End of life care in nursing homes in Spain: exploratory analysis and evidences of validity of a new scale.

This document is the accepted manuscript version of the following article: Maria Remedios Sánchez-GarcÍa, Jose Antonio Gutiérrez-Romero, Manuel Fernández Alcántara, César Hueso-Montoro, Claire Goodman, and Rafael Montoya-Juárez, ‘End of life care in nursing homes in Spain: Exploratory analysis and evidences of validity of a new scale’, Applied Nursing Research, Vol. 37: 6-12, October 2017. Under embargo until 5 July 2018. The final, definite version is available online at DOI: https://doi.org/10.1016/j.apnr.2017.07.001.Quality end-of-life care is a central issue in nursing homes, requiring the assessment of individual and family needs by health professionals. Although previous instruments have been developed, they usually rely on family reports and have been adapted from other clinical contexts (hospital or primary care). It is important to consider how health care professionals working in nursing homes perceive what is necessary to achieve quality end-of-life care. In this study, the objective was to develop an instrument to assess quality of end-of-life care in the context of Spanish care homes. A 24 item scale Nursing Home End of Life Care Scale (NHEOLC) was developed through a systematic evaluation of existing tools combined with an iterative process of consultation with group experts in end of life care in long term care settings. A total of 307 health care professionals agreed to participate in the study and completed the scale. The scale was grouped in six dimensions: physical, psychological aspects and spiritual aspects of care, family care, bereavement, and patient/family preferences management. The results suggest an adequate factorial structure of the scale and good internal consistency for the total score and the subscales. In addition, the results showed significant differences depending on the size of the nursing home, the category of health professionals, and their own perceptions of his work regarding end-of-life care.Peer reviewe

Impact of the COVID-19 Pandemic on the Perceived Quality of Palliative Care in Nursing Homes

The Nursing Homes End-of-life Programme (NUHELP) was developed in 2017 and is based on quality standards of palliative care, but it was not implemented due to the outbreak of the COVID-19 pandemic. Objectives: To describe perceptions among staff at nursing homes and primary health care (PHC) centres regarding the relevance, feasibility, and degree of achievement of quality standards for palliative care in nursing homes and to determine the differences in these perceptions before and after the pandemic. Methodology: Cross-sectional descriptive study. Professionals at eight nursing homes and related PHC centres who participated in NUHELP development assessed 42 palliative care standards at two time points (2018 and 2022). The Mann–Whitney U test was applied to analyse differences in the scores between these two times and between perceptions at nursing homes and at PHC centres. Results: The study population consisted of 58 professionals in 2018 and 50 in 2022. The standard regarding communication with persons affected by the death of a family member was considered less relevant (p = 0.05), and that concerning the culturally sensitive and dignified treatment of the body was less fully achieved (p = 0.03) in 2022 than in 2018. Social support (p = 0.04), sharing information among the care team (p = 0.04), patient participation (p = 0.04) and information about the treatment provided (p = 0.03) were all more poorly achieved in 2022 than in 2018. The perceptions of nursing home and PHC workers differed in several respects. Conclusions: Professional intercommunication and social support should be reinforced, and residents should be more actively involved in decision-making.Consejeria de Salud y Familias, Junta de Andalucia (Fundacion Publica Andaluza Progreso y Salud) AP-0105-201

NUrsing Homes End of Life care Program (NUHELP): developing a complex intervention

