Background A significant number of Australian adolescents consume alcohol, with almost two thirds of them doing so at risky levels. This is continuing to increase despite recent National Health and Medical Research Council (NHMRC) guidelines stipulating that no alcohol is the safest option. Measures initiated to reduce and prevent alcohol consumption by adolescents have limited effectiveness. Consumption of alcohol by Australian adolescents is a national concern because of the deleterious effects of alcohol consumption on adolescents’ social, physical and neurological development, as well as other short‐ and long‐term health risks, and the negative impact of alcohol‐related violence and injury on the community. Understanding adolescents’ decisions to abstain or refrain from alcohol consumption may provide valuable insights to assist in dealing with this significant social and health issue, more particularly about the mechanisms used by adolescents or their ability to make decisions about resisting or abstaining from alcohol consumption when exposed to alcohol in their social setting(s). Objectives The review aimed to synthesize the best available qualitative evidence on the decisions made or mechanisms used by adolescents who abstain or refrain from consuming alcohol in any social setting where alcohol is available. Inclusion criteria Types of participants Adolescents aged between 14 and 19 years who reside in Australia. Phenomena of interest The phenomenon of interest was abstinence from or resistance to alcohol consumption when exposed to alcohol in social situations. Types of studies This review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, action research and exploratory studies. Search strategy A three‐step search strategy was used. An initial search to identify keywords only was undertaken in Medline and CINAHL. This was followed by an expanded search using all identified keywords and index terms specific to each included database. The reference lists of included papers were then searched for any other relevant studies. Methodological quality No studies met the inclusion criteria sufficiently to progress to critical appraisal. Data extraction No studies progressed to data extraction. Data synthesis Data synthesis was not undertaken as no study met the inclusion criteria. Results Although a number of studies retrieved indicated they had qualitative elements to their studies, the qualitative data was not reported. Conclusions Although a number of studies met some aspects of the inclusion criteria there was insufficient reporting of the phenomenon of interest. Due to the lack of studies meeting the inclusion criteria, no conclusions can be drawn for clinical practice. A lack of qualitative data on this topic has been identified. Thus there is a great need for qualitative research to understand and know more about what enables an adolescent to abstain or refrain from consumption in order to inform or formulate effective interventions, policies or plans to prevent or reduce the volume of alcohol consumed by Australian adolescents.
Executive summary Background Obstetric fistula is a medical condition whereby an abnormal opening occurs between the vagina and the rectum or bladder. It is caused by several delays during obstructed labor without timely medical intervention, typically a caesarean section to relieve the pressure. While obstetric fistula affects women at all ages, the risk is higher among very young mothers between the ages of 14 and 20, who live in very poor conditions in rural settings. Obstetric fistula inflicts a significant health, economic, physiological, socio-cultural and psychological burden on the sufferers. Objectives To present the best available evidence on the experiences of women and young girls living with obstetric fistula in developing countries using a qualitative approach to evidence synthesis. Review questions: Inclusion criteria Types of participants This review considered studies with a focus on the social, cultural and economic consequences on women and young adolescents of child bearing age suffering from obstetric fistula living in developing parts of the world such as Latin America, Asia and Africa. Phenomena of interest The experiences of women and young adolescent girls living with obstetric fistula with a particular focus on the support, management, surgical intervention, social reintegration and relationships of these women. Context Women and young girls living with obstetric fistula in community and hospital settings. Types of studies This review considered qualitative studies with approaches such as phenomenology, ethnography, grounded theory, ethnomethodology, phenomenography, behavioral studies, knowledge attitudes and practice, narrative and critical, interpretative or feminist analysis studies that illuminate the experiences of women and young girls suffering from obstetric fistula and was limited to studies conducted in developing countries. Search strategy A three-step search strategy was used to identify published and unpublished studies. MEDLINE and CINAHL were initially searched, and text words in titles, abstracts and index terms were analyzed. Identified keywords and index terms were used to search for studies across all include databases. Finally, the reference lists of all studies included for appraisal were searched for additional papers. Due to the lack of resources for translation, only studies published in English were considered. Papers published from 1990 onwards were considered as those published before this year were deemed not to reflect the current reality of the topic. Methodological quality Studies that met the inclusion criteria were assessed by two independent reviewers for methodological validity using the standardized critical appraisal tools of the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Data collection Data was extracted using a standardized data extraction tool of JBI-QARI. Data synthesis Using the JBI-QARI degrees of credibility assessment, the findings of included studies were categorized, synthesized and further meta-synthesized. Results From the seven included studies, 61 findings were derived, and grouped into seven categories which were finally meta-synthesized into three synthesized findings: Synthesized finding 1 The negative impact of obstetric fistula on marital and sexual relationship includes divorce, abandonment, neglect and interruption of sexual activities. Furthermore, some women suffer from infertility, difficulty in conceiving and loss of pregnancy, thereby depriving them from performing their roles as wives and mothers irrespective of their marital status. Synthesized finding 2 Women with obstetric fistula suffer from urine incontinence, bad odor, body depreciation, stigma, loss of societal roles, depression, mental illness, desperation, the desire to commit suicide, drop in economic activities and loss of financial viability. Synthesized finding 3 Women with obstetric fistula experience a variety of challenges regarding treatment in hospitals such as fear and uncertainty about treatment, wrong diagnosis, difficulty in seeing a doctor and poor quality service delivery. However, successful fistula surgery restored the dignity of women living with obstetric fistula and enhanced their social reintegration. Conclusions Women living with obstetric fistula have a variety of negative experiences regarding treatment and social relationships. Health professionals and decision makers need to acknowledge the negative experiences of women living with obstetric fistula and understand that interventions to combat fistula has to go beyond biomedicine to include psycho-social factors. Implications for practice The experiences of women and young girls must be understood by clinicians, policy makers and Non- Governmental Organizations and integrated in programs to combat fistula. Implications for research Further high-quality qualitative studies are needed to address the experiences of women and young girls who underwent unsuccessful surgical repairs and those who still suffer from social rejection despite successful surgical repairs.
Review question/objective The objective of this review is to identify the effectiveness of surveillance systems and community-based interventions in identifying and responding to emerging and re-emerging zoonotic infections in Southeast Asia (SE Asia). More specifically the research questions are: 1.What is the effectiveness of community-based surveillance interventions designed to identify emerging zoonotic infectious diseases? 2.What is the effectiveness of non-pharmaceutical community-based interventions designed to prevent transmission of emerging zoonotic infectious diseases? 3.How do factors related to the emergence and management of emerging zoonotic infectious diseases impact the effectiveness of interventions designed to identify and respond to them? Inclusion criteria Types of participants As mentioned above, the control of infectious diseases in resource constrained settings is more likely to be influenced by community-based and behavioural change interventions. This review will consider studies that evaluate infectious disease surveillance and control interventions that are non-pharmaceutical, non-vaccine, and community-based. Community-based is defined as implemented outside a healthcare institution with at least one component of the intervention targeted directly at the community (e.g. educational meetings, involvement of local leaders). Interventions with no community participation (i.e. top-down vector control programmes) will be excluded as they are outside the scope of this project. This review will consider studies conducted in communities in Southeast Asian countries. We define SE Asia as the ten member countries of the Association of Southeast Asian Nations (ASEAN). 18 The ASEAN countries are Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam. We will include studies which report on interventions to prevent the following zoonotic emerging and re-emerging infections. This list has been developed from the list of emerging and re-emerging zoonotic infections published on the CDC website 19 as commonly occurring in SE Asia: • Avian Influenza • Dengue Fever • Nipah Virus • Severe Acute Respiratory Syndrome • Rabies Types of intervention(s)/phenomena of interest On the basis of preliminary searches identifying the following types of intervention, interventions of interest will include, but not be limited to: Surveillance Interventions: syndromic surveillance programs, communications programs, training/education of health workers and TRUNCATED AT 350 WORDS
Review Questions/Objectives Objectives This systematic review seeks to synthesise the best available evidence in relation to preventing and/or treating hypothermia in mothers after Caesarean Section surgery. More specifically, the objective is to synthesise the best available evidence on the effectiveness of interventions to prevent heat loss in this group of patients. This may include active warming measures (including forced air warming and IV fluid warming), passive warming measures (such as leg wrapping and prewarming) or even pharmacological therapy, on the core temperature of the mother and newborn after surgery. Review questions What are the most effective interventions for preventing and managing perioperative hypothermia in women undergoing Caesarean Section surgery? Are there any differences in effectiveness for warming interventions between patients undergoing different modes of anaesthesia for Caesarean Section (general anaesthesia/epidural anaesthesia/spinal anaesthesia)? Inclusion Criteria Types of participants The review will include all studies that include adult patients over the age of 18 years, of any ethnic background, with or without co-morbidities, undergoing any of the different modes of anaesthesia (general anaesthesia/epidural anaesthesia/spinal anaesthesia) for any type of Caesarean Section (emergency or planned) at healthcare facilities receiving interventions that may limit or manage perioperative core heat loss. Studies that focus on patients undergoing any other type of surgery other than Caesarean Section or pregnant patients not undergoing Caesarean Section will be excluded. Types of interventions The types of intervention will consist of active warming methods, or passive warming methods or pharmacological interventions such as Lorazepam versus usual care or placebo, that aim to limit or manage core heat loss as applied to women undergoing Caesarean Section. Active warming methods in this review may include forced air warming devices, warmed fluids, warmed mattresses and warmed coverings. Passive interventions may include unheated coverings, such as leg wrapping or aluminium wraps. Types of outcomes The review will focus on the following outcomes: Primary outcome: maternal core temperature measured via the following sites: pulmonary artery, oesophageal, tympanic, bladder or oral, during the preoperative, intraoperative and postoperative phases of care. TRUNCATED AT 350 WORDS
Objectives The objective of this systematic review is to identify the best available evidence related to the effectiveness of psychosocial interventions for caregivers on the psychosocial wellbeing, physical health and quality of life of family caregivers and their stroke survivors. The specific review questions to be addressed are: Family caregivers • What are the effectiveness of varying formats and types of psychosocial intervention on the family caregiver’s psychosocial wellbeing including anxiety, depression, burden and strain of caregiving, mental health, social relationship and support? • What are the effectiveness of varying formats and types of psychosocial intervention on the family caregiver’s physical health including somatic complaints and incidence of accidents or injuries? • What are the effectiveness of varying formats and types of psychosocial intervention on the family caregiver’s quality of life including the psychological, physical, social, and environmental domains? Stroke survivors • What are the effectiveness of varying formats and types of psychosocial intervention on the stroke survivor’s psychosocial wellbeing including anxiety, depression and social recovery? • What are the effectiveness of varying formats and types of psychosocial intervention on the stroke survivor’s physical health including physical functioning? • What are the effectiveness of varying formats and types of psychosocial intervention on the stroke survivor’s quality of life including the psychological, physical, social, and environmental domains from the stroke survivors’ perspective and also their family caregivers’ perspective? Criteria for considering studies for this review Population Adult patients aged 18 or above, with a clinical diagnosis of ischemic or hemorrhagic stroke, which was confirmed by computed tomography (CT) or magnetic resonance imaging (MRI), and were the community-dwelling survivors of the first or recurrent of stroke, received in-patient stroke treatment and were discharged home after hospitalization. Family caregivers will be the adult family member of stroke survivors, aged 18 or above, who were the primary caregivers that was the one who spent the most time of caring their stroke survivors, or the one who was identified by the stroke survivors as their primary caregivers. In addition, investigator’s definition of family caregivers, for example, family members spent on average TRUNCATED AT 350 WORDS
BACKGROUND:Successful tuberculosis control depends upon effective treatment of patients which requires adherence throughout the full course of medical treatment. Poor adherence to treatment is a major obstacle in the global fight against tuberculosis. Therefore, interventions that promote adherence to the tuberculosis treatment regimen should be implemented.OBJECTIVE:To review and synthesise the best available research evidence that investigates the effectiveness of strategies to promote adherence to treatment by patients with pulmonary tuberculosis.INCLUSION CRITERIA:This review considered all studies that included adults aged ≥ 15 years diagnosed with smear positive and smear negative pulmonary tuberculosis (regardless of HIV infection) in community settings who had never received anti-tuberculosis drugs, or had taken them for less than one month.Intervention included strategies to promote adherence to tuberculosis treatment by patients with pulmonary tuberculosis.Outcomes included measures for treatment completion rate, cure rate, and success rate.The review primarily considered any randomised controlled trials that explored different strategies to promote adherence to tuberculosis treatment of patients with pulmonary tuberculosis but also included quasi-experimental studies.SEARCH STRATEGY:The search sought to find published and unpublished studies. The time period of the search covered articles published from 1990 to 2010 in English and Thai language. The database searches included: CINAHL, EMBASE, Cochrane Library, PubMed, Science Direct, Current Content Connect, Thai Nursing Research Database, Thai thesis database, Digital Library of Thailand Research Fund, Research of National Research Council of Thailand, and Database of Office of Higher Education Commission. Studies were additionally identified from reference lists of all studies retrieved.METHODOLOGICAL QUALITY:Studies selected for retrieval were assessed by two independent reviewers for methodological quality using a standardised critical appraisal tool from the Joanna Briggs Institute.DATA COLLECTION:Data extraction was performed using a standardised data extraction form from the Joanna Briggs Institute.DATA SYNTHESIS:The quantitative study results were pooled in statistical meta-analysis using the Review Manager software (RevMan 5.0) and summarised in narrative form where statistical pooling was not appropriate or possible.RESULTS:This systematic review included ten randomised controlled trials and eight quasi-experimental studies that report on the effectiveness of a number of specific interventions to improve adherence to tuberculosis treatment among newly diagnosed pulmonary tuberculosis patients. These interventions included Directly Observed Treatment coupled with alternative patient supervision options, case management with Directly Observed Treatment, Short-course, the intensive triad-model program, and an intervention package consisting of improving patients' counselling and communication, decentralisation of treatment, patient choice of Directly Observed Treatment supporter, and reinforcement of supervision activities.CONCLUSION:The interventions that had the best outcomes for treatment adherence among newly diagnosed pulmonary tuberculosis patients were Directly Observed Treatment and Directly Observed Treatment, Short-course combined with case management, improving counselling and communication and decentralisation of treatment. These interventions should be implemented by health care providers and tailored to local contexts and circumstances, where appropriate.It would be beneficial to shift the treatment of all pulmonary tuberculosis patients to facilities within the primary health care structure. Directly Observed Treatment coupled with alternative patient supervision options, formalised educational programs and a tuberculosis case management team should be used to improve adherence to tuberculosis treatment among newly diagnosed pulmonary tuberculosis patients.Our review shows the need for further large-scale on adherence to treatment by newly diagnosed pulmonary tuberculosis patients. Factors that determine the usefulness of Directly Observed Treatment in various settings require further study. Further strategies, especially those that are feasible in developing countries or countries with limited resources, should be evaluated in randomised controlled trials before being introduced into routine practice.
