• End-of-life discussions as a component of advance care planning and their associations with care received near death

      Cheon, Jooyoung; Wiegand, Debra J. Lynn-McHale; 0000-0001-9622-0937 (2016)
      Background: Advance care planning (ACP) is an ongoing process of communication of end-of-life (EOL) preferences between patients, families, and health care professionals (HCPs). ACP includes having EOL discussions, durable power of attorney for health care (DPAHC), and living will (LW). Engagement in DPAHC and LW can lead to less aggressive treatments and more comfort care, but little is known about the effects of EOL discussions of patients' preferences on their outcomes. Purposes: The purposes of this study were: 1) to examine patient characteristics influencing engagement in ACP; 2) to determine the effect of engagement in EOL discussions alone and the combined effect of EOL discussions with DPAHC and/or LW on EOL care; and 3) to examine the effect of EOL discussions and DPAHC on congruency between patients' preferences for care and care they received. Method(s): This study was a secondary data analysis using the Health and Retirement Study Exit Interviews of 6,001 decedents aged 50 years or older. Five different types of engagement in ACP were selected for this study. Sequential logistic regression and multivariable logistic regression were used. Results: Decedent characteristics significantly associated with engagement in ACP were different by the types of engagement. Engagement in EOL discussions only was not a predictor of receiving all possible care to prolong life but was a predictor of receiving comfort care. Engagement in all three types of ACP was the strongest predictor of receiving both all possible care to prolong life and comfort care. Among decedents who had a LW, there was a synergistic effect of engagement in EOL discussions and DPAHC on receiving care consistent with decedents' preferences for EOL care. Engaging in more types of ACP was associated with lower odds of receiving all possible care, higher odds of receiving comfort care, and higher odds of receiving care consistent with decedents' preferences. Conclusions: Findings suggests that there was a synergistic effect of engagement in EOL discussions, DPAHC, and LW on receiving EOL care. HCPs should make more effort to communicate with patients and their families about their preferences at the EOL.
    • Interruptions within the Culture of the Nursing Unit Work Environment

      Hopkinson, Susan L.; Geiger-Brown, Jeanne; Wiegand, Debra J. Lynn-McHale (2011)
      Statement of the problem: Interruptions result in omissions, increased mental effort and increased total work time in controlled settings. Even though interruptions in nurses' work would seem to increase errors, consistent supporting evidence has not been provided. Inconsistent definitions, guiding frameworks, and outcome measures have resulted in a knowledge gap in how and why interruptions occur within the nursing unit. The purpose of this study was to better understand interruptions within the medical nursing unit work environment. The research question was: What within the culture of the nursing unit contributes to a work environment that is vulnerable to interruptions? Methods: A philosophical framework of symbolic interactionism and a micro ethnographic approach was used. The setting was a medical nursing unit in a large teaching hospital. Data collection included 108 hours of observation of the entire nursing unit, document review, 81 hours of individual participant observation and 9 interviews. Purposive sampling guided participant selection. Data were analyzed from unstructured field notes and interview transcripts. Definitions of interruptions and culture guided coding, categorizing, and identification of themes as data moved to higher levels of abstraction. Results: Complexity emerged as a primary theme. Interconnection, constant change and unpredictability were prevalent. Subthemes were grouped by cultural elements. Values were a) excellence in patient care and b) meeting personal needs. Beliefs were a) I have to do it all myself and b) phone calls are important. Patterns included a) changing patients, b) patient admissions, c) patient transport, and d) required resources. Normative practices included a) communicating, b) coordinating care, c) developing relationships, d) filtering, and e) adapting. Trustworthiness of findings was established. Conclusions: Interruptions are an integral part of nursing unit culture. The inherent complexity of the nursing unit suggests that complex adaptive systems is a useful framework for future research. Initiatives to improve clinical practice should investigate how cultural elements of the nursing unit contribute to interruptions. Uniformly decreasing or eliminating interruptions will disrupt current practices, such as communicating and coordinating care, that are central to nursing work. Education and training should focus on team development and identification of self-initiated and system-initiated interruptions.
    • New treatment targets in heart failure: Patient reported outcome measures and subjective well-being