This study has been totally funded by Consejeria de Salud, Junta de Andalucia (Fundacion Publica Andaluza Progreso y Salud, Proyecto AP-0105-2016). Funding has been received for data collection, analysis and interpretation of data and manuscript writing.Background: Nursing homes are likely to become increasingly important as end-of-life care facilities. Previous studies indicate that individuals residing in these facilities have a high prevalence of end-of-life symptoms and a significant need for palliative care. The aim of this study was to develop an end-of-life care program for nursing homes in Spain based on previous models yet adapted to the specific context and the needs of staff in nursing homes in the country. Methods: A descriptive study of a complex intervention procedure was developed. The study consisted of three phases. The first phase was a prospective study assessing self-efficacy in palliative care (using the SEPC scale) and attitudes towards end-of-life care (using the FATCOD-B scale) among nursing home staff before and after the completion of a basic palliative care training program. In the second phase, objectives were selected using the Delphi consensus technique, where nursing home and primary care professionals assessed the relevance, feasibility, and level of attainment of 42 quality standards. In phase 3, interventions were selected for these objectives through two focus group sessions involving nursing home, primary care, and palliative care professionals. Results: As a result of the training, an improvement in self-efficacy and attitudes towards end-of-life care was observed. In phase 2, 14 standards were selected and grouped into 5 objectives: to conduct a comprehensive assessment and develop a personalized care plan adapted to the palliative needs detected; to provide information in a clear and accessible way; to request and record advance care directives; to provide early care with respect to loss and grief; to refer patients to a specialized palliative care unit if appropriate, depending on the complexity of the palliative care required. Based on these objectives, the participants in the focus group sessions designed the 22 interventions that make up the program. Conclusions: The objectives and interventions of the NUHELP program constitute an end-of-life care program which can be implemented in nursing homes to improve the quality of end-of-life care in these facilities by modifying their clinical practice, organization, and relationship with the health system as well as serving as an example of an effective health intervention program.Consejeria de Salud, Junta de Andalucia (Fundacion Publica Andaluza Progreso y Salud) AP-0105-201

Crisis económica, políticas sociales y desigualdades en salud

In recent years, the European Public Health Systems have been mired in the worst financial crisis in its history, pointing to the welfare state as the main responsible for it. The objective of this work has been to analyze the extent to which the economic crisis that began in 2008 has affected the social policies and inequalities in health, specifying the effects of this on the health of the population. To properly analyze the current situation, it is important to know to what extent the economic crisis has affected the health of populations and in particular, certain vulnerable groups (children, elderly, women, others). Contrary to the recent UN resolution urging governments to provide universal access and quality of health services, the tendency has been to prioritize the reduction in the deficit through austerity measures focused on health and education. The effects of this health crisis depends on the social protection policies undertaken, and its extension of services to the most vulnerable groups, as these crises have been associated with an increase in most diseases, mainly mental, as well as an increase in suicide mortality.En estos últimos años los Sistemas Públicos de Salud europeos se han visto sumidos en la peor crisis financiera de su historia, señalándose al Estado de Bienestar como principal responsable de la misma. Para analizar correctamente la actual situación habría que conocer en qué medida influyen las crisis económicas en la salud de las poblaciones y más aún sobre ciertos grupos vulnerables (niños, ancianos, mujeres,…). En contra de la reciente resolución de la ONU instando a los gobiernos hacia un acceso universal y de calidad de sus servicios sanitarios, se ha priorizado la reducción del déficit mediante programas de austeridad en sanidad y educación principalmente. Los efectos de esta crisis sobre la salud van a depender fundamentalmente de las políticas de protección social, y de su extensión a los grupos más vulnerables, ya que estas crisis se han asociado a un aumento de la mayoría de las enfermedades, fundamentalmente mentales, además, de un incremento de la mortalidad por suicidio

La muerte ante uno mismo. Respuestas de jóvenes estudiantes ante el pensamiento de la propia muerte.