Contact: [email protected] Centres submitting review Pace University, College of Health Professions, Lienhard School of Nursing and New Jersey Center for Evidence Based Practice at UMDNJ School of Nursing; A Collaborating Centre of the Joanna Briggs Institute Review question/objective The overall objective of this systematic review is to determine the best available evidence related to the effectiveness of continuity of care interventions on patient outcomes. The specific review questions to be asked are: What continuity of care interventions are most effective in improving patient satisfaction in adult patients receiving home care services? What continuity of care interventions are most effective in reducing all-cause hospital readmission rates among adults receiving home care services? Background Over the past several years, international efforts have heightened to ensure the delivery of high quality patient care and simultaneously curtail health expenditures. In order to determine which current practices would benefit from improvement and to further identify effective interventions, outcome measures must be analysed. Two outcomes that are employed worldwide as measures of success include patient satisfaction and hospital readmission rates. Patient satisfaction is recognised as the patient's perception of the care he is receiving. Providers have come to believe that this is an important indicator of health care quality. Many practices provide their clients with satisfaction surveys, which are then analysed in order to learn where changes might be made. Health care has become a competitive market and Internet technology has empowered patients, which has led them to be identified as health care consumers. Their satisfaction is crucial to positive outcomes as it is linked to patient trust 1. A patient who trusts his clinician is more likely to: seek guidance from that provider; follow pertinent advice; and report symptom improvement2. These are all essential elements to maintaining an optimal health status and decreasing the use of hospitals and emergency rooms. Hospital readmission rates are identified as the number of recurrent hospitalisations by a single patient over a specific timeframe. The exorbitant cost of a hospitalisation is without question and it has been evidenced that a proportion of readmissions are avoidable3. The United States government has now imposed payment regulations on health care institutions when a patient with Medicare insurance is brought back into the hospital within 30 days of discharge. Not only are the hospitals not being reimbursed for this patient population, they are also subject to fines. Readmissions give insight into quality so providers are beginning to look beyond the 30-day timeframe imposed by Medicare and realising that recurrent admissions within longer time periods are also an issue. This has been a major driving force behind prioritisation of this outcome. Continuity of care is a concept that is being explored internationally. It describes the connection and coordination of care between patients and providers across time and settings 4. Numerous studies have evidenced a positive correlation between continuity and patient outcomes including health care utilisation and patient satisfaction5,6. A systematic review consisting of 139 English language retrospective cohort and cross-sectional design studies from the years 2000 to 2005, that investigated the exploration between continuity of care and outcomes identified that health care utilisation is decreased and patients are happier when continuity of care is present5. In a literature review consisting of 32 English language clinical trials taking place between the years of 1996 and 2005; that looked at continuity of care in the chronically ill patient, a positive correlation was also noted6. It has been evidenced when looking at patient satisfaction alone, results were not consistently linked to high continuity1. In a systematic review consisting of 12 English language studies of various designs; that explored this variable singularly, it was ascertained that satisfaction was dependent on the patient's perception of continuity1. Therefore, it would appear that there is connection between high levels of patient satisfaction and continuity of care that needs to be explored. The World Health Organization, an agency responsible for providing leadership in global health matters, is involved in a number of continuity of care projects across various disciplines around the world. They support the idea of patient-centred care and believe that continuity is a provider's responsibility in ensuring this provision7. The Joint Commission International has identified continuity in their hospital standards for accreditation that focus on continuity as a factor to ensure patient safety8. Continuity of care has different meanings to different stakeholders. In a multidisciplinary review of the concept of continuity of care, various perceptions were identified. In primary care, continuity is viewed as the relationship between one patient and one clinician. In the field of acute care nursing, continuity is viewed as communication between nurses, and in mental health it is viewed as a consistent relationship between a patient and a team of clinicians with accessibility playing a key role9. As noted earlier, the two fundamental elements to continuity, regardless of setting, are care of a patient and care over time. Three types of continuity exist in every discipline; informational, management and relational9. Information continuity focuses on communication between providers over time and is concerned with more than just medical data but important personal knowledge that is necessary for caregivers to form a trusting bond with the patient. Management continuity focuses on the care of the patient with multiple co-morbidities who is managed by multiple providers. It centres around the importance of shared management plans so that all clinicians are working together to optimise the patient's health. Relational continuity bridges care across the past, present and future. There exists a set of core providers who establishes predictability for the patient9. The context of care determines which of these three types of continuity are employed. As is evidenced from the literature, continuity of care is important to improved patient outcomes, which is the reason for efforts around the world to focus on practice improvement in this area5,6. These efforts include continued research on practice changes to support continuity as well as clinician education on this concept. Numerous sectors of the health care industry have created position statements to stress the value of prioritising strategies to improve continuity in the provision of cost-effective high quality care. Examples of organisations include the American Medical Association and the Alberta Association of Professional Nurses10,11. Home care is a critical segment of patient care where continuity is fundamental to the patient's ability to achieve optimal health goals. Clinicians in this field provide care to patients with multiple co-morbidities. The clients receive regular visits by a health care provider, ensure that patients have and are taking their medications and have the ability to identify issues that may result in hospital readmissions. The goal of home care is to provide a trusting relationship between patient and providers as well as open access to health care. At present a policy statement does not exist for this sector but there is strong interest in exploring the concept of continuity and planning improvement strategies to positively impact care. A preliminary search of Medline, CINAHL, JBI Library of Systematic Reviews was performed and no existing or ongoing systematic review on this topic was identified. Inclusion Criteria Types of participants The review will consider studies that include all adults, male and female (aged 18 years old and above) receiving home care services, regardless of diagnosis, stage or severity of disease, co-morbidities, and previous treatment received. Types of interventions/phenomena of interest This review will consider studies that evaluate all models/types of interventions for continuity of care of adult patients delivered by registered nurses in home care settings. Comparator: no intervention Types of outcome measures This review will consider studies that include the following outcome measure, but not limited to: All-cause hospital readmissions measured as patients who experience an unplanned admission to the same hospital, a different hospital, or another acute care facility for the same diagnosis or for a different diagnosis. Patient satisfaction measured by patient self-report. Types of studies The review will consider randomised controlled trials. In the absence of randomised control trials other research designs, such as non-randomised controlled trials, quasi-experimental studies, and before and after studies will be considered for inclusion to enable the identification of current best evidence. Search strategy The search strategies used will seek published and unpublished full text studies written in the English language from the inception of the databases to the current date. A three-step strategy will be used in this review. An initial limited search of MEDLINE and CINAHL using EBSCOhost will be undertaken followed by an analysis of the text contained in the title and abstract, as well as the index terms used to describe the article. A second search using all of the identified keywords and index terms will be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies identified through reference list searches will be assessed for relevance based on the study title. The databases that will be used include but are not limited to: Academic Search Premiere, CINAHL, Clin-eguide, Embase, ERIC, Health Reference Center, Health Source Nursing Academic, MEDLINE, Nursing & Allied Health Source, Ovid, ProQuest Health Management, and PscyhINFO. Grey literature sites to be explored are: Dissertation Abstracts online, Google scholar, government health department websites, Institute of Medicine, UpToDate.com, the Virginia Henderson Library of Sigma Theta Tau International and any relevant home care web sites. In employing the search strategy of reviewing the reference list of relevant articles, a hand search of appropriate journals (e.g. Journal for Healthcare Quality, Journal of Health Services Research and Policy, Journal of the American Geriatrics Society, Home Healthcare Nurse, Home Health Care Management and Practice) will be done as well. The references of chosen studies will be searched to find the entire texted document for studies that meet the inclusion criteria. Keywords contained within the title will be used to narrow relevant articles. The initial keywords that will guide this initial review are: continuity of care, patient satisfaction, admissions, adult and home care A full list of keywords to be used will be developed following the first stage of searching (as detailed above), and are thought to contain: continuity of care, patient satisfaction, decreased hospital admissions, continuity, continuity of patient care, care pathways, integrated care, home care, home care services, hospital, hospital admissions, readmissions, patient care, patient outcomes, acute care, acute patient care, and post-discharge. All material identified as being relevant to the review objectives will be examined. If the material from the search is deemed to be relevant then full text articles of the studies will be retrieved, and then assessed to determine if they meet the inclusion and exclusion criteria. Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. If necessary, the reviewers may contact the principal investigators for data clarification. Data synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of Interest There are no conflicts of interest regarding this systematic review Acknowledgements The authors would like to thank the following individuals for their invaluable assistance and guidance with the systematic review: Dr. Bonnie Lauder, Dr. Patrick Mattis and Dr. Cheryl Holly. This systematic review is a partial degree requirement for Gwendolyn D. Constantini, Michele McDermott, Denise Primiano, and Michelle Santomassino for completion of the Doctor of Nursing Practice Program at the Pace University, College of Health Professions, Lienhard School of Nursing, New York, NY.
