Increasing the uptake of exercise programs in the dialysis unit: A protocol for a realist synthesis

Background: For people with end-stage kidney disease on hemodialysis, exercise during the dialysis treatment ( intradialytic exercise ) may promote exercise adherence and enhance aspects of the dialysis treatment. However, intradialytic exercise programs are complex and how to adapt program components to local context so that the program is more likely to attain its intended health outcomes have not been well described. To increase the uptake of exercise in clinical practice, more evidence is needed on how contextual factors influence the program’s impact. Methods: Using the realist approach, we aim to understand how the processes and structures of intradialytic exercise programs work to influence patient participation according to different contextual factors. The focus of a realist review is explanatory and aims to develop and test theory on how contextual factors trigger specific processes or behaviors ( or “mechanisms” ) to produce outcomes. Using the realist context-mechanism-outcome configuration of theory development, we will use a range of sources to develop initial candidate theories: a scoping review of published papers and the gray literature, and discussion with stakeholders. To provide a theoretical basis for how contextual factors could work to influence patient participation in intradialytic exercise ( IDE ), several of our preliminary theories will be based on dominant theories of exercise adherence and behavior change. To support or refute these initial theories, we will synthesize data from a systematic literature review and semi-structured interviews with intradialytic exercise program stakeholders, sampled from a range of programs worldwide. Discussion: The complexity of intradialytic exercise programs poses challenges to their implementation. Using the “context, mechanism, outcome” approach, the knowledge gained from this study will be used to develop general recommendations for renal care providers and administration on how to adapt components of an intradialytic exercise programs according to different contextual factors in order to promote patient participation. Systematic review registration: PROSPERO CRD4201603333

Quality of life of older adults in rural southern Brazil

Introduction: Ageing in rural communities poses unique challenges that can have an impact on older adults' quality of life (QoL). These limitations can be costly to the healthcare system but there is potential for them to be addressed with a better understanding of factors that affect QoL. The goal of this study was to assess the perceptions of QoL of older adults living in rural areas of southern Brazil and to identify factors associated with QoL in this population. Methods: A cross-sectional study was conducted with 197 older adults (mean age 69.7±7.5 years). Instruments included the Katz and Lawton activities of daily living scales, QoL instruments and a questionnaire that addressed social, economic, demographic and health variables. Multiple regression analysis was performed, using various domains and overall QoL as dependent variables. Results: Older adults who were more independent, living with a spouse, with higher income and educational levels, fewer morbidities, fewer years of tobacco use, and who did not report falls in the last year were significantly more likely to rate their QoL higher on one or more domains/measures. Conclusions: Factors associated with QoL of older adults in rural areas are similar to those found in studies conducted in urban areas, but the rural context may influence these variables in unique ways

An Assessment of Dialysis Provider's Attitudes towards Timing of Dialysis Initiation in Canada

Background: Physicians' perceptions and opinions may influence when to initiate dialysis. Objective: To examine providers' perspectives and opinions regarding the timing of dialysis initiation. Design: Online survey. Setting: Community and academic dialysis practices in Canada. Participants: A nationally-representative sample of dialysis providers. Measurements and Methods: Dialysis providers opinions assessing reasons to initiate dialysis at low or high eGFR. Responses were obtained using a 9-point Likert scale. Early dialysis was defined as initiation of dialysis in an individual with an eGFR greater than or equal to 10.5 ml/min/m 2 . A detailed survey was emailed to all members of the Canadian Society of Nephrology (CSN) in February 2013. The survey was designed and pre-tested to evaluate duration and ease of administration. Results: One hundred and forty one (25% response rate) physicians participated in the survey. The majority were from urban, academic centres and practiced in regionally administered renal programs. Very few respondents had a formal policy regarding the timing of dialysis initiation or formally reviewed new dialysis starts (N = 4, 3.1%). The majority of respondents were either neutral or disagreed that late compared to early dialysis initiation improved outcomes (85–88%), had a negative impact on quality of life (89%), worsened AVF or PD use (84–90%), led to sicker patients (83%) or was cost effective (61%). Fifty-seven percent of respondents felt uremic symptoms occurred earlier in patients with advancing age or co-morbid illness. Half (51.8%) of the respondents felt there was an absolute eGFR at which they would initiate dialysis in an asymptomatic patient. The majority of respondents would initiate dialysis for classic indications for dialysis, such as volume overload (90.1%) and cachexia (83.7%) however a significant number chose other factors that may lead them to early dialysis initiation including avoiding an emergency (28.4%), patient preference (21.3%) and non-compliance (8.5%). Limitations: 25% response rate. Conclusions: Although the majority of nephrologists in Canada who responded followed evidence-based practice regarding the timing of dialysis initiation, knowledge gaps and areas of clinical uncertainty exist. The implementation and evaluation of formal policies and knowledge translation activities may limit potentially unnecessary early dialysis initiation