Narratives produced by thinking and reflecting about death and dying may be themselves a source of new knowledge in the study of anxiety and attitudes toward death.  A qualitative descriptive study aimed to explore the features of thoughts, emotions and feelings about young people's own death, (nursing students) was conducted. 85 students voluntarily answered a self-administered questionnaire with open questions based on Mortality Salience, used in the Terror Management Theory. Content analysis using Atlas.ti software was performed. When reflecting upon their own death, participants reported substantive emotions such as fear, pain, distress, sadness or loneliness. The fear of their own death was specified as the inability to achieve goals in life, to leave the family and the dying process itself. When reflecting upon been physically dead, attributes of the decomposition of the body, spiritual attributes, beliefs, denial and preferences were identified. Cultural worldview, values and beliefs of each person were remarkably present when thinking about their own death.Las narraciones sobre lo que evoca pensar en la propia muerte y describir los pensamientos y sentimientos sobre el morir,  pueden ser  por sí mismas una fuente de conocimiento nuevo  en el estudio de la ansiedad y las actitudes ante la muerte. Se llevó a cabo un estudio cualitativo descriptivo con el objetivo de explorar las características de los pensamientos, las emociones y sentimientos sobre la propia muerte de jóvenes, estudiantes de enfermería. 85 estudiantes respondieron voluntariamente un cuestionario autoadministrado de preguntas abiertas basadas en la Mortality Salience empleada en la Teoría de la Gestión del Terror. El análisis se realizó mediante la estrategia de análisis de contenido con el programa Atlas ti. Ante el pensamiento sobre la propia muerte respondieron con los sustantivos miedo, dolor, angustia, tristeza o soledad. El miedo a la propia muerte se concretó como la imposibilidad de lograr las metas en la vida, dejar a la familia y el proceso de muerte en sí mismo. Ante las creencias sobre estar físicamente muerto señalaron atributos de la descomposición del cuerpo, atributos espirituales, creencias, negación  y preferencias. La visión cultural, los valores y creencias de cada persona, se encuentran muy presentes cuando piensan en su propia muerte

Opinions of Family Doctor son the involvement of patients in the taking of decisions: a study with focus groups

Objetivo: Conocer qué opinan los médicos de familia de nuestro entorno sobre distintos aspectos relacionados con la implicación de los pacientes en la toma de decisiones clínicas en atención primaria. Diseño: Estudio cualitativo mediante grupos focales. Emplazamiento: Atención primaria. Participantes: Médicos de familia expertos y no expertos en comunicación clínica. Métodos: Se formaron 3 grupos focales de 6-8 profesionales que participaron en 2 reuniones. Las conversaciones fueron registradas y transcritas literalmente. El discurso se analizó sobre categorías basadas en la bibliografía y otras emergentes del texto, codificando la información y realizando una interpretación inductiva. Resultados: Los médicos de familia refieren mayoritariamente que implicarían al paciente en las decisiones proponiéndole un plan adaptado al conocimiento que de él y su problema tienen y posteriormente comprobando su aprobación o rechazo. Sin embargo, algunos profesionales reflexionan si esto podría ser calificado como implicación del paciente, cuestionando el protagonismo real que adoptarían ambos actores a la hora de decidir. Conclusiones: La explicación de los médicos de familia sobre cómo involucrarían al paciente en las decisiones se enfrenta a las teorías más divulgadas sobre el tema e, igualmente, se opone a la visión de los pacientes, que desearían ser involucrados más activamente. Observando algunas reflexiones disonantes sobre la pertinencia de considerar el proceso así expuesto como verdadera implicación del paciente, se hace necesario describir para nuestro medio un modelo teórico realista que permita desarrollar posteriormente estrategias para mejorar la actitud y formación de los profesionales hacia la implicación del paciente en las decisiones clínicas.Objective: To determine what family doctors think about various aspects of patient involvement in clinical decision making in Primary Care. Design: Qualitative study using focus groups. Location: Primary Care. Participants: Family physicians with and without expertise in clinical communication. Methods: Three focus groups were developed, involving 6-8 professionals per group, and took part in two meetings. The conversations were recorded and transcribed verbatim. The discussion was analysed using literature-based categories and other emerging from the text, encoding the information and making an inductive interpretation. Results: Family physicians refer mainly to involving the patient in decisions by proposing a plan tailored to the knowledge of patient problems and then verifying their approval or rejection. However, some professionals ponder whether this could be classified as patient involvement, questioning the real role that both players would take at the time of deciding. Conclusions: The explanation of how family physicians would involve the patient in decisions clashes with the most widespread theories on the subject and, also opposes the view of patients who would like to be involved more actively. Taking into account discordant reflections on the relevance of considering this process as real patient involvement, it is necessary to describe a realistic theoretical model that allows further development of strategies to improve the attitude and training of professionals to patient involvement in clinical decisions.Este proyecto fue financiado por los fondos FIS del Instituto Nacional Carlos III (expediente PI050527, convocatoria 2005), y por las ayudas a la investigación de la Consejería de Salud de la Junta de Andalucía (expediente 147/2005)