BACKGROUND:Effective management of diabetes not only relies on lifestyle modification and adherence to a treatment regime, but also the ability to cope with the impact of the disease on daily activities. Stress associated with the multi-caregiver role of women may affect the ability to manage the disease effectively. OBJECTIVES:To explore the experience of women living and coping with type 2 diabetes. INCLUSION CRITERIA:Adult women aged 18 years and above diagnosed with type 2 diabetes.The meaning of living and coping with type 2 diabetes.Qualitative studies, including designs such as phenomenology, grounded theory, ethnography, action research and feminist research. SEARCH STRATEGY:The search strategy used sought only to identify published English research papers from the year 1990 to 2010. A three-step search strategy was undertaken. METHODOLOGICAL QUALITY:The retrieved papers were assessed for methodological quality by two independent reviewers using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. DATA COLLECTION:Data was extracted using the Joanna Briggs Institute Qualitative Assessment and Review data extraction tool. DATA SYNTHESIS:The data were synthesised using the Joanna Briggs Institute approach of meta-synthesis by meta-aggregation. RESULTS:Nine studies were included in the review. Forty-one findings were obtained and then grouped into 11 categories which were then aggregated into four synthesised findings: "Living with type 2 diabetes is emotionally and mentally challenging", "Support (of self, by others, spiritual) provides the ability to cope with diabetes", "Women see their personal responsibility in the management of diabetes and try to maintain their autonomy. Despite this, women place the needs of the family over their own needs thereby resulting in ineffective management" and "Effective management of diabetes is hindered by role duties of women as well as their attitudes and the attitudes of the healthcare providers". CONCLUSIONS:Women are challenged by their multi-caregiving roles and the complexities of managing their diabetes simultaneously. Holistic, individual psycho-education programs for female patients with diabetes and carer programs educating families and friends will facilitate more effective and successful management. IMPLICATIONS FOR PRACTICE:As supported by the evidence obtained in this review, diabetic education programs should include strategies that facilitate emotional coping. Family members should be encouraged to attend diabetes management programs or workshops designed for caregivers or family members to enable them to support female family members with diabetes effectively. Education programs for doctors should focus on the therapeutic helping relationship and the role this relationship plays in facilitating improved health outcomes for patients. IMPLICATION FOR RESEARCH:Implementation of action research with interventions that address the key issues identified in this systematic review would be useful. Additionally, further longitudinal studies that link the incidence and severity of complications and quality of life issues associated with diabetes management to such intervention programs will clarify the benefits, modifying factors and barriers. Despite a plethora of literature examining the coping styles and experiences of Caucasian people with diabetes there is a paucity of literature investigating similar issues among Asian populations. Thus further research studies that examine the experience of living and coping with type 2 diabetes in Asian populations are needed to enhance understanding for these patients.
BACKGROUND:Cancer care nursing is perceived as personally and professionally demanding. Developing effective coping skills and resilience has been associated with better health and wellbeing for nurses, work longevity and improved quality of patient care. OBJECTIVES:The objective of this systematic review was to identify personal and organizational strategies that promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy. METHODS:The search strategy identified published and unpublished studies from 2007 to 2013. Individual search strategies were developed for the 12 databases accessed and search alerts established. The review considered qualitative, quantitative and mixed methods studies that assessed personal or organizational interventions, programs or strategies that promoted coping and resilience. These included studies employing clinical supervision, staff retreats, psycho-educational programs, compassion fatigue resilience programs, stress inoculation therapy and individual approaches that reduced the emotional impact of cancer care work. The outcomes of interest were the experience of factors that influence an individual's coping and resilience and outcomes of validated measures of coping or resilience. Methodological quality of studies was independently assessed by two reviewers prior to inclusion in the review using standardized critical appraisal instruments developed by the Joanna Briggs Institute. Standardized Joanna Briggs Institute tools were also used to extract data. Agreement on the synthesis of the findings from qualitative studies was reached through discussion. The results of quantitative studies could not be statistically pooled given the different study designs, interventions and outcome measures. These studies were presented in narrative form. RESULTS:Twenty studies were included in the review. Ten studies examined the experience of nurse's caring for the dying, the emotional impact of palliative care and oncology work and strategies to prevent burnout or avoid compassion fatigue, challenges in self-care, and processes nurses adopted to cope with work related stress. Six studies evaluated different interventions provided by organizations to improve coping and resilience. Evidence for the effectiveness of interventions was limited to three studies. The results are discussed under four headings: (i) preventative measures (ii) control measures (iii) unburdening and "letting go", and (iv) growing and thriving. CONCLUSION:This review identified a number of strategies to better prepare nurses for practice and maintain their psychological wellbeing. Although no firm conclusions can be drawn in respect to the most effective interventions, strategies with merit included those that: a) foster connections within the team; b) provide education and training to develop behaviors that assist in controlling or limiting the intensity of stress, or aiding recovery; and c) assist in processing emotion and learning from experiences. Although individuals must take responsibility for developing personal strategies to assist coping and resilience, organizational support is integral to equipping individuals to deal with work related challenges. IMPLICATIONS FOR PRACTICE:A range of formal and informal support is required to promote coping and resilience. IMPLICATIONS FOR RESEARCH:There is a need for large, well designed, multisite, experimental studies to evaluate the effectiveness of interventions that promote coping and resilience in adult palliative care or oncology nurses.
REVIEW QUESTION/OBJECTIVE:The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared-decision making for adult patients and health care providers in all health care settings.The specific questions to be answered are: BACKGROUND: Patient-centered care is emphasized in today's healthcare arena. This emphasis is seen in the works of the International Alliance of Patients' Organizations (IAOP) who describe patient-centered healthcare as care that is aimed at addressing the needs and preferences of patients. The IAOP presents five principles which are foundational to the achievement of patient-centered healthcare: respect, choice, policy, access and support, as well as information. These five principles are further described as:Within the description of these five principles the idea of shared decision-making is clearly evident.The concept of shared decision-making began to appear in the literature in the 1990s. It is defined as a "process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient-centered care." The details of the shared decision-making process are complex and consist of a series of steps including:Three overall representative decision-making models are noted in contemporary literature. These three models include: paternalistic, informed decision-making, and shared decision-making. The paternalistic model is an autocratic style of decision-making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision-making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement. Finally, the shared decision-making model is representative of a sharing and a negotiation towards treatment decisions. Thus, these models represent a range with patient non-participation at one end of the continuum to informed decision making or a high level of patient power at the other end. Several shared decision-making models focus on the process of shared decision-making previously noted. A discussion of several process models follows below.Charles et al. depicts a process model of shared decision-making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included:This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker. This model also depicts the need to take steps to participate in the shared decision-making process. To take steps means that there is an agreement between and among all involved that shared decision-making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision-making and the actuality of shared decision-making in practice is not strong. Research concerning patients and patient preferences on shared decision-making points to variations depending on age, education, socio-economic status, culture, and diagnosis. Healthcare providers may also hold preferences for shared decision-making; however, research in this area is not as comprehensive as is patient focused research. Elwyn et al. explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision-making process. An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patient's preference is different from clinical practice guidelines. This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.The notion of information sharing as a prerequisite to shared decision-making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision-making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision-making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patient's ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al. portrays shared decision-making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the "test of a shared decision (as distinct from the decision-making process) is if both parties agree on the treatment option."Towle and Godolphin developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision-making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision-making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include:Patient competencies include:This model illustrates the shared decision-making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model. This model, however, gives greater emphasis to the process of the co-participation of the healthcare provider and the patient. The co-participation depicts a mutual partnership with mutual responsibilities that can be seen as "reciprocal relationships of dialogue." For this to take place the relationship between and among the participants of the shared decision-making process is important along with other internal and external influences such as communication, trust, mutual respect, honesty, time, continuity, and commitment. Cultural, social, and age group differences; evidence; and team and family are considered within this model.Elwyn et al. presents yet another model that depicts the shared decision-making process; however, this model offers a view where the healthcare provider holds greater responsibility in this process. In this particular model the process focuses on the healthcare provider and the essential skills needed to engage the patient in shard decisions. The competencies outlined in this model include:The healthcare provider must demonstrate knowledge, competencies, and skills as a communicator. The skills for communication competency require the healthcare provider to be able to elicit the patient's thoughts and input regarding treatment management throughout the consultation. The healthcare provider must also demonstrate competencies in assessment skills beyond physical assessment that includes the ability to assess the patient's perceptions and readiness to participate. In addition, the healthcare provider must be able to assess the patient's readiness to learn the information that the patient needs to know in order to fully engage in the shared decision-making process, assess what the patient already knows, what the patient does not know, and whether or not the information that the patient knows is accurate. Once this assessment is completed the healthcare provider then must draw on his/her knowledge, competencies, and skills necessary to teach the patient what the patient needs to know to be informed. This facilitates the notion of the tailor-made information noted previously. The healthcare provider also requires competencies in how to check and evaluate the entire process to ensure that the patient does understand and accept with comfort not only the plan being negotiated but the entire process of sharing in decision-making. In addition to the above, there are further competencies such as competence in working with groups and teams, competencies in terms of cultural knowledge, competencies with regard to negotiation skills, as well as, competencies when faced with ethical challenges.Shared decision-making has been associated with autonomy, empowerment, and effectiveness and efficiency. Both patients and health care providers have noted improvement in relationships and improved interactions when shared decision-making is in evidence. Along with this improved relationship and interaction enhanced compliance is noted. Additional research points to patient satisfaction and enhanced quality of life. There is some evidence to suggest that shared decision-making does facilitate positive health outcomes.In today's healthcare environment there is greater emphasis on patient-centered care that exemplifies patient engagement, participation, partnership, and shared decision-making. Given the shift from the more autocratic delivery of care to the shared approach there is a need to more fully understand the what of shared decision-making as well as how shared decision-making takes place along with what internal and external influences may encourage, support, and facilitate the shared decision-making process. These influences are intervening variables that may be of significance for the successful development of practice-based strategies that may foster shared decision-making in practice. The purpose of this qualitative systematic review is to identify internal and external influences on shared decision-making in all health care settings.A preliminary search of the Joanna Briggs Library of Systematic Reviews, MEDLINE, CINAHL, and PROSPERO did not identify any previously conducted qualitative systematic reviews on the meaningfulness of internal and external influences on shared decision-making.