      Russo, Marguerite M.; Wiegand, Debra J. Lynn-McHale (2015)
      Background: Despite costly advances in heart failure management, heart failure is characterized by pervasive adverse and complex symptoms, functional decline, and poor quality of life. A robust theoretical framework comprehending provider and patient paradigms guided this study seeking new treatment targets to augment existing advanced therapies. Aims: The aim of this study is to examine subjective well-being associations with other patient reported outcome measures, and disease and treatment outcomes, in individuals with heart failure. Methods: This cross sectional, correlational study used data collected from 88 individuals undergoing inpatient heart failure treatment in a large urban academic medical center (50% male, average age 67±6. 9, median duration of heart failure >4 years, mean vEF =32%). Following consent, patients completed a 30 minute interview consisting of valid, reliable ‘patient reported outcome measures’ of subjective well-being, symptom burden, intrusion of illness and treatment in meaningful life pursuits, and health related quality of life. Disease, treatment and social characteristics were abstracted from medical records. Data analyses were conducted using correlation, non parametric statistics and regression models. Results: ‘Patient reported outcome measures’ had good internal reliability (Cronbach’s alpha >.8). Subjective well-being scores detected differences based on age, functional, employment and insurance statuses. Health related quality of life and subjective well-being measures correlated with illness intrusiveness (.53, -.40). The most prevalent symptoms reported (75-97%), were xerostomia, dyspnea, fatigue, pain, worry and sleep disruption. In multiple regression models, illness intrusiveness predicted subjective well-being (R2 change=.29, p≤.01) health related quality of life (R2 change= .24, p≤.01), after controlling for functional and insurance statuses. Conclusion: ‘Patient reported outcome measures’ including subjective well-being scales contribute unique findings to inform individualized heart failure treatment. New heart failure treatment targets identified in this sample include multidimensional symptom management, functional support, prognostication and advance care planning, all components of primary palliative care.
    • A Phenomenological Study on Lived Experiences of Psycho-Socio-Spiritual Healing in Cardiac Rehabilitation Patients

      Nadarajah, Sheeba Raaj; Wiegand, Debra J. Lynn-McHale (2012)
      Abstract Background: Coronary artery disease is the single leading cause of death in the United States. Secondary prevention programs such as cardiac rehabilitation focus on physical aspects of healing and psycho-socio-spiritual aspects of healing are often given minimal attention or neglected. Considering the chronic nature of cardiac disease, a holistic approach to secondary prevention programs might help to improve health outcomes. Purpose: The purpose of this investigation was to describe the lived experiences of psycho-socio-spiritual healing in cardiac rehabilitation patients. Methods: A descriptive, qualitative, phenomenological approach guided the investigation. A purposive sample of 10 patients was recruited from a cardiac rehabilitation center. In-depth interviews were conducted with each participant. An interview guide was used that included open ended and specific questions related to psycho-socio-spiritual aspects of healing. Interviews were recorded and audio files were transcribed. Colaizzi (1978) method was used to guide data analysis and formulate the structure of the psycho-socio-spiritual healing phenomenon. An audit trail was developed, detailed memos regarding steps in the data anlaysis were written, and peer debriefing was performed. Member checks were conducted to determine credibility. All of the data were reviewed by a second researcher to confirm dependability and confirmability. Results: Participants described the entire experience as life-transforming. Experiencing an acute cardiac event was shocking. Participants were suddenly faced with their own mortality. When faced with this life and death situation, participants chose life and healing. Participants reordered priorities and made necessary lifestyle changes. Living with heart disease had its own challenges that included: maintaining lifestyle changes, living with one's genetic vulnerability, and fear of recurrence of another cardiac event. Heart disease led to positive changes such as weight loss, motivation to others without heart disease and most importantly, transformation and growth. Barriers to healing included lack of support and psychological distress. Healing was facilitated by having a positive attitude and being committed, participating in cardiac rehabilitation, using mind-body interventions, and having social support. Conclusions: This study explored the psycho-socio-spiritual healing phenomena in CR participants. A holistic approach to care that integrates psycho-social-spiritual healing with physical healing may help to support patients and facilitate recovery.