BACKGROUND: Patients visit the emergency department (ED) for life-threatening conditions, such as broken bones or chest pain, and non-life threatening conditions such as medication refills and pain management. Patients may make ED visits for non-life threatening conditions because they lack access to primary care. Research has shown that patients who are low-income, have chronic conditions, such as pain, and have depression are among those most likely to use the ED at a high rate. One of the most common reasons for visiting the ED is for pain relief, and therefore an intervention on patient self-management might prevent ED visits. The Program for Integrative Medicine and Health Care Disparities at Boston Medical Center (BMC) developed the Integrative Medicine Group Visit (IMGV) model to address chronic pain and depression among low-income patients, with the goal to improve patient’s adherence to self-management of pain and depression. The IMGV model consists of three non-pharmacologic components: evidence-based complementary medicine, mindfulness-based stress reduction, and group medical visits – all of which have been used to manage pain and depression. In a pre-post study of IMGV conducted in 2014, IMGV was associated with a significant decrease in ED utilization. Currently, the Program is conducting a randomized clinical trial (RCT) to compare a number of outcomes between the IMGV model and standard of care. The aim of this study was to determine if IMGV affects ED utilization in adult patients diagnosed with chronic pain and depression from an urban safety-net hospital population. METHODS: We conducted a secondary database analysis of participants enrolled in the IMGV RCT. The RCT is a two-armed study, and the medical chart review is part of the RCT. The study had patients who sought primary care at BMC and two affiliated outpatient urban community clinics. Only emergency visits made at BMC’s Emergency Department were included in our analysis. The inclusion criteria included reporting a pain level score > 4 on a 0-10 scale and having a score > 5 on the Patient Health Questionnaire-9. The intervention consisted of 10 IMGV sessions over 21 weeks. The control was standard treatment of care. Data extraction was completed in two ways: (1) the BMC Clinical Data Warehouse was extracted from Epic and (2) hand review took place by research assistant. The primary outcomes included ED encounters at two different time points: (1) 90 days before Session 1 and (2) Session 1 to Session 9. The extracted information also included information about patients’ chief complaints and discharge diagnoses. A visit was categorized as being a preventable emergency visit (PEV) or a non-preventable emergency visit (NEPV). Descriptive statistics and two-sample T-tests were used to analyze outcomes. RESULTS: At baseline, 22 of the 31 participants made at least one ED visit in the 90 days before Session 1. At 9-weeks, 14 of the 26 participants made at least ED visit. From baseline to 9-weeks, the number of participants who had at least one ED visit decreased for the intervention group (13 to 4), but increased for the control group (9 to 10). From baseline to 9-weeks, the number of visits decreased among intervention participants (16 to 5) but increased among control participants (11 to 12). The two-sample T-test, which compared the ED utilization among the intervention and control, resulted in the mean values of -0.7333 and 0.0625, respectively. This result indicated that intervention participants had overall lower ED visit use from baseline to 9-weeks. Emergency visits were also analyzed by whether they were PEV or NPEV. Of the 27 ED visits at baseline, 21 were classified as being a PEV, and 6 were classified as being a NPEV. Of the 17 ED visits at 9-weeks, the number of visits decreased for both PEVs (21 to 13) and NPEV (6 to 4). CONCLUSION: We wanted to determine if the IMGV reduces ED utilization in patients with chronic pain and depression. Our results suggest that the IMGV model may be associated with reduced overall ED utilization and reduced preventable ED visits. However, one limitation is that we have a very small sample size. This finding needs to be produced in an adequately powered clinical trial. Further research might explore the mechanisms for how the IMGV model can lead to lower ED utilization among patients with chronic pain and depression.