BACKGROUND:Studies suggest possible newer risk factors for hypertension including Khat chewing, a plant which grows wild in countries bordering the Red Sea and along the east coast of Africa and the Arabian Peninsula.OBJECTIVES:The objective was to synthesise the best available evidence on the epidemiological association between Khat chewing as exposure (potential risk factor) and hypertension.INCLUSION CRITERIA:Subjects aged 16 years old or older regardless of gender and ethnicity, country of residence, Khat dose, frequency, duration of chewing or other characteristics of Khat exposure and co-presence of other known risk factors for hypertension.The focus of interest of this review was the epidemiological association between Khat chewing as exposure (potential risk factor) and hypertension as an outcome.Observational analytical studies (cohort studies, case-control studies and cross-sectional studies) were considered for inclusion.SEARCH STRATEGY:Three staged search strategy was used to identify all relevant published and grey literature in English language from 1988 to 2011. Databases searched were PubMed, CINAHL, PopLine, LILACS, MedNar and Embase.METHODOLOGICAL QUALITY:All papers selected for inclusion in the review were subjected to a rigorous, independent appraisal by the two reviewers prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute.DATA COLLECTION AND SYNTHESIS:Due to poor internet service in our setting we were unable to use the Joanna Briggs Institute -software for data extraction and synthesis as approved in the protocol. Quantitative papers were pooled in statistical meta-analysis using the Review Manager Software. Odds ratios and their 95% confidence intervals were calculated for analysis.RESULTS:Two studies from Ethiopia and one from Saudi Arabia were identified. In the study done by Getahun et al. 44 of the chewers (n=324) and 34 of the non chewers (n=319) were found to have hypertension. Analysis of this study showed no statistically significant association between Khat chewing and hypertension (OR=1.29, 95% CI =0.80-2.08). In the second study done by Mossie, 29 of the chewers (n=277) and 73 of the non chewers (n=621) were found to have hypertension and there was no statistically significant association between Khat chewing and hypertension (OR=0.88, 95% CI =0.56-1.38). Seventy seven of the chewers (n=568) and 160 of the non chewers (n=1207) were found to have hypertension) in the third study done by Ibrahim, similarly there was no statistically significant association between Khat chewing and prevalence of hypertension (OR=1.03, 95% CI =0.77-1.37 in this study.On meta analysis, a total of 3321 subjects were involved. Of the Khat chewers (1174), 150 were found to have hypertension. On contrary, 267 of non chewers (2147) were found to have hypertension. Finding of the analysis showed no statistically significant association between Khat chewing and hypertension (Odds ratio=1.04, 95% Confidence Interval= 0.84, 1.29). The studies were homogenous, Heterogeneity test: Chi = 1.35, df = 2, (P = 0.51). The test for overall effect also showed no statistical significance at conventional levels (P>0.05).CONCLUSIONS:We did not find sufficient evidence to conclude that Khat as epidemiologic risk factor for hypertension.The present systematic review did not identify a statistically significant association of Khat chewing as epidemiologic risk factor for hypertension.IMPLICATIONS FOR RESEARCH:This review identifies the need for further studies on Khat as an epidemiologic risk factor for hypertension considering further aspects of chewing, like dose-response, duration of chewing and co-existence of other co-morbid factors of hypertension.
Background Natural childbirth occurs without medication or obstetric intervention.1 Vaginal birth may involve any number of medical interventions with the baby ultimately born vaginally.1 These medical interventions may include surgical or medical induction, oxytocics for augmentation, electronic cardiotocographic monitoring, analgesics for pain relief, episiotomy, and the delivery can be spontaneous (i.e. unassisted) or assisted (i.e. by forceps or vacuum extractor).1 Caesarean section involves surgical delivery of the fetus, and rates of this procedure have risen dramatically during the past decade, reaching more than 50% in some countries, despite a lack of evidence of any increase in obstetric emergencies.2 This trend is of concern as Caesarean deliveries increase the risk of neonatal morbidity and mortality and maternal morbidity, compared with spontaneous vaginal delivery.2 Several studies have examined possible reasons for the increasing Caesarean delivery rates. Some authors concluded that maternal request is a significant factor in the rising Caesarean section rates.3 Key reasons cited for women preferring a Caesarean delivery related to perceptions about safety for both mother and baby, previous negative birth experiences, poor care and perceived inequalities in care.4 One study identified fear of vaginal birth as the most important reason why some women preferred an elective Caesarean delivery after their first birth.5 Despite the high Caesarean delivery rates, many women maintain a strong commitment to vaginal birth.6 One study identified that few women request a Caesarean delivery in the absence of any current or previous obstetric complications.7 In an another study women who preferred a vaginal birth after Caesarean (VBAC) revealed that their individual belief that birth was a significant and important event8. Participants also reported that attitudes of family and friends and the woman’s reflections of the previous Caesarean experience influenced their choice to have a VBAC.8 Although many recent studies have examined reasons for women’s birth preference for either normal vaginal birth or Caesarean delivery, few studies have investigated factors that influenced women’s birth preferences. Some factors found to influence women’s preferred type of birth were specific types of information provided by health professionals,6 and information assessed through public and private discourses of family, friends and acquaintances.9 An understanding of factors contributing to the escalating Caesarean delivery rates is important to enable the design and implementation of safe and successful strategies to reduce unnecessary obstetric interventions in childbirth.7 Understanding factors that influence women’s decisions about childbirth may also inform strategies to address misconceptions about childbirth, promote normal vaginal birth, as well as improve the delivery of care provided by health professionals. This systematic review aims to examine factors that influence women’s birthing preferences for normal vaginal birth or Caesarean delivery. A search of the Cochrane Collaboration and Joanna Briggs Institute Library of Systematic Reviews did not reveal any previous systematic reviews on this topic. Review Objective The objective of this systematic review is to identify factors influencing women’s birthing preferences. More specifically, the review question(s) are: Quantitative What factors influence women’s preference for a normal vaginal birth? What factors influence women’s preference for a Caesarean delivery? What factors influence women’s preference for a vaginal birth after Caesarean (VBAC)? Qualitative What is the meaning of factors influencing childbirth preferences for women? Criteria for considering studies for this review Types of Studies Quantitative This component of the review will consider any randomised controlled trials (RCTs) that examine childbirth preferences by women. In the absence of RCTs other research designs, such as non-RCTs, before and after studies, cross sectional studies such as surveys, and observational studies including cohort studies, case control studies, descriptive studies and case series will be considered for inclusion in a narrative summary. Qualitative This component of the review will consider any interpretive studies that investigate women’s child birth preferences within the first postnatal year, including but not limited to, designs such as phenomenology, grounded theory and ethnography. In the absence of research studies, other text such as opinion papers and reports will be considered in a narrative summary. Types of participants Quantitative This component of the review will consider studies that involve women regardless of parity status, age, education, race, culture, ethnicity and living with or without partners, with low-obstetric risk who have given birth at term (37-42 weeks) or are going to give birth in both private and public hospitals. A low-risk pregnancy is one where the fetus is full-term, singleton, and in the vertex position, and the mother has no reported medical risk factors or complications of labor and/or delivery.10 Studies involving high-risk pregnant women would be excluded as they may potentially conflate preferred type of birth with perceptions of safety.11 Pregnancy is labeled high risk when adverse maternal or fetal complications occur, placing the woman or the fetus at some measure of medical risk12. Events include preterm labor, placenta previa, placenta abruption, dynamic cervix, preterm rupture of membranes, multi-fetal gestation, hypertensive disorders, placenta insufficiency, fetal growth retardation, or other conditions that may compromise the health of the mother or baby.13 Qualitative This component of the review will consider studies that involve women regardless of parity, age, education, race, culture, ethnicity and living with or without partners, with low-obstetric risk who have given birth at term (37-42 weeks) or are going to give birth in both private and public hospitals. A low-risk pregnancy is one where the fetus is full-term, singleton, and in the vertex position, and the mother has no reported medical risk factors or complications of labor and/or delivery.10 Studies involving high-risk pregnant women, as defined above, would be excluded as they may potentially conflate preferred type of birth with perceptions of safety.11 Types of Interventions/Phenomena of Interest Quantitative This component of the review will consider studies that investigate factors, which influence birth preferences in terms of mode of delivery. These include any type of vaginal birth (natural, normal unassisted and assisted, that is, forceps or vacuum extraction) and Caesarean deliveries (emergency and elective). Studies investigating VBAC will also be included. Studies which include women who experienced a stillbirth and/or neonatal death would not be considered. Births in hospitals, homes and birthing centres are included. Studies investigating preferences on choice of site of delivery would be excluded. Qualitative This component of the review will consider studies that investigate women’s experience of birth and factors influencing their birth preferences in terms of mode of delivery such as vaginal: natural, normal unassisted and assisted (forceps or vacuum extraction) births. Women’s experience of emergency and elective Caesarean deliveries will be included. Women’s experience of VBAC will also be included. Studies which include the experience of mothers following a stillbirth and/or neonatal death will not be considered. Births in hospitals, homes and birthing centres are included. Types of outcome measures/anticipated outcomes Quantitative This component of the review will consider studies that include the following outcomes: Studies indicating women’s preference for normal vaginal birth. Studies indicating women’s preference for Caesarean delivery. Studies indicating factors which have impact over women’s preference such as previous birth experience, discussions with health care professionals, family members and friends, and information from the media. Qualitative This component of the review will consider studies that present women’s subjective accounts related to the factors influencing their birth preferences during their antenatal period or the first postpartum year. Search Strategy for identification of studies The search strategy aims to find both published and unpublished studies and papers. The search will be limited to English language reports. A three-step search strategy will be utilised in each component of this review. An initial limited search of PubMed and CINAHL Plus with full text will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken (Appendix I). Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: CINAHL Plus with Full Text PubMed Scopus Web of science OvidSP ScienceDirect Mosby’s Nursing Consult The Cochrane Library The search strategy will be limited to the following years 1990 to 2009. Initial Keywords to be used for the three review components will be: Childbirth* Vaginal birth* C*esarean section Vaginal birth after c*esarean Women prefer* Women satisf* Normal delivery Vaginal delivery Caesarean delivery Methods of review Critical Appraisal Quantitative Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II, III, IV, V). Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer. Qualitative Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument) (Appendix VI). Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer. Data Extraction Quantitative Quantitative data will be extracted from papers included in the review using standardised data extraction tools from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix VII, VIII, IX). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer. Qualitative Qualitative data will be extracted from papers included in the review using standardised data extraction tools from the Joanna Briggs Institute Qualitative Assessment and Review Instrument) (Appendix X). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer. Data Synthesis Quantitative Where possible, quantitative research study results will be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be double entered. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Qualitative Where meta-synthesis is possible, qualitative research findings will be pooled using the Qualitative Assessment and Review Instrument (JBI-QARI). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Conflicts of Interest There were no conflicts of interest.
