoLC) teaching for first-year nursing students on dealing with their first death experiences in clinical placements. METHODS: A qualitative phenomenography approach was taken. First-year nursing students (n=187) were randomly allocated to receive either classrtoom-based (n=139) or high-fidelity simulation-based EoLC teaching (n=48). When all participants had returned from their first clinical placement, 12 individual in-depth interviews were carried out. Data were analysed using framework analysis. RESULTS: Comparative data analysis revealed four key themes as clinical outcomes: recognising death and dying; knowledge into practice; preparedness for clinical eventualities; and emotional preparedness. CONCLUSIONS: Despite the fact that both strategies improved students' knowledge of EoLC, simulation-based EoLC education was perceived as better in terms of enhanced practical skills and improved emotional experience in their first clinical placement.

'Being a conduit' between hospital and home: stakeholders' views and perceptions of a nurse-led Palliative Care Discharge Facilitator Service in an acute hospital setting.

AIMS AND OBJECTIVES: To explore and critically examine stakeholders' views and perceptions concerning the nurse-led Palliative Care Discharge Service in an acute hospital setting and to inform sustainability, service development and future service configuration. BACKGROUND: The drive in policy and practice is to enable individuals to achieve their preferred place of care during their last days of life. However, most people in UK die in acute hospital settings against their wishes. To facilitate individuals' preferred place of care, a large acute hospital in northeast England implemented a pilot project to establish a nurse-led Macmillan Palliative Care Discharge Facilitator Service. DESIGN: A pluralistic evaluation design using qualitative methods was used to seek stakeholders' views and perceptions of this service. METHODS: In total, 12 participants (five bereaved carers and seven health professionals) participated in the evaluation. Semi-structured interviews were conducted with bereaved carers who used this service for their relatives. A focus group and an individual interview were undertaken with health professionals who had used the service since its inception. Individual interviews were also conducted with the Discharge Facilitator and service manager. Analysis of all data was guided by Framework Analysis. RESULTS: Four key themes emerged relating to the role of the Discharge Facilitator Service: achieving preferred place of care; the Discharge Facilitator as the 'conduit' between hospital and community settings; delays in hospital discharge and stakeholders' perceptions of the way forward for the service. CONCLUSION: The Discharge Facilitator Service acted as a reliable resource and support for facilitating the fast-tracking of end-of-life patients to their preferred place of care. RELEVANCE TO CLINICAL PRACTICE: Future planning for hospital-based palliative care discharge facilitating services need to consider incorporating strategies that include: increased profile of the service, expansion of service provision and the Discharge Facilitator's earlier involvement in the discharge process.