Prospective Evaluation of Intensity of Symptoms, Therapeutic Procedures and Treatment in Palliative Care Patients in Nursing Homes

The aim of the study is to evaluate the intensity of symptoms, and any treatment and therapeutic procedures received by advanced chronic patients in nursing homes. A multi-centre prospective study was conducted in six nursing homes for five months. A nurse trainer selected palliative care patients from whom the sample was randomly selected for inclusion. The Edmonton Symptoms Assessment Scale, therapeutic procedures, and treatment were evaluated. Parametric and non-parametric tests were used to evaluate month-to-month differences and differences between those who died and those who did not. A total of 107 residents were evaluated. At the end of the follow-up, 39 had (34.6%) died. All symptoms (p < 0.050) increased in intensity in the last week of life. Symptoms were more intense in those who had died at follow-up (p < 0.05). The use of aerosol sprays (p = 0.008), oxygen therapy (p < 0.001), opioids (p < 0.001), antibiotics (p = 0.004), and bronchodilators (p = 0.003) increased in the last week of life. Peripheral venous catheters (p = 0.022), corticoids (p = 0.007), antiemetics (p < 0.001), and antidepressants (p < 0.05) were used more in the patients who died. In conclusion, the use of therapeutic procedures (such as urinary catheters, peripheral venous catheter placement, and enteral feeding) and drugs (such as antibiotics, anxiolytics, and new antidepressant prescriptions) should be carefully considered in this clinical setting

Quality of life in workers in the environmental areas

Artículos originales[ES] Objetivo: El objetivo de este trabajo es describir la calidad de vida relacionada con la salud de una población de trabajadores en el contexto de la salud medioambiental. Material y Métodos: Estudio descriptivo transversal sobre una muestra de 401 trabajadores del área medioambiental de la provincia de Granada. Se aplicó un cuestionario con variables sociodemográficas, clínicas y de estilos de vida, junto con las láminas de Medición del Estado Funcional COOP-WONCA. Resultados: La puntuación media obtenida en COOP-WONCA fue de 14,34 (DT: 3,39). Las diferencias en las puntuaciones medias obtenidas en COOP-WONCA en relación a las variables sociodemográficas, clínicas y de estilos de vida no son relevantes, pero sí estadísticamente significativas en las siguientes variables: Lugar de Residencia (p=0,030); Tener una enfermedad común (p=0,017); Practicar algún deporte (p=0,041); Categoría profesional (p<0,001); Número de comidas al día (p=0,041), IMC (p=0,002); Nivel de Triglicéridos (p=0,022). Conclusiones: La percepción de la calidad de vida relacionada con la salud en la población de estudio es buena. Se observa una tendencia significativa en algunos factores que podemos considerar como protectores para una mejor percepción de la calidad de vida: residir en el ámbito urbano, no sufrir patología o enfermedad común, practicar algún deporte o afición, tener mayor cualificación profesional y estar en normopeso. [EN] Fundamentals: Uric acid and metabolic syndrome are strongly related to cardiovascular disease. Objective: To assess the prevalence of metabolic syndrome as well as the levels of uric acid among aircrew members and to determine the relationship between the levels of uric acid and the prevalence of metabolic syndrome. Methods: We studied a population of 790 male airline pilots. We used the definition of metabolic syndrome of the National Cholesterol Education Program Adult Treatment Panel III, but modified by replacing waist circumference for the measurement of body mass index. Results: 25.4% of the pilots presented elevated level of uric acid. 19.9% of pilots presented metabolic syndrome. The risk to present metabolic syndrome in pilots with uric acid elevated in relation to those pilots with normal uric acid was 2.6 higher with a confidence interval of 95% between 2 and 3,4 with a significance of p<0.001. There is a positive linear association between the increased concentration of uric acid and the number of metabolic syndrome diagnostic criteria (p<0,001). Conclusions: Our results suggest that hyperuricemia can be a complication related to the metabolic syndrome. The abdominal obesity may condition an increased concentration of serum uric acid. It is necessary to increase the number of studies on aircrew members in relation to the above mentioned metabolic factors in order to increase the flight safety.N