Background Non-melanoma skin cancer is the most common cancer in humans and the most important risk factors are thought to be age, skin type, and exposure to ultraviolet radiation. Lifestyle factors may also play a part. To date no systematic review has been performed to collate evidence of the effects of smoking, alcohol or body mass index. Objectives We performed a systematic review and meta-analysis to assess the effects of smoking, alcohol and body mass index on the risk of non-melanoma skin cancer and its subtypes. Inclusion criteria Types of participants Adults (18+ years old) of either sex from any ethnicity Types of exposures Smoking, alcohol, or body mass index (including other anthropometric measurements, such as weight, waist to hip ratio, and the percentage body fat) Types of outcomes Non-melanoma skin cancer, cutaneous squamous cell carcinoma, or basal cell carcinoma Types of studies Comparative observational epidemiological studies Search strategy We performed a comprehensive search of MEDLINE, EMBASE, CINAHL, Cochrane Library and CAB Abstracts from inception to October 2010. We also scanned reference lists to identify further eligible studies. Methodological quality Data from eligible studies were extracted and quality assessed using the Newcastle Ottawa Scale independently by two reviewers. Data collection The titles, abstracts and full text identified from the search were assessed independently by two reviewers against pre-specified inclusion/exclusion criteria. Disagreements were resolved through discussion with a third reviewer. Data synthesis For studies with similar exposures, a meta-analysis was performed using a random effects model and results were expressed as pooled odds ratio with 95% confidence intervals. Heterogeneity was assessed using I2. Publication bias was assessed using funnel plots. Data were analysed using Review Manager. Results Thirty studies were included of which 22 used a case control design and the remaining used a cohort design. The overall quality of the studies was variable with a Newcastle Ottawa Scale median score of 6 out of 9 stars. No evidence of asymmetry was detected in the funnel plots. Smoking was not significantly related to increased risks of non-melanoma skin cancer (Odds Ratio 0.62, 95% CI 0.21 to 1.79, I2=34%, 2 studies) or basal cell carcinoma (Odds Ratio 0.95, 95% CI 0.82 to 1.09; I2=59%, 14 studies). However, smoking was significantly associated with a 52% increase in the risk of cutaneous squamous cell carcinoma (95% CI 1.15 to 2.01; I2=64%; 6 studies). Subgroup analysis found no significant difference in results based on the definition of smoking (current, former, or ever smoker) for basal cell carcinoma, cutaneous squamous cell carcinoma or non-melanoma skin cancer. Alcohol was not significantly related to increased risks of non-melanoma skin cancer (1 study), basal cell carcinoma (Odds Ratio 1.03, 95% CI 0.94 to 1.13, I2=0%, 9 studies) or cutaneous squamous cell carcinoma (1 study). Similar results were found irrespective of the type of alcohol assessed (beer, wine, or spirits) for basal cell carcinoma and cutaneous squamous cell carcinoma. A pooled analysis of five studies found a non-significant decrease in the risk of basal cell carcinoma associated with a higher body mass index (Odds Ratio 0.94, 95% CI 0.84 to 1.04, I2=40%). In a subgroup analysis based on sex, the potential reduction in risk of basal cell carcinoma appeared to be confined to males (Males: Odds Ratio 0.90, 95% CI 0.78 to 1.04, I2=45%, 4 studies; Females: Odds Ratio 1.01, 95% CI 0.85 to 1.19, I2=14%, 3 studies). Conclusion It is unclear at present if smoking modifies the risk of basal cell carcinoma; however, smoking clearly increases the risk of cutaneous squamous cell carcinoma. Limited evidence has been published about the risk of non-melanoma skin cancer with alcohol and body mass index; however there is some suggestion a high body mass index may be slightly protective of basal cell carcinoma, particularly in males. Implications for Practice This study highlights the importance for clinicians to actively survey high risk patients, including current smokers. Implications for Research The majority of studies included in this systematic review assessed the associations between basal cell carcinoma and smoking, alcohol or body mass index. However, more evidence is needed before conclusive recommendations can be formed regarding the relationship between cutaneous squamous cell carcinoma and alcohol or body mass index.
Review question/objective The review objective is to determine the current evidence related to the effectiveness of resistance training with thera band on physiological functions for older adults, such as muscular function, physical functional capacities and body composition.More specifically, the review question is: Is resistance training with thera band effective for improving physiological functions in older adults? Inclusion criteria Types of participants This review will consider studies that include adults aged 60 years or older and reside in community or long-term care institutions. Types of intervention This review will consider studies that had at least one group of participants who received resistance training using thera band (tube). Training could be delivered in group exercise programs, individual personal training arrangements, community settings or institutional settings. The comparator is anticipated to be usual activities or exercise trainings without use of thera band. Types of outcomes This review will consider studies that include the following outcome measures: muscular function, physical functional capacities and body composition.
Background Agitation is recognised by aged care literature as the most common behavioural problem in residential aged care facilities. Complementary therapies are advocated by some as a solution to reduce the effect of agitation in older people and are becoming increasingly incorporating into nursing care. Complementary therapies in nursing management, is endorsed by the Australian Nurses and Midwifery Board for nurse initiation. Objectives The review objective was to discover which types of Complementary therapies are being implemented in RACFs for agitation management and which of these therapies where effective in reducing agitation. Inclusion criteria Types of participants Participants were people over the age of 65 years living permanently in a residential aged care facility and experiencing agitation, regardless of cognitive ability, gender or ethnicity and existing co‐morbidities. Types of intervention(s)/phenomena of interest The types of complementary therapy interventions explored in this systematic review were Aromatherapy, Exercise, Massage, Music Therapy and Therapeutic Touch Types of studies The systematic review considered randomised controlled trials of complementary therapy interventions that could be initiated by a nurse Types of outcomes Outcomes measured were the frequency and/or severity of verbal, non‐physical aggressive and physical aggressive agitation among the participants. Search strategy A comprehensive search strategy was developed for eleven electronic databases with dates ranging from January 2000 to September 2010. Searches included unpublished studies and the reference lists from identified papers. Only English language papers were considered due to a lack of interpreter facilities. Methodological quality An adapted version of the Joanna Briggs Institute quality appraisal checklist was used to assess the methodological quality of studies. Appraisal was performed separately by two independent reviewers with any disagreement between appraisers settled by a third appraiser. Data collection Data was extracted using the standardised Joanna Briggs Institute Data Extraction Tool. Data synthesis Measurement tools reported different subcategories of agitated behaviours making data comparison difficult. A variety of complementary interventions made the comparing of this data inappropriate. Extracted data was unable to be synthesised in meta analysis, a narrative analysis of results was therefore more appropriate. Results The ten included randomised controlled trials reported all interventions effective in reducing non‐physical and verbal agitation. Two interventions, aromatherapy and music therapy, showed significant effect in reducing physical aggressive agitation. Conclusions The results of this systematic review support the growing evidence that Complementary Therapies are effective in agitation management of older people in Residential Aged Care Facilities. Nurse initiation of complementary therapies will see timely and expedient management of agitation for older people. Therapies can be implemented with relative ease and low cost to the facility.
Review question/objective The objective of this review is to analyse and synthesise the best available evidence on the experiences of Indigenous people who engage in health care encounters in Western settings and contexts. The review question is: What are the experiences of Indigenous people engaged in health care encounters in Western settings and contexts? Background According to the United Nations, “Indigenous communities, peoples and nations are those which, having a historical continuity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing on those territories, or parts of them”.(1, p.2) Unfortunately, Indigenous populations around the world today experience grave health inequities. In Canada, for example, First Nations people experience the most socioeconomic disadvantage and hence the poorest health status in the country.2 They have higher rates of suicide, lower levels of income and employment, higher rates of school dropout, shorter life expectancy, and higher rates of infectious and non-infectious diseases.2 Likewise, Indigenous Australians experience three times the burden of disease than their non-Indigenous national counterparts.3 In the United States of America (USA), health disparities between Indigenous and non-Indigenous populations are significant and long standing.4 For example, USA national data reveals earlier first use of drugs and alcohol, greater frequency and intensity of use, and much higher drug and alcohol related mortalities among Indigenous populations than any other racial group.4 There is also disparity between Indigenous and non-Indigenous populations, in terms of how these health and socioeconomic problems are understood and addressed. In general, Indigenous beliefs about the causes of illness vary considerably from Western biomedical explanations.3 Western, as opposed to Eastern, health care services are the focus of this review because of the unique colonial and post-colonial tensions that exist between Western and Indigenous cultures. Unfortunately, Western approaches to health and health care often ignore and render invisible Indigenous health beliefs and practices.2 Reliance on Western concepts of health and illness, without incorporating Indigenous explanatory models of the same, results in largely ineffective care that alienates rather than supports Indigenous people.2,5 Researchers have recently revealed that Indigenous people rarely receive culturally safe and relevant health care that effectively addresses their unique needs.5 Culturally safe care goes beyond cultural awareness and sensitivity toward actively promoting self-empowerment of Indigenous people to influence their care and support positive health outcomes.6 The concept of cultural safety emerged in postcolonial New Zealand in the late 1980s in response to the needs of the Maori people.7 Like Indigenous populations in other parts of the world, it was observed that the Maori people often did not access health care services until advanced stages of disease, were “non-compliant”, and often prematurely dropped out of treatment programs.7 In response to these trends, cultural safety was developed as a lens from which to critique and better understand health care encounters between ethno-cultural minority groups, such as the Maori of New Zealand, and service providers working in Western health care systems and contexts. Western providers and health care systems guided by cultural safety pay special attention to power imbalances and seek to redress the same.7 This review is rooted in the concept of cultural safety. Our aim is to better understand issues and challenges experienced by Indigenous people in their health care encounters in Western settings and contexts. Health care encounters occurring in a wide variety of settings, such as acute, chronic, palliative, and perinatal care, can serve to either invalidate or affirm Indigenous peoples' health-related experiences. For example, qualitative researchers have found that Indigenous clients can feel invalidated during health care encounters when health care providers dismiss their concerns, apply negative stereotypes, make them feel marginalised and lessened as persons, and/or disregard their unique socioeconomic and personal circumstances.8,9 Conversely, these researchers have also revealed that Indigenous clients can feel affirmed during health care encounters when health care providers treat them as equals, encourage them to actively participate in decisions related to their care, convey a genuine caring attitude, affirm their unique personal circumstances and cultural identity, and develop long-term trusting relationships with them.8,9 Understanding Indigenous people's health care encounters in Western settings and context -both positive and negative-is a critical step toward addressing issues and ensuring more equitable, accessible, and culturally safe health care for Indigenous people globally. The results of this review can be used to support ongoing efforts on the part of countries around the world to address health disparities experienced by Indigenous populations through improved education of health care providers and enhanced collaboration and consultation with Indigenous communities in the organisation and operation of their health care services.6 Of course, addressing health inequities among Indigenous people requires multiple approaches.10 Such approaches must go beyond illness care and include the social determinants of health. The way health services are designed and delivered is a powerful determinant of health.11 Appropriately configured health services, including individual, family, and community health care encounters, can be a resource to improve people's lives, protect them from the vulnerability of disease, enhance their sense of security, and build a common purpose.11 However, poorly configured health services and health care encounters can do just the opposite—they can “actively perpetuate injustice and social stratification”.