Nursing Theory Makes a Practice Turn in the 21st Century

The author assumes that practice became prominent in nursing theory in the first two decades of the 21st century. The end of the last century saw a burgeoning of literature on what is known as grand theories, their implementation, and evaluation. The era of healthcare quality research began when the Institute of Medicine issued a report on building a safer health system. At this time, the 21st-century literature in nursing took a distinct turn toward practice, influencing nursing theory. The movement to individualize care acted to further this influence. The nurse and patient relationship is the source of data for knowledge development. Established research approaches such as grounded theory and new approaches such as story theory were being used to create nursing theory from practice. Grand theory work moved to the development of instruments to measure the effects of theory in practice, such as that of Watson and Roy. The middle-range theories were developed and seen as closer to and easier to use in practice. The evidence-based practice movement also contributed to the role of theory in practice. These knowledge developments led to nurses having expanded roles in nursing.

Men’s Positive and Negative Experiences Following Acute Myocardial Infarction

(1) Objective: To describe men’s experiences as acute myocardial infarction sufferers from a social phenomenological perspective, a year after the event (2) Methods: The phenomenological interview was used to capture the participants’ discourse. The data were analyzed according to the theoretical methodological approach of social phenomenology. (3) Results: The discourse analysis of the content produced the following categories, set out according reasons “why”: personal biography, knowledge set, warning signs prior to the illness, experience at the intensive care unit, and rehabilitation process; and reasons “for”: expectations as regards the illness, health professionals, and future social life and work prospects. (4) Conclusions: Participants had not established a healthy condition one year after myocardial infarction, perceiving a very thin line between life and death. Personal biography influences the coping of the disease. They feel like the illness helped them to create new meanings and value of life. They envisage a future full of great restrictions and uncertainty. The results of this study have underlined the need to involve care at all stages of the illness: the physical and emotional dependence upon admittance at the intensive care unit, the need to be cured, the constant demand for information about the illness, the difficulties encountered upon returning home, uncertainty about the future, etc. All these moments indicate that proper nursing care adapted to the specific needs of each individual and their family members must be provided in order to help them to overcome all the stages involved in this process. It is necessary to individualize care because the sense of reality is common and universal, but the ways of expressing are subjective, and it depended on the totality of experiences accumulated throughout life.

Clinical Decision Support for Diabetes Care in the Hospital: A Time for Change Toward Improvement of Management and Outcomes

The increasing prevalence of diabetes permeates hospitals and dysglycemia is associated with poor clinical and economic outcomes. Despite endorsed guidelines, barriers to optimal management and gaps in care prevail. Providers’ limitations on knowledge, attitudes, and decision-making about hospital diabetes management are common. This adds to the complexity of dispersed glucose and insulin dosing data within medical records. This creates a dichotomy as safe and effective care are key objectives of healthcare organizations. This perspective highlights evidence of the benefits of clinical decision support (CDS) in hospital glycemic management. It elaborates on barriers CDS can help resolve, and factors driving its success. CDS represents a resource to individualize care and improve outcomes. It can help overcome a multifactorial problem impacting patients’ lives on a daily basis.

Perspectivas sobre o uso da análise da atividade na Terapia Ocupacional: um estudo com preceptores / Perspectives on the use of activity analysis in Occupational Therapy: a study with preceptors