Challenges and opportunities in graduate nursing education by distributed learning in Canada and Brazil

In this paper, the authors share their experience related to graduate nursing programs offered by distributed learning (DL) in Canada and Brazil. Although degrees offered by DL are often the subject of criticism, the authors’ experience has been that learning outcomes have been very good. Nevertheless, a number of challenges and opportunities have been encountered including those associated with flexibility of the program, delivering practice courses at a distance, facilitating interaction, faculty workload and preparation and student support, Newer technologies that may assist in this effort are identified. Despite the challenges encountered, students rate the program highly and ongoing efforts are underway to ensure excellence of such flexible innovative graduate programs in nursing. The authors argue that despite the challenges, DL programs offer high quality graduate education that meets the needs of many nurses

Brief Communication: Patient Satisfaction with the Use of Tablet Computers: A Pilot Study in Two Outpatient Home Dialysis Clinics

Background: Electronic capture of patients' reports of their health is significant in clinical nephrology research because health-related quality of life (HRQOL) for patients with end-stage renal disease is compromised and assessment by patients of their HRQOL in practice is relatively uncommon. Objective: The purpose of this study was to evaluate patient satisfaction with and time involved in administering HRQOL and symptom assessment measures using tablet computers in two outpatient home dialysis clinics. Design: A cross-sectional observational study design was employed. Setting: The study was conducted in two home dialysis clinics. Patients: Fifty-six patients participated in the study; 35 males (63%) and 21 females (37%) with a mean age of 66 ± 12 (36–90 years old) were included. Forty-nine participants were on peritoneal dialysis (87%), 6 on home hemodialysis (11%), and 1 on nocturnal home hemodialysis (2%). Measurements: Measures included the Kidney Disease Quality of Life-36 (KDQOL-36), the Edmonton Symptom Assessment Scale (ESAS) and Participant's Level of Satisfaction in Using a Tablet Computer. Methods: Using a tablet computer, participants completed the three measures. Descriptive statistics and bivariate correlations were calculated. Results: Participants' satisfaction with use of the tablet computer was high; 66% were “very satisfied”, 7% “satisfied”, 2% “slightly satisfied”, and 18% “neutral”. On the 7-point Likert-type scale, the mean satisfaction score was 5.11 (SD = 1.6). Mean time to complete the measures was: Level of Satisfaction 1.15 minutes (SD = 0.41), ESAS 2.55 minutes (SD = 1.04), and KDQOL 9.56 minutes (SD = 2.03); the mean time to complete all three instruments was 13.19 minutes (SD = 2.42). There were no significant correlations between level of satisfaction and age, gender, HRQOL, time taken to complete surveys, computer experience, or comfort with technology. Comfort with technology and computer experience were highly correlated, r = .7, p (one-tailed) < 0.01. Limitations: Limitations include lack of generalizability because of a small self-selected sample of relatively healthy patients and a lack of psychometric testing on the measure of satisfaction. Conclusions: Participants were satisfied with the platform and the time involved for completion of instruments was modest. Routine use of HRQOL measures for clinical purposes may be facilitated through use of tablet computers

Evaluation of real-time use of electronic patient-reported outcome data by nurses with patients in home dialysis clinics

Abstract Background Internationally, the use of patient-reported outcomes (PROs) is increasing. Electronic PROs (ePROs) offer immediate access of such reports to healthcare providers. The objectives of this study were to assess nurses’ perspectives on the usefulness and impact of ePRO administration in home dialysis clinics and assess patient perceptions of satisfaction with nursing care following use of ePROs. Methods A concurrent, longitudinal, mixed methods study was conducted over 6 months during home dialysis outpatient clinic visits in two cities. Patients (n = 99) provided ePROs using tablet computers when they visited the clinic on two consecutive occasions approximately 3 months apart. Results were scored, printed, and given to nurses before patient appointments. Patients completed satisfaction items from the Comox Valley Nursing Centre Client questionnaire following their appointments. All clinic nurses (n = 11) participated and they were each interviewed twice, three months and six months after the start of the study. Results The five themes that emerged from the interviews with the nurses include: enhancing focus of the nurses, directing interdisciplinary follow-up, offering support to patients through the process, interpreting results from the visual display, and integrating into workflow. Scores on the Client Questionnaire suggested that patients believed that they received excellent care (97%), and that the nurses perfectly understood their needs (90.9%). However, their satisfaction with care did not change over time when ePRO data was repeatedly provided to their nurses. Conclusions Nurses reported that sharing ePRO data in real-time informed their practice. Although there was no statistically significant change in patient satisfaction scores over time, some patients reported changes and benefits from the use of ePROs. Further research is needed to provide guidance about how ePRO data could enhance person-centered care