(11, p.32) Unfortunately, the latter is more often than not the experience of Indigenous peoples around the world. Too often health care providers who engage in health care encounters with Indigenous people fail to take into account Indigenous cultural values, life ways, and social determinants of health. Instead, generalised care plans are applied that do not facilitate individualised and culturally safe approaches.5 Individual patients' explanatory models of health and illness, as well as their social, political and economic location within the wider social context must be taken into account. Unfortunately, such an individually tailored yet broadminded approach to health care does not occur often enough. To achieve culturally safe and relevant care, it is imperative that we gain a consolidated qualitative understanding of how health care encounters in Western settings and context are experienced by Indigenous people worldwide. Doing so will illuminate the gaps in preparedness among health care providers and identify areas of needed change in policy and in Western health care delivery systems, in general. The Joanna Briggs Institute Library of Systematic Reviews, Medline, CINAHL, and ProQuest Nursing and Allied Health databases were searched and no systematic reviews of this topic were found. From this it was determined that a systematic review of the experiences of Indigenous people in health care encounters in Western settings and contexts is needed. Inclusion Criteria Types of Participants Studies including two groups of participants, regardless of age or gender, will be considered for this systematic review. The first group is persons of Indigenous descent from the following countries and continents appearing most frequently in the literature: North America, South America, New Zealand, Australia, and Scandinavian countries. These countries include peoples such as First Nations, Native Americans, Metis, Inuit, North American Indians, South American Indians, Inca, Maori, Aboriginal and Torres Strait Islander peoples of Australia, and Sápmi. This list is not exhaustive, and any Indigenous population identified in a study will be included. Indigenous populations who immigrate to new countries will be excluded, given that immigrant status can confound Indigenous status. The second group of participants to be considered for inclusion is health care providers who work in Western settings and context, including, but not limited to, nurses, physicians, nutritionists, midwives, social workers, physiotherapists, occupational therapists, speech and language therapists, and respirologists. Phenomena of Interest The phenomenon of interest is the experience of Indigenous people in health care encounters in Western health care settings and context. Health care encounters refer to any interactions between an Indigenous person and a health care provider within the scope of Western health care services. All reasons for health encounters will be considered. Context The context will be Indigenous persons seeking health care services in Western settings and context. These services may be located within urban, rural, or remote health care settings where Western health care services are delivered. Types of Studies Qualitative studies using an interpretive, qualitative descriptive or qualitative observational approach, phenomenology, ethnography, grounded theory, hermeneutics, participatory action research, or critical theory will be considered for inclusion. In the absence of research studies with qualitative methodologies, text and opinion papers and reports will be considered. Search Strategy The search will include qualitative articles/studies in all languages (where translations resources are available) from 1985 to 2012. The start date 1985 was selected given that this was deemed as the relevant time frame for the emergence of this topic in the literature. The search strategy aims to be comprehensive by locating both published and unpublished studies. A three-step strategy will be utilised in this review. An initial limited search of MEDLINE, CINAHL, Embase, and Sociological Abstracts will be undertaken followed by analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search using all identified keywords and index/thesaurus terms will then be undertaken across all included databases. Thirdly, the reference lists of identified reports and articles will be hand searched for additional studies. The databases to be searched include: Academic Search Premier BioMed Central Canadian Electronic Library Canadian Periodicals CINAHL Cochrane Library CultureVision Current Contents EbscoHost HealthSource: Nursing/Academic Edition eHRAF World Cultures Elsevier ScienceDirect Embase Health Source Health Source Plus Health Star International Index Medicus (WHO) ISI Web of Science MEDLINE via PubMed ProQuest Nursing and Allied Health Psychiatry Online Psychology and Behavioral Sciences Collection PsycINFO Research Library Scirus SCOPUS Social Services Abstracts SocIndex Sociological Abstracts TRIP WorldCat and other library catalogues (for books) Other regional databases The search for unpublished studies or grey literature will include: Aboriginal Nurses Association of Canada Agency of Healthcare Research and Quality Australian Indigenous Doctors' Association Australian Indigenous Health InfoNet British Columbia EOHRN Grey Literature Wiki/Healthcare Canadian Centre for Substance Abuse (CCSA) Canadian Institute of Health Research Centre for Traditional Medicine Conference proceedings DIVA [dissertations and other publications in full text from Nordic universities] Google Scholar Grey Literature Bulletin (North West Health Library and Information Services UK) Health Canada Index to Theses Indian and Northern Affairs Canada Indigenous Health Research Development Program Indigenous Physicians Association of Canada Institute for Health and Social Care Research (IHSCR) Institute of Aboriginal Peoples' Health National Library of Medicine Networked Digital Library of Theses and Dissertations (NDLT) New York Academy of Medicine's Grey Literature Report NLM Gateway Ontario Public Health Libraries Association (OPHLA) ProQuest Dissertations and Theses PsycExtra Public Health Agency of Canada Science.gov Stats Can System for Information on Grey Literature in Europe (SIGLE) Theses Canada Portal Trove Virginia Henderson International Nursing Library Initial keywords to be used will include, but not be limited to: Terms relating to Indigenous populations from North America, South America, New Zealand, Australia, and Scandinavian countries, such as First Nations, Native Americans, Aboriginal and Torres Strait Islander peoples of Australia, Metis, Inuit, Sápmi, North American Indians, South American Indians, Inca, and Maori.In the database PubMed, some of these population groups are represented by Medical Subject Heading (MeSH) terms such as “Oceanic Ancestry Group,” “American Native Continental Ancestry Group,” and others. The controlled vocabulary terms and any other synonyms for persons of Indigenous descent will be used in the searches. Terms related to health care setting, such as Indigenous health, health services, health care services, mental health, primary health care, primary care, emergency treatment, emergency medical services, emergency medicine, emergency department, emergency room, urgent care center/centre, rehabilitation, public health, community health, mobile outreach, resident care, long term care, nursing home, home care, home nursing, extramural, community health centre, homeless nursing, street nursing, clinic, surgery, and school nursing. Terms related to the health care encounter, such as clinical encounter, client encounter, patient encounter(s), therapeutic interaction, therapeutic relationship, therapeutic partnership, non-therapeutic interaction, client meeting, family meeting, non-judgemental (and non-judgmental) care, clinical relationship, clinical care, clinical relationship, professional-patient relationships, patient engagement, client engagement, nurse-client communication, nurse-patient communication, doctor-client communication, doctor-patient communication, physician-patient communication, physician-client communication, nurse-client relationship, helping relationships, caring relationships, relational practice, critical caring approach, welcomeness, unwelcomeness, conversation, attitude of health personnel, respect, trust, cultural competency, cultural safety, health care disparity, inequality, inequity, marginalize (and marginalise), intersectionality, multiple jeopardy, seeking care, seeking help, access to healthcare. Terms related to health care providers, such as health care professional, health care provider, health care personnel, Western health care providers, non-Indigenous health care providers, non-Aboriginal health care providers, nurses, physicians, nutritionists, midwives, and social workers. Terms related to qualitative research, such as qualitative design, ethnography, auto-ethnography, phenomenology, hermeneutics, interpretive phenomenology, descriptive phenomenology, grounded theory, lived experience, narrative inquiry, participatory research, action research, participatory action research, interpretive description, case study, field study, focus group, interview, observation, photovoice, document analysis, narrative analysis, and thematic analysis. The search strategy will be adapted to the features and vocabulary of each database searched. Assessment of Methodological Quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using a standardised critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. In the absence of research studies, textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using a standardised critical appraisal instrument from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data Collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). In the absence of research studies, textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix II). Data Synthesis Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorising these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. In the absence of research studies, textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the conclusions will be presented in narrative form. Conflicts of Interest No conflict of interest. Acknowledgements We wish to gratefully acknowledge the Queens Joanna Briggs Collaboration for Patient Safety for their ongoing support and feedback.
Centre submitting review Pace University, College of Health Professions, Lienhard School of Nursing and New Jersey Centre for Evidence Based Practice at UMDNJ School of Nursing: A Collaborating Centre of the Joanna Briggs Institute Review questions/objectives The objective of this systematic review is to synthesise the best available evidence on the impact of the effectiveness of delegation interventions by the registered nurse (RN) to the unlicensed assistive personnel (UAP) and their impact on quality of care, patient satisfaction, and RN staff satisfaction. Background The Institute of Medicine's (IOM) 2001 report, Crossing the Quality Chasm, identified coordination of care, team effectiveness, and workforce shortages as important areas that must be addressed in an effort to improve the quality and safety of healthcare in the 21st century.1-3 In 2003, the IOM challenged nursing professionals with attaining excellence in five areas of proficiency and competence to improve patient care in safe work environments. These areas were considered to be the fundamentals of quality nursing care, and included: patient centred care, interdisciplinary teamwork, quality improvement, the use of information technology, and the use of evidence-based practice.4 Delegation is recognised as a fundamental nursing skill that can be utilised effectively to improve quality care.1 The workload, responsibility, and increasing age of a shrinking RN workforce worldwide, has resulted in a growing dependency on UAP to provide certain aspects of patient care.5 Globally, RNs are dependent on UAP to assist in the provision of safe patient care.6 Delegation and communication are important skills for the RN in order to provide clear direction to the UAP.7 The standards of nursing care, quality of care, patient safety, and staff satisfaction outcomes may not be achieved if there is lack of communication between the RN and the UAP. Studies on RN delegation have shown that omissions and errors were related to poor communication between the RN and UAP.6,8 The World Health Organization has enjoined patient safety groups to urge better communication among personnel who are providing patient care. There are similarities that exist between the United Kingdom (UK) and the United States (US) regarding effective delegation. Both the UK and the US use the National Council of State Board of Nursing's Five Rights of Delegation as a guideline for effective delegation.5 The American Nurses Association defines the UAP as an individual trained to assist RNs in direct and indirect care when an RN delegates tasks to them.9 The UAPs have been referred to by many titles, including nursing assistants, certified nurse's aide, nursing attendant, patient care associate, and patient care technician. The tasks most commonly delegated to the UAP by an RN include feeding, turning and positioning, ambulation, mouth care, hygiene, and vital signs.8,10 The International Council of Nurses has published a position statement about the relationship between nurses and assistive personnel. The statement describes the delegation and supervision of nursing care by the RN to the UAP emphasising that the RN retains all responsibility for nursing care at all times. The International Council of Nurses statement recognises the centrality of RN responsibility for nursing care and the role of the UAP to maintain safe effective care within defined standards and based on the code of conduct of its country and employer. The International Council of Nurses supports the independence of each country and locality to determine the nature of care delivery, and the standards of quality, training and allocation of resources.11 Similarly, the American Nurses Association and the US-based National Council of State Board of Nursing define ‘delegation’ as the process for the RN to direct another person to perform nursing tasks and activities. There are Five Rights of Delegation to be considered when delegating: right circumstance, right task, right person, right supervision, and right communication.12 The essence of the Five Rights of Delegation highlights the RN's accountability for all aspects of patients care. Communication between the RN and the UAP is fundamental to the delegation process. The delegation process between the RN and the UAP has been reported in the literature since the early 1990s.14-16 Effective delegation in a health care setting between the RN and the UAP can impact patient outcomes, patient safety, job satisfaction, efficiency of care delivery, and facilitate cost containment.14,17,18 The delegation of specific tasks associated with patient care from the RN to the UAP is a process and incorporates skills such as communication, evaluation, feedback, and mutual respect.2,19 The use of the UAP is common practice and often provides a cost offset in terms of human resource expenditures.12,13,20-22 The National Council of State Board of Nursing outlines the process of delegation for RNs in the Nurse Practice Act.12,13 In the current health care environment, it is imperative that an acute care setting maintains an effective RN to UAP staffing ratio in order to