As atividades, bem como sua análise, são ferramentas importantes para o terapeuta ocupacional. Tomando-as como instrumento, o profissional poderá favorecer ações para a experimentação, ensinar novas maneiras de fazer, estabelecer um elo entre o falar e o fazer, além de auxiliar na significação do que é e foi vivido pelo indivíduo. Objetivo: apresentar a percepção dos terapeutas ocupacionais quanto ao uso da análise da atividade na sua prática e a relação com o local de atuação. Método: Estudo quantitativo exploratório e descritivo, realizado através de questionário em meio eletrônico entre julho e agosto de 2018. Os dados coletados foram analisados através de frequência simples e categorias das falas dos participantes. Resultados: A amostra foi composta por 13 preceptores, na maioria mulheres, atuantes no campo da saúde. Todos os participantes relataram utilizar a análise da atividade com ou sem roteiro específico. A maioria utilizou a análise da atividade para planejamento da intervenção e individualização do atendimento. Os participantes também ressaltaram a importância da análise da atividade e sua influência no serviço de atuação. Conclusão: Para os terapeutas ocupacionais avaliados, a análise da atividade tem importância na sua prática profissional e seu uso tem relação ou influência nos serviços que atuam. Não houve uma única maneira de conceber e utilizar a análise da atividade, mas sim diferentes formas de enxergar e de proceder. Ressalta-se que neste estudo todos os participantes atuavam no campo da saúde, desta forma, os dados aqui apresentados podem ser reflexo deste campo de atuação.Palavras-chave: Terapia Ocupacional; Atividades; Atividades cotidianas; Preceptoria. ABSTRACT: Activities, as well as their analysis, are important tools for the occupational therapist. Taking them as an instrument, the professional can favor actions for experimentation, teach new ways of doing, establish a link between speaking and doing, in addition to helping in the meaning of what is and was experienced by the individual. Objective: to present the perception of occupational therapists regarding the use of activity analysis in their practice and the relationship with the place of practice. Method: Quantitative exploratory and descriptive study, carried out through a questionnaire in electronic media between July and August 2018. The data collected were analyzed through simple frequency and categories of the participants' statements. Results: The sample consisted of 13 preceptors, mostly women, working in the health field. All participants reported using the activity analysis with or without a specific script. Most used the activity analysis to plan the intervention and individualize care. Participants also stressed the importance of analyzing the activity and its influence on the service. Conclusion: For the occupational therapists evaluated, the analysis of the activity is important in their professional practice and its use has a relationship or influence on the services they work on. There was no single way to conceive and use the analysis of activity, but different ways of seeing and proceeding. It is noteworthy that in this study all participants worked in the field of health, thus, the data presented here may reflect this field of action.Keywords: occupational therapy; activities; activities of daily living; preceptorship. RESUMEN: Las actividades, así como su análisis, son herramientas importantes para el terapeuta ocupacional. Tomándolos como instrumento, el profesional puede favorecer acciones de experimentación, enseñar nuevas formas de hacer, establecer un vínculo entre hablar y hacer, además de ayudar en el significado de lo que es y fue experimentado por el individuo. Objetivo: presentar la percepción de los terapeutas ocupacionales sobre el uso del análisis de actividad en su práctica y la relación con el lugar de práctica. Método: Estudio cuantitativo, exploratorio y descriptivo, realizado a través de un cuestionario electrónico entre julio y agosto de 2018. Los datos recolectados fueron analizados mediante frecuencia simple y categorías de declaraciones de los participantes. Resultados: La muestra estuvo conformada por 13 preceptoras, en su mayoría mujeres, que trabajan en el campo de la salud. Todos los participantes informaron haber utilizado el análisis de actividad con o sin un guión específico. La mayoría utilizó el análisis de actividad para planificar la intervención e individualizar la atención. Los participantes también destacaron la importancia de analizar la actividad y su influência en el servicio. Conclusión: Para los terapeutas ocupacionales evaluados, el análisis de la actividad es importante en su práctica profesional y su uso tiene relación o influencia en los servicios en los que trabajan. No había una única forma de concebir y utilizar el análisis de la actividad, sino diferentes formas de ver y de proceder. Es de destacar que en este estudio todos los participantes trabajaron en el campo de la salud, por lo que los datos aquí presentados pueden reflejar este campo de acción.Palabrasclave: terapia ocupacional; actividades; actividades diarias; preceptoría.

QOLP-01. OUTCOME ASSESSMENT OF MULTIDISCIPLINARY BRAIN TUMOR BOARD MEETING RECOMMENDATIONS FOR BRAIN METASTASIS: IS THERE A GAP?

BACKGROUND Brain metastasis (BM) is the most common form of brain cancer affecting 20-40% of cancer patients. Advancements in cancer therapy has prolonged survival but BM incidence has increased. BM management requires a multidisciplinary approach to individualize care via an ever-growing sum of surgical, radiation, and systemic therapy options. Consensus is achieved by multidisciplinary tumor board meeting (MTBm). Nevertheless, BM diagnosis predicts poor prognosis. Palliative Care (PC) is essential for proper BM management. Yet, formal PC assessment may not be available for MTBm. We evaluated whether MTBm consensus recommendations were followed. RESULTS Our weekly MTBm discussed 157 BM cases during 2019 (median age: 64 years [range 28-91], male/female: 82/75). The most common primary diagnosis was lung (n=49, 31%), breast (n=24, 15%), melanoma (n=16, 10%). The majority was newly diagnosed BM (n=143, 91%). MTBm recommendations were divided into three not-mutually-exclusive categories: surveillance/workup (n=78, 50%), BM-directed treatment (n=101, 64%) and GOC discussion (n=7, 4%). MTBm recommendations were fully followed in 113 cases (72%), partially in 13(8%), and not followed in 25(16%). Of the 38 patients whose recommendations were partially/not followed, the main reason was transition to hospice/death (n=26, 68%). Of the 101 patients recommended treatment, 68% (n=68) fully followed it, yet 31% (n=21) of them died within 3 months; for those living longer than 3 months (n=47, 69%), median KPS at 3 months was 70 (range 30-90). Of the entire cohort (n=157), only 20 (13%) established consistent PC follow-up (>1 outpatient visit) and 69 cases (44%) transitioned to hospice/died within 6 months, 30 of which (43%) still completed surgery (n=6) or radiotherapy (n=24) within this period. CONCLUSION Periodic assessment of MTBm recommendations is relevant for sensible BM management. Balancing treatment while focusing on QoL in a patient population with limited survival is challenging. PC assessment at MTBm could close this gap.