Considering performativity as methodology and phenomena

"Performativität ist beides, Methodologie und Phänomen: Das Konzept und dessen Genese zu verstehen und auch zu sehen, in welcher Weise Performativität Untersuchungsräume öffnet, verhilft zu Wissen über interprofessionelle Pflegeteams. Dabei ist es essenziell, zwischen Performanz und Performativität zu unterscheiden. In diesem Beitrag beschäftigen wir uns mit methodologischen Aspekten von Performativität bei der Nutzung des Forumtheater, wobei Dialoge aus einem Workshop mit Mitgliedern von Pflegeteams zur Veranschaulichung herangezogen werden. Ausgangsmaterial für den Workshop waren wiederkehrende Charakteristika von Interprofessionalismus in solchen Teams, die in Interviews mit den Teilnehmenden erhoben worden waren. Performativität erlaubt dann, die relationale Arbeit innerhalb der Teampraktiken zu untersuchen. Die methodologische 'Unordnung' performativer Forschung wird diskutiert." (Autorenreferat)"Performativity is both a methodology and in its complexity, phenomena. Understanding the concept, the evolution of the term and how performativity can open spaces for inquiry adds to knowledge about interprofessional healthcare teams. Distinguishing between performance and performativity is essential. In this article, we examine methodological aspects of performativity through the use of forum theater. Dialogue from a performance-based inquiry workshop with healthcare team members provides a way to discuss performative methodology. The workshop was built upon recurrent characteristics of interprofessionalism in healthcare teams seen in conversational interviews with healthcare practitioner participants. Performativity provides a way to explore the relational work in interprofessional team practices. The methodological messiness of performative inquiry is discussed." (author's abstract

Performativität als Methodologie und Phänomen

Performativity is both a methodology and in its complexity, phenomena. Understanding the concept, the evolution of the term and how performativity can open spaces for inquiry adds to knowledge about interprofessional healthcare teams. Distinguishing between performance and performativity is essential. In this article, we examine methodological aspects of performativity through the use of forum theater. Dialogue from a performance-based inquiry workshop with healthcare team members provides a way to discuss performative methodology. The workshop was built upon recurrent characteristics of interprofessionalism in healthcare teams seen in conversational interviews with healthcare practitioner participants. Performativity provides a way to explore the relational work in interprofessional team practices. The methodological messiness of performative inquiry is discussed.URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs1402112La performatividad es una metodología y un fenómeno. Comprender el concepto, la evolución del término y cómo la performatividad puede abrir espacios para la investigación, enriquece el conocimiento acerca de los equipos sanitarios interprofesionales. Es esencial distinguir entre performance y performatividad. En este artículo, examinamos los aspectos metodológicos de la performatividad mediante el uso del teatro foro. El diálogo en un taller de investigación- basada-en performance con miembros de un equipo de profesionales del cuidado de la salud permite una vía para discutir la metodología performativa. El taller fue construido sobre las características recurrentes del inter-profesionalismo en los equipos de cuidado de la salud visualizadas en entrevistas conversacionales con los participantes. La performatividad proporciona una manera de explorar el trabajo relacional en las prácticas del equipo interprofesional. Se discute el desorden metodológico de la investigación performativa.URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs1402112Performativität ist beides, Methodologie und Phänomen: Das Konzept und dessen Genese zu verstehen und auch zu sehen, in welcher Weise Performativität Untersuchungsräume öffnet, verhilft zu Wissen über interprofessionelle Pflegeteams. Dabei ist es essenziell, zwischen Performanz und Performativität zu unterscheiden.In diesem Beitrag beschäftigen wir uns mit methodologischen Aspekten von Performativität bei der Nutzung des Forumtheater, wobei Dialoge aus einem Workshop mit Mitgliedern von Pflegeteams zur Veranschaulichung herangezogen werden. Ausgangsmaterial für den Workshop waren wiederkehrende Charakteristika von Interprofessionalismus in solchen Teams, die in Interviews mit den Teilnehmenden erhoben worden waren. Performativität erlaubt dann, die relationale Arbeit innerhalb der Teampraktiken zu untersuchen. Die methodologische "Unordnung" performativer Forschung wird diskutiert.URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs140211