deliver safe, quality, cost effective health care to their consumers.23 The evidence provided by an international study, which included five countries, 43,000 RNs and hundreds of thousands of patients, points to the relationship between healthy work environments and patient satisfaction, staff satisfaction, and positive patient outcomes.24-26 The skillful use of the delegation process between the RN to the UAP may impact quality of care, patient satisfaction, and staff satisfaction. Nursing practice environments and poor delegation skills may adversely impact quality of care and patient outcomes.24 Effective delegation occurs when the desired patient outcome is achieved when the RN delegates, communicates and supervises a task given to a UAP.27 Identification of the most effective delegation strategies can contribute to achieving the highest quality nursing care delivery in any complex and dynamic healthcare environment. Stressful RN-UAP relationships typically result in poor communication and teamwork that can contribute to ineffective delegation, missed care, and poor patient outcomes.2,8 An important aspect of delegation is relational coordination. Relational coordination is a process that includes communication and relationship building. It is measured by the frequency of communication, strength of shared goals, and the degree of mutual respect among care providers.19 Relational coordination is associated with improved quality of care and it enhances positive patient outcomes.19 The RN must be familiar and comfortable with patient care responsibilities and the scope of practice, as well as understanding the skills needed to delegate effectively to the UAP. The RN who delegates must clearly communicate the specific tasks to the UAP and is responsible for ensuring that the delegate is qualified to do the task. Aiken et al.24, 26 describes organisational characteristics that impact delegation to enhance positive patient outcomes. These characteristics include staffing ratios, the availability of the UAP, and the RN's ability to exercise professional judgment and control over their practice environment. These organisational characteristics impact risk mortality rates and job satisfaction.24,26 Teamwork and communication are necessary for effective delegation and they are key in building a solid relationship among the staff. It is up to the directors, managers, and educators to teach the staff effective communication and delegation skills. The RN must be available if there are any questions in the execution of the task.12,13 Lack of trust, participation; understanding, communication, and preparation are five major reasons why delegation may not be successful. It is important that RNs continue to evaluate their own practice as well as to evaluate and find the best strategies to train and educate the UAP to ensure competent and efficient care. Efficiency, quality patient care, and the satisfaction of both the patient and staff members may impact effective delegation between the RN and the UAP.2 The IOM defines quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.1 (p.1) To measure outcomes, institutions in the US and abroad have utilised various tools to measure quality of care, patient satisfaction, and staff satisfaction. Examples of commonly used tools are The National Quality Forum's (NQF) NQF-15, used to measure the quality of care; the Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS) used to assess patient satisfaction; and the National Database of Nursing Quality Indicators (NDNQI), used to measure staff satisfaction in the US and other countries. The NQF and the Agency for Health Research and Quality (AHRQ), along with the IOM, are in agreement about the definition of quality.29,30 The NQF, a non-profit organisation, has developed a three-part mission to improve quality of care, provide goals for performance improvement, publicly set and report standards, and promote national goals through education and outreach programs.42 A specific nursing-sensitive tool, the NQF-15, was developed by the NQF to measure quality of care and consists of three domains: patient, nursing, and system measures.28 Patient centred care is one of six priority areas identified for improvement of quality by the IOM.1 Achieving patient satisfaction is an important element of patient centred care. Patient satisfaction with nursing care is achieved when the care received by the patient meets or exceeds expectation.31 These expectations have been described as including technical, interpersonal, environmental, financial, and outcome components.31 An established tool for measuring patient satisfaction with inpatient hospital care is the HCAHPS or the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey. Effective communication with nurses and nursing services are among the eight components used to evaluate patient satisfaction with hospital care.32, 33 In addition, ratio of RNs to patient days is used as a characteristic of a hospital to evaluate patient satisfaction.33 The HCAHPS has been translated into Spanish for use in the US, as well as being internationally accepted in countries such as Singapore, Belgium, Japan, Korea and the Netherlands.34,39 The NDNQI tool has been utilised to measure staff satisfaction. NDNQI was established in 1998 as part of the American Nurses Association's Safety and Quality Initiative and is currently being utilised in over 1425 hospitals, as well as over six countries globally.13 It is the only nursing database which provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level. It consists of several indicators, including RN Satisfaction Survey and Nurse Staff Turnover.4,40 Delegation by the RN to the UAP may have considerable impact on quality of care, patient satisfaction, and staff satisfaction. Identifying the best available evidence on delegation intervention can enhance patient outcomes. This review will identify the best available evidence about the impact of RN-UAP delegation strategies on quality of care, patient satisfaction, and RN staff satisfaction. No existing systematic review on this topic was identified in The Joanna Briggs Institute Library of Systematic Reviews, the Cochrane Library, CINAHL, or Medline, PubMed - Clinical Inquiries. Inclusion criteria Types of participants The review will consider studies that include RNs and unlicensed assistive personnel in any patient care setting where delegation by the RN to the UAP occurs. For the purposes of this systematic review we will use the following definitions: Registered nurse: A person that has graduated from a nursing program and has been licensed to practice.12,13 Unlicensed assistive personnel: Persons that are in a position to assist the RN under the registered nurse's direct supervision. Activities are generally restricted to patient care activities delegated to them by the RN based on the nursing process.12, 13 Types of interventions This review will consider studies that evaluate the effectiveness of delegation interventions by the RN to the UAP and their impact on quality of care, patient satisfaction, and RN staff satisfaction. For the purposes of this systematic review we will use the following definition: RN-UAP delegation: “Entrusting the performance of a selected nursing task to an individual who is qualified, competent, and able to perform such tasks. The nurse retains the accountability for the total nursing care of the individual”.45(p1) Comparator: The comparator is to that of usual nursing cares delivery. Types of outcomes The outcomes to be examined are quality of care, patient satisfaction, and RN staff satisfaction measured by validated and reliable tools. Validated and reliable measurement tools are considered measurement tools that have been previously tested and found to have acceptable psychometric properties. For the purposes of this systematic review we will use the following definitions: Quality of care (as defined by the IOM, the National Quality Forum, and the Agency for Health Research and Quality): The ability for desired health outcome to be achieved consistent with the current professional knowledge.41,42 Examples of quality of care measurement include a decrease in the incidence of missed care, a decrease in the incidence of medication errors, a decrease in falls, and a decrease in call bell response time. Patient satisfaction: The patients' perception that their nursing care needs were met or exceeded.31 The expected outcomes can be technical, interpersonal, environmental, or financial in nature. RN Staff satisfaction (as defined by the American Nurses Association): Job satisfaction expressed by nurses as determined by a scaled response to a series of questions to identify the nursing staff's attitudes towards their employment situations and environment in a hospital setting.44 Tasks, autonomy, RN-RN interactions, professional status, Nurse-Physician interactions, pay, and nursing management are a few examples of categories surveyed to determine staff satisfaction. Types of studies The review will consider randomised controlled trials (RCTs); in the absence of RCTs other research designs, such as non-randomised controlled trials, quasi-experimental studies, observational studies, descriptive and case studies will be considered for inclusion to enable the identification of current best evidence regarding delegation between the RN and the UAP and its effect on quality of care, patient satisfaction, and staff satisfaction. Search strategy The search strategy aims to find both published and unpublished research studies available in the English language. The timeframe for database searches will be from the inception of included databases through to the current date of the review. A three-step search strategy will be utilised in each component of the review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. A full report will be retrieved for all studies that meet the inclusion criteria. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies identified from reference list searches will be assessed for relevance based on the study title. Journals specific to the topic of delegation by RNs will be hand-searched in order to have as complete an initial listing of eligible studies for review as possible. Journals to be hand searched include: Journal of Nursing Management, Journal of Nursing Administration, and Nursing Administration Quarterly. The databases to be searched include the Cochrane Library, MEDLINE, CINAHL, PsycINFO, and Healthsource: Nursing/Academic edition. The search for unpublished studies will include: Scirus, New York Academy of Medicine, Google Scholar, The Virginia Henderson International Nursing Library, reference lists from selected articles, and communication with leading authors in the field. An initial list of keywords to be used includes, but is not limited to: delegation interventions, unlicensed assistive personnel, nursing assistant, certified nursing assistant, patient care associate, patient care technician, registered nurse, professional nurse, medical surgical unit, community hospitals, inpatient units, quality of care, patient satisfaction, and RN staff satisfaction. Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods, and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative papers will, where possible, be pooled in statistical meta-analysis using the JBI-MAStARI method of data synthesis. All results will be subject to double data entry. Relative risk (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form. Conflicts of interest None. Acknowledgements This review will partially fulfill requirements for successful completion of a doctoral program for Una Hopkins, Any Sajan Itty, Helen Nazario, and Miriam Pinon. The authors are thankful to Cheryl Holly, PhD and Patrick Mattis, PhD for their collaboration and editorial comments during this protocol development.
Background Asymptomatically colonised MRSA carriers serve as a substantial reservoir for person‐to‐person transmission of MRSA in the acute care setting. Although many studies have evaluated prognostic risk factors for MRSA colonisation on patient admission to an acute care setting, a comprehensive review of all the prognostic risk factors was not identified in a preliminary search of the literature. Objectives A systematic review was performed to identify and evaluate the association between risk factors and MRSA colonisation. Inclusion criteria Types of participants Studies that included all adult patients on admission in acute care settings were considered in this review. Types of intervention(s)/phenomena of interest All independent risk factors of MRSA colonisation were analysed in this review. Types of studies Cohort and case‐control studies are main designs associated identifying the independent risk factors for MRSA colonisation. Types of outcomes The primary outcome of interest was presence and absence of MRSA on admission, and then independent risk factors associated with MRSA colonisation on admission were identified. Search strategy MEDLINE, EMABSE, and CINAHL databases were searched for prognostic studies published between 1990 and 2010 that examined the association between risk factors and MRSA colonisation. The search included both published and unpublished studies written in the English language. Methodological quality Included studies were assessed using a standardised critical appraisal instrument that was developed for prognostic studies in infection control field. Data collection Data were collected from included papers in the review using the standardised data extraction tool from the JBI SUMARI Program; and the data extraction form was modified based on the characteristics of prognostic studies for infection control. Data synthesis All risk factors in included studies were aggregated depending on their clinical characteristics. Data of any aggregated factors was pooled into meta‐analysis based on univariate estimates and multivariate estimates separately when more than two groups of data in selected studies were available. Results Fifteen prospective studies, including a total 16,467 patients, were eligible for inclusion in the meta‐analyses. More than 30 independent risk factors were identified and aggregated. The risk factors associated with MRSA colonisation in the meta‐analyses include hospitalisation within the last 24 months, previous admission to a long‐term care facility (LTCF) or a rehabilitation facility within the last 18 months, antibiotic use within the past 12 months, the presence of skin lesion, surgical intervention within the last 60 months, indwelling urinary catheter, intensive care unit (ICU) admission in the last 5 years, previous MRSA colonisation, intra‐hospital transfer, male sex, comorbidity of chronic health evaluation class C or D, and the presence of fatal illness. Conclusions The identification of risk factors for MRSA colonisation on admission may contribute to improved effectiveness and efficiency of current MRSA prevention strategies and control MRSA spread and acquisition in acute care settings. The outcomes of this review may facilitate prediction model development to quickly identify potential MRSA carriers before admission.