Clinical dilemmas in local and regional testis cancer

At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician’s assistants, residents, fellows, nurses, patients, and patient advocacy group members. This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe to do so.

A comprehensive study on disease risk predictions in machine learning

Over recent years, multiple disease risk prediction models have been developed. These models use various patient characteristics to estimate the probability of outcomes over a certain period of time and hold the potential to improve decision making and individualize care. Discovering hidden patterns and interactions from medical databases with growing evaluation of the disease prediction model has become crucial. It needs many trials in traditional clinical findings that could complicate disease prediction. Comprehensive survey on different strategies used to predict disease is conferred in this paper. Applying these techniques to healthcare data, has improvement of risk prediction models to find out the patients who would get benefit from disease management programs to reduce hospital readmission and healthcare cost, but the results of these endeavours have been shifted.

Major adverse renal events (MARE): A proposal to unifying renal endpoints

Background In renal studies, various outcome endpoints are used with variable definitions, making it nearly impossible to perform meta-analyses and deduce meaningful conclusions. Increasing attention is directed towards standardization of renal outcome reporting. Methods A working group was formed to produce a unifying definition of renal outcomes that can be used by all investigators. We propose major adverse renal events (MARE) as the term for a standardized composite of hard renal outcomes. We discuss the components for inclusion in MARE from existing evidence. Results MARE could include three to five items, considered relevant to patients and regulators. New onset of kidney injury, that is persistent albuminuria/proteinuria and/or decreasing glomerular filtration rate (GFR) <60 ml/min/1.73 m2, persistent signs of worsening kidney disease, development of end-stage kidney disease with estimated GFR <15 ml/min/1.73 m2 without or with initiation of kidney replacement therapy, and death from renal cause are core items of MARE. Additionally, patient reported outcomes should be reported in parallel to MARE as a standard set of primary (or secondary) endpoints in studies on kidney disease of diabetic, hypertensive-vascular, or other origin. Conclusions MARE as a reporting standard will enhance the ability to compare studies and thus, facilitate meaningful meta-analyses. This will result in standardized endpoints that should result in guideline improvement to better individualize care of patients with kidney disease.

The Burden of Frailty Among U.S. Veterans and Its Association With Mortality, 2002–2012

Background Frailty is a key determinant of clinical outcomes. We sought to describe frailty among U.S. Veterans and its association with mortality. Methods Nationwide retrospective cohort study of regular Veterans Affairs (VA) users, aged at least 65 years in 2002–2012, followed through 2014, using national VA administrative and Medicare and Medicaid data. A frailty index (FI) for VA (VA-FI) was calculated using the cumulative deficit method. Thirty-one age-related deficits in health from diagnostic and procedure codes were included and were updated biennially. Survival analysis assessed associations between VA-FI and mortality. Results A VA-FI was calculated for 2,837,152 Veterans over 10 years. In 2002, 35.5% were non-frail (FI = 0–0.10), 32.6% were pre-frail (FI = 0.11–0.20), 18.9% were mildly frail (FI = 0.21–0.30), 8.7% were moderately frail (FI = 0.31–0.40), and 4.3% were severely frail (FI > 0.40). From 2002 to 2012, the prevalence of moderate frailty increased to 12.7%and severe frailty to 14.1%. Frailty was strongly associated with survival and was independent of age, sex, race, and smoking; the VA-FI better predicted mortality than age alone. Although prevalence of frailty rose over time, compared to non-frail Veterans, 2 years’ hazard ratios (95% confidence intervals) for mortality declined from a peak in 2004 of 2.01 (1.97–2.04), 3.49 (3.44–3.55), 5.88 (5.79–5.97), and 10.39 (10.23–10.56) for pre-frail, mildly, moderately, and severely frail, respectively, to 1.51 (1.49–1.53), 2.36 (2.33–2.39), 3.68 (3.63–3.73), 6.62 (6.53–6.71) in 2012. At every frailty level, risk of mortality was lower for women versus men and higher for blacks versus whites. Conclusions Frailty affects at least 3 of every 10 U.S. Veterans aged 65 years and older, and is strongly associated with mortality. The VA-FI could be used to more accurately estimate life expectancy and individualize care for Veterans.