Développement d’une approche intégrée de soins curatifs et palliatifs : Aux personnes atteintes d’insuffisance cardiaque sévère en centre hospitalier

L’insuffisance cardiaque (IC) est une maladie chronique complexe, touchant plus de 300 000 Canadiens, qui évolue vers une phase terminale. Le taux de mortalité s’élève à 50 % dans la première année suivant le diagnostic d’IC de stade IV. L’émergence des soins palliatifs a permis de centrer les soins sur la qualité de vie, le soulagement de la douleur et des symptômes en fin de vie. Plusieurs études relatent que les personnes atteintes d’IC à un stade avancé présentent des symptômes similaires aux personnes atteintes de cancer. Cependant, les personnes qui bénéficient des soins palliatifs sont surtout celles atteintes de cancer. Un centre de cardiologie tertiaire de la région de Montréal a implanté une approche intégrée de soins curatifs et palliatifs pour la clientèle IC. La trajectoire particulière de l’IC rend complexe et essentiel le développement d’une approche intégrée de soins curatifs et palliatifs pour maximiser la qualité de vie des personnes atteintes d’IC en fin de vie.Heart failure (HF) is a chronic and incurable disease evolving toward a terminal phase. More than 300 000 Canadians suffered from HF. Patients with a severe form of HF (phase IV, according to the New York Heart Association) have a one year survival of 50 %. Palliative care has been extensively developed over the last years for the benefit of the cancer patient, these cares emphasizes a biopsychosocial approach that includes quality of life, pain control and symptoms relief at the end of life. Unfortunately, palliative care is rather poorly offered to the people suffering from a non malignant condition. Many authors stated that the symptoms of HF failure patients are quite similar to those observed for palliative cancer patients. The Montreal Heart Institute (MHI) has integrated a palliative care approach according to the Quebec policy on palliative care. This palliative care approach contributes to the quality of care and promotes the patients and clinicians satisfaction

Testing nursing students’ clinical judgment in a patient deterioration simulation scenario : development of a situation awareness instrument

Background: Situation awareness may be used to operationalize nursing students' clinical judgment of patient deterioration simulation scenarios. Objectives: To develop and test an instrument to measure bachelor-level nursing students' situation awareness in a patient deterioration simulation scenario, using the Situation Awareness Global Assessment Technique (SAGAT). Design: Instrument development and validation. Settings: A faculty of nursing of a French-Canadian university. Participants: 15 critical care experts and 234 bachelor-level nursing students from a critical care course. Methods: The queries were developed from evidence and guidelines regarding nurses' assessment and response to patient deterioration and an inventory of nursing diagnosis. After expert content validation, the instrument was administered to three cohorts of nursing students in a high-fidelity simulation with a scenario of hypovolemic hemorrhagic shock. Difficulty, discrimination, and fidelity indices were computed. The impact of the instrument on student's performance was assessed with a post-simulation survey. Results: The instrument comprised 31 queries, which obtained high content validity indices. Most showed satisfying difficulty, discrimination, and fidelity properties. Inadequate properties of the queries may be explained by the content of the simulation scenario, the assessment practices of nursing students, and their reliance on medical assistance. Students perceived that completing the instrument helped them realize what they forgot to assess in the simulation. Conclusions: This instrument appears as a promising research tool, although it still needs to be tested with other populations and in other patient deterioration simulation scenarios

Development of a post-simulation debriefing intervention to prepare nurses and nursing students to care for deteriorating patients

To provide optimal care, nurses need to be prepared to recognize signs and symptoms of patient deterioration so they can obtain assistance from appropriate respondents and initiate rescue interventions when needed. In this paper, we describe the development of a post-simulation educational intervention aimed at improving nurses' and nursing students' recognition and response to patient deterioration. This intervention takes the form of a debriefing after a simulated patient deterioration experience. Following the Medical Research Council's guidance on complex interventions, we reviewed empirical studies of existing educational interventions for content, teaching strategies, and outcomes, as well as for frameworks, theoretical underpinnings, and rationale. Based on those results, we reviewed theoretical literature (Tanner's clinical judgment model and Dewey's theory of experiential learning) that might inform our understanding of our intervention's intended effect (learning outcomes) and of the mechanisms by which the intervention could lead to it. Integrating results from the empirical and theoretical phases helped us define the new intervention's rationale and develop its components according to relevant standards of best practices. The resulting educational intervention, REsPoND, consists in a reflective debriefing after a patient deterioration simulation. It will be tested in an upcoming mixed methods study

Debriefing approaches for high-fidelity simulations and outcomes related to clinical judgment in baccalaureate nursing students

Simulation followed by debriefing is increasingly common in clinical nursing education. Yet, limited studies have compared approaches to debriefing—the portion of simulations where participants re-examine and make sense of their experience. In this study, 120 baccalaureate nursing students in Quebec were randomized to receive one of two types of debriefing (selfassessment with Plus-Delta vs. guided reflection using a structured tool with REsPoND) after each of four simulations (a hemorrhage scenario, two sepsis scenarios, and a trauma simulation) during which their situation awareness was measured as a proxy for their clinical judgment. Unexpectedly, situation awareness scores showed little to no consistency across students or simulations and no clear improvements over time were noted, which rendered the comparison of the debriefing approaches across scenarios problematic. However, when comparing the two iterations of the sepsis scenario, students who participated in a reflective debriefing showed greater improvement in their recognition of abnormalities in patient vital signs and level of consciousness than students whose debriefing involved self-assessment

Feasibility and acceptability of a nursing intervention with family caregiver on self-care among heart failure patients : a randomized pilot trial

Background: Self-care practices in heart failure (HF) contribute to quality of life, symptom stabilization, and extended life expectancy. However, adherence to practices such as liquid and salt restriction or symptom monitoring require high motivation on a daily basis. The aim was to assess the feasibility, acceptability, and potential effectiveness of a nursing intervention with family caregivers, aimed at improving self-care practice of HF patients. Methods: This pilot study involved 32 HF patient-caregiver dyads (16/group) randomized to an experimental (EG) or control group (CG). The intervention, based on the Self-Determination Theory, was designed to enhance patients’ autonomy and motivation in self-care practices, by involving their caregivers’ support. Five encounters were planned with the EG dyads—two face-to-face during hospitalization and three by telephone after discharge. The feasibility of delivering the protocol was evaluated as well as the acceptability of the intervention. The potential effectiveness of the intervention was assessed based on patient outcomes, including general self-care management and self-care specific to HF, perceived competence to manage HF, autonomous motivation (A-motivation, external extrinsic motivation, internal extrinsic motivation, and intrinsic motivation), and perceived support from the caregiver. Caregiver outcomes included level of support provided to the patient. Results: Despite recruitment challenges, the intervention was feasible, with 12 of the 16 dyads receiving all 5 encounters delivered per protocol. The 4 other dyads received the two hospital encounters, but at least 1 of the 3 post-discharge planned telephone encounters was not feasible because the patients had been re-hospitalized or was deceased. Participant’s satisfaction with the intervention was high. Outcomes favoring the EG include self-care specific to HF, internal extrinsic motivation, intrinsic motivation, and caregiver’s feeling that they provide a higher level of support. Conclusions: Caregiver involvement was found to be both a feasible and acceptable means of supporting self-care practice in HF patients. This approach presents a potential avenue for enhancing patients’ efforts in this regard. However, this pilot study offers preliminary findings only, which need to be replicated in a phase 3 clinical trial