Review objective The objective of this systematic review is to synthesise the best available evidence informing the effects of prosthetic socket design on outcomes of function, mobility, comfort and pain, energy expenditure, prosthetic and health related quality of life of adults with a trans-tibial amputation. Specifically, the review will consider studies evaluating the effects comparing the contemporary total surface bearing (TSB) socket design with the more traditional specific surface bearing (SSB) socket design. Background Mobility and function are often seen as primary indicators to successful rehabilitation for persons with a lower limb amputation1. Goal's of the medical rehabilitation team, including the prosthetist who is responsible for the design, manufacture and fitting of the limb prosthesis; are to provide care, education, equipment, resources and physical training to enable amputees the opportunity to reach a level of functional independence. The prosthesis, as an external attachment to the residuum (amputated stump), is a piece of equipment requiring custom manufacture to assist ambulatory mobility. Ambulatory mobility in the community setting can provide the amputee with a degree of regained independence2. Whether standing to prepare a meal, attending to self-care, returning to work or participating in high-level activities, mobility is a significant measure of ambulatory rehabilitation. Goals of rehabilitation and progressive community participation are established in collaboration with the amputee and the multi-disciplinary rehabilitation team, with prosthetic prescription largely determined by the prosthetist and the amputee. The trans-tibial (or below-knee) prosthesis consists of a ‘socket’ and ‘componentry’. The prosthetic socket is the surrounding encasement of the residuum, and the ‘componentry’ is the connecting hardware including foot/ankle module. Prescription indicators for componentry selection take into consideration patient ambulation potential or actual mobility, patient body weight, activities of daily living and greater activities of participation and recreation3. Typical prescription for the prosthetic socket is often more subjective and varies between countries, rehabilitation centres and individual clinicians. Clinical knowledge of the residuum with its physical tolerances, and the patients' ability to don and doff the prosthesis are factors considered during socket prescription. However lack of knowledge or inexperience with different socket techniques may be a barrier to introducing contemporary designs, as may cost of interface and equipment required for manufacture, time allowed for service provision or an amputee's accessibility to prosthetic service providers. The measure of effect of different socket designs could be confounded by factors including suspension method, interface liner used, and clinician experience. The socket is a critical aspect of the prosthesis, specifically enabling weight bearing through the residuum. The socket design, providing fit and resultant function, is the key factor influencing prosthetic use by amputees regardless of componentry used. The TSB and SSB socket designs have been chosen for this review as they represent the typical prescription seen in clinical practice. Objective outcome measures are increasingly used to justify clinical prescription through assessing mobility, function and quality of life of person's with an amputation using a prosthesis.4, 5, 6 Whilst there is a reasonable amount of literature evaluating effect of prosthetic componentry choice on functional outcomes for amputees7 there is a need for a review of the evidence relating to prosthetic socket design and the possible influence of socket design on health outcomes. This systematic review seeks to identify if there is a differing effect on health domains for people with amputation comparing two trans-tibial socket designs, the SSB with the TSB design, both of which are currently used throughout the world in prosthetic provision. The SSB socket design Following World War 2 the need for prosthetic provision across Europe increased markedly and provided the stimulus for the design of the SSB trans-tibial socket, commonly known as patellar tendon bearing (PTB). Described in the 1950's by Radcliff8, the PTB socket allowed persons with trans-tibial amputation to tolerate weight-bearing through the residuum. With pressure concentrated on the tolerant patellar tendon, the posterior musculature of the gastrocnemius/soleus and medio-anteriorly on tibial flare; coupled with relief over bony prominences within the residuum8, suspension of the prosthesis was achieved mostly via supracondylar cuff. The Patella Tendon Supracondular socket (PTS or PTB-SC), Patellar Tendon Kegel (PTK), Kondylen-Bein-Muenster (KBM) socket designs each follow a similar principle to the PTB with extra functional effect derived from extended proximal socket trimlines forming supracondylar self-suspension, increased medio-lateral stability of the knee joint, and improved cosmesis.9 This SSB socket design was an improvement on its predecessor the ‘conventional’ prosthesis consisting of proximal leather thigh corset, which allowed for minimal weight to be borne through the residuum, was heavy, cumbersome and restricted knee joint range of motion. For the purposes of this review the SSB socket design will include descriptors PTB, PTS, PTB-SC, PTK or KBM socket designs. The SSB is usually manufactured with a foam interface liner fitting however may have a silicone or gel based liner within the rigid socket. The SSB is identified by the specific areas of pressure relayed to the residuum during casting, rectification and manufacture; and this design remains in popular use throughout the world today. Beneath the foam liner the amputee wears cotton or woollen sock/s directly onto the residuum, to assist with accommodating volume fluctuation and wicking away sweat to optimise socket fit and comfort. Advantages of the SSB include relative low cost to manufacture,10, 11 readily available materials for use, and greater adjustability within socket foam interface to ensure fit for the changing residuum.9 The TSB socket design In the early 1980's Ossur Kristinsson, a trans-tibial amputee and prosthetist, developed the Icelandic roll-on silicone socket (ICEROSS) liner, widely used in Iceland from 1986.12 Made from silicone and cylindrical in shape, the liner is inverted and rolls onto the residuum providing upward compression forces.12 The resultant intimate fit and the nature of silicone serves to provide a stabilising interface liner that offers skin and tissue protection from the prosthetic socket and external forces that are transferred upward through the residuum.13 The original ICEROSS liner incorporates an attachment in the external distal end, which a corrugated pin is secured to. The pin engages into a lock component fabricated into the distal end of the prosthetic socket, thus providing a secure connection between the silicone interface liner and the prosthetic socket, becoming the suspension mechanism. By the 1990's ICEROSS liners were introduced to the worldwide prosthetic community dissolving the need for supracondylar suspension for trans-tibial amputees. Advantages of using ICEROSS liners include a superior suspension system, stabilisation of soft tissue, minimal pistoning (stretching), helping to improve circulation and increase in comfort.13 To complement the ICEROSS system Ossur Kristinsson in 1993 described the TSB socket concept; where within the TSB socket weight was borne by the entire surface of the residuum and the socket design was used in collaboration with the silicone liner system.12 The TSB socket design was also described by Staats, advocating the hydrostatic principle achieved by suction suspension with or without silicone interface use.14 Essentially the TSB design relied on the hydrostatic principle of containing the entire mass of the residuum in an equal volume of socket with minimal movement/pistoning to keep the residuum in contact with the socket at all times during the gait cycle.12, 14 The TSB design concept has spread to clinical practice and has been reported to have had varied results depending on residuum suitability, clinician knowledge, skill in fabrication, and suspension systems used in conjunction with the TSB design.10, 13 Although at times described as a hydrostatic design, as the TSB socket commonly used in practice follows the hydrostatic principle of load transfer; in reality the socket uses a hybrid style of limited area loading combined with hydrostatic load transfer to cater for the changing mechanics of the human residuum throughout the gait cycle. TSB socket design will be defined to include designs reported as TSB, hydrostatic, and limited area loading. All of these TSB socket descriptions utilise a silicon or gel interface liner achieving suspension through distal pin, lanyard or velcro attachment; or a sealed system secured by expulsion valve, elevated vacuum, or membrane incorporated within the interface liner with or without the use of a knee sleeve. The TSB design can be differentiated from the SSB design as it lacks a foam interface liner, has no suspension via supracondylar means of cuff or straps, and has no specific increased pressure loading areas onto the residuum. Adults may present as trans-tibial amputees for a variety of reasons. Vascular disease, trauma, cancer, infection and congenital reasons are the leading causes for amputation of the lower-limb15. Different countries and regions have varied numbers of amputees within each causal category.15 The trans-tibial prosthesis is the most commonly prescribed as the majority of lower-limb amputees have this level of amputation irrespective of aetiology. Although data is unavailable comparing prescription of TSB versus SSB transtibial prosthetic designs in Australia or elsewhere; this review aims to include as many studies comparing the two socket designs, regardless of reason for amputation, in order to represent the complement of amputees treated in most prosthetic clinics worldwide. This review seeks to retrieve studies using SSB and TSB socket designs where outcome measures were utilised, to quantify and indicate the effect on health domains for transtibial amputees. The use of domains relating to health can be somewhat complex depending on your area of interest and interpretation. For this review our terminology and understanding stems from World Health Organisation (WHO)'s International Classification of Disability and Health, known as ICF whereby health domains and health-related domains are areas of interest for measuring the effect of health both negative and positive on any set disease, diagnosis or disability group. The WHO domains relate to two categories 1) body functions and structures, and 2) activities and participation.16 The outcome measures in included studies are anticipated to be typical measures used in hospital, rehabilitation and community settings. Generic and amputee specific measures are expected, as these are reflective of measures used in every-day clinical practice. Essentially domains are ‘what’ we want to measure, as determined by patients and their medical teams as being relevant; and the outcome measures used relate to ‘how’ we are going to measure it. In a preliminary search of PubMED, Scopus, and CINAHL one systematic review by Van der Linde et al7 was identified as having a reference to, though not a focus on, transtibial socket design. Studies retrieved for the review were published from 1996 - 2001. Only one study in the review focused on the effect of socket design, and that study compared two suspension methods within the TSB socket design. No systematic reviews were identified comparing the effects of different trans-tibial socket designs. Irrespective of the reasons for prescription choice, there is a need for a greater understanding of the effect using different socket designs in terms of patient rehabilitation, mobility, function and quality of life; so that the importance of socket design prescription is thoroughly considered during the prescription process. The aim of this systematic review of published and grey literature comparing SSB and TSB designs is to assist the prosthetic community with decisions and recommendations for prosthetic prescription through identification of evidence based indicators for socket design use, rather than relying on anecdotal, subjective preference or experimental reasons for prescription. Inclusion criteria Types of participants This review will consider adult trans-tibial amputees 18 years or older, with acquired or congenital limb loss irrespective of the aetiology, gender or the presence of co-morbidities using prostheses with either the contemporary total surface bearing (TSB) socket design or the traditional specific surface bearing (SSB) socket design. Each of the studies considered for inclusion will have documented study populations utilising both TSB and SSB socket designs within the study. Types of interventions The intervention of interest is the use of TSB socket. This is the ‘hydro static’ design or ‘limited load bearing’ often using silicon or gel liner interface, with suspension achieved via distal attachment of pin and lock or lanyard, expulsion valve and sleeve, vacuum assisted, integrated membrane seal or a combination of these. The comparative intervention will be the use of a SSB socket. This is often referred to as PTB, PTS, PTB-SC, PTK or KBM, typically utilising soft foam liner interface paired with supracondylar suspension. Types of outcomes This review will consider studies that include but will not be limited to the following outcomes: • Function and Mobility measured for example using Amputee Activity Score (AAS) or Locomotor Capabilities Index (LCI-5) or Timed Walk Tests (TWTs) or Step Activity Monitor (SAM); • Comfort and Pain measured for example using Socket Comfort Score (SCS) or Brief Pain Inventory (BPI); • Quality of Life including: Prosthetic Related Quality of Life (PRQoL) measured for example using Prosthetic Evaluation Questionnaire (PEQ) and Health Related Quality of Life (HRQoL) measured for example using Trinity Amputation & Prosthesis Experience Scales (TAPES) or Short Form 36 (SF-36); • Energy Expenditure measured for example using Physiological Cost Index (PCI). Types of studies This review will consider both experimental and observational study designs including randomised controlled trials, non-randomised controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. It will also consider descriptive studies including case series and individual case reports for inclusion as long as participants have utilised both TSB and SSB designs within the study. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised. An initial limited search of PubMED, Scopus and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe each article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Only studies published in English language will be considered for inclusion in this review. Studies published from inception of databases until present day (June 2012) are to be considered. The databases to be searched include: PubMED CINAHL Plus Scopus Embase PEDro The search for unpublished studies will include: MedNar, Cochrane central register of controlled trials (CENTRAL), ProQuest Dissertations and Theses, National Library of Australia's Trove service, Electronic Thesis Online Service (EThOS), Australian New Zealand Clinical Trial Registry (ANZCTR), EU Clinical trials Registry (EU-CTR), Clinical Trials.gov - USA trial registry, The professional bodies of International Society of Prosthetics and Orthotics, the Australian Orthotic and Prosthetic Association (AOPA), and the American Academy of Orthotics and Prosthetics (AAOP) in partnership with oandp.com have resources such as websites, gazettes, conference and congress proceedings; and Conference Proceedings Citation Indexes (Web of Science) will also be explored for unpublished studies. Initial keywords to be used will be: ‘TSB’, ‘SSB’, ‘PTB’, ‘total surface bearing’, ‘specific surface bearing’, ‘patella tendon bearing’, ‘prosthetic’, ‘functional outcomes’, ‘socket design’, ‘amputee’, ‘trans-tibial’ ‘outcome measures’, ‘domains’, ‘lower-limb’. Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix III). The data extracted will include details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Studies selected for appraisal that also report on cost-effectiveness will have such data extracted for commentary only without analysis, as cost-effectiveness is not part of the scope of this systematic review. Data synthesis Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in the review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest Nil. Acknowledgements This review forms part of the primary reviewer's submission for Masters of Clinical Sciences program, and as such a second reviewer is required only for assistance with critical appraisal. Edward Ko Ko Aung is acknowledged for his support to act as second reviewer for this systematic review.