The improvement in cancer remission rates in children and adolescents due to advances in cancer treatment and therapy has led to the development of guidelines that address long-term follow up for survivors of childhood cancers. Adolescents often experience negative emotions related to the fear of uncertainty about long-term survival after cancer remission, yet often report feelings of hope and optimism for the future more than adult cancer survivors. The purpose of this study was to understand the role of self-efficacy and coping in adolescents after remission of cancer. A secondary purpose was to analyze which coping strategies supported long-term survival goals after cancer remission in adolescent populations. A systematic literature review was conducted from the following online databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature On-line (MEDLINE), Education Resources Information Center (ERIC), and PsycInfo. Selected articles included those published between 2000-2016 that were written in English and were peer-reviewed. The results of the study revealed that most adolescents with cancer remission do not experience long term psychosocial issues related to their cancer diagnosis and treatment. However, a large percentage of adolescent cancer survivors report intermittent depression, suicidal ideation and a lower quality of life due to survival after remission. The literature indicates that multiple, integrative forms of behavioral therapy: cognitive, psychosocial, and family based treatment models, help to enhance long term quality of life in adolescent cancer survivors. Strategies that use positive coping methods and improve self-efficacy related to long term survival after remission have demonstrated improvement in psychosocial behaviors in adolescents and promote a better outlook on planning for the future. Future research that analyzes the most effective coping skills to practice after cancer remission and that optimize self-efficacy related to long term survival can positively influence quality of life for adolescent cancer survivors.

The purpose of this study was to conduct an integrated review of the literature examining the use of non-pharmacologic pain management strategies in premature neonates and to explore the relationship between health outcomes and time to discharge from the neonatal intensive care unit (NICU). Non-pharmacologic pain management strategies include human touch, facilitated tucking, non-nutritive sucking, and kangaroo care. A systematic review of the literature was conducted from multiple online databases. Peer reviewed, English-language articles containing the keywords ‘pain management’, ‘neonatal intensive care unit’, and ‘non-pharmacologic’ were included for synthesis. Exclusion criteria included articles with a focus on infants not admitted to the NICU and infants with a gestational age greater than 37 weeks. Results revealed positive outcomes when alternative pain-relieving methods, rather than drug therapy, were used in the NICU. A majority of articles suggest facilitated tucking is very successful in lowering a preterm infant’s pain. However, facilitated tucking alone was significantly less effective in relieving procedural pain compared to facilitated tucking in combination with oral sucrose administration. Kangaroo care and gentle human touch also proved to reduce physiologic and behavioral signs of pain in neonates. The literature reveled an overall positive outcome when non-pharmacologic pain interventions are used in the NICU, with some behavioral interventions showing better efficacy than others at relieving neonatal pain. None of the reviewed articles explored the relationship between reduced length of stay and parameters assessing health outcomes based on pain control in neonates. The literature indicated nurses play a significant role in the use of pain-relieving methods in neonatal populations. Implications for future research that focuses on successful behavioral based pain management strategies that assists in refining neonatal pain relief would be of great benefit to improving health outcomes related to infant survival after discharge from the NICU.

The purpose of this integrative review was to examine the effects of music therapy, a complementary intervention, on individuals with dementia. Peer-reviewed journals were retrieved from MEDLINE, CINAHL, CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Music Index to evaluate their relevance to music therapy use in people diagnosed with dementia. English and Spanish-language research articles published from 2000-2017 were included for the review (n=15). The literature indicates the use of music therapy as an adjuvant therapy for the treatment of dementia in older adults may be beneficial in decreasing symptoms of aggression, anxiety, agitation and depression. Music therapy is used in varying settings, but more specifically in long term care facilities. This complementary therapy enhances the quality of life in persons with dementia and facilitates empathetic relationships between residents and the staff.The literature indicates that music therapy, involving singing, listening to music, music and movement, when performed by a certified music therapist can have beneficial effects for people with dementia, especially when pharmacological treatments alone do manage symptoms associated with this disorder. Implications for nursing practice, education, policy and research are discussed along with study limitations.

Integrative Medicine (IM) is a care approach that focuses on the overall well-being and healing process of patients rather than solely on their disease. IM educates and empowers people to be active players in their own care, emphasizes the therapeutic relationship, and makes use of all appropriate evidence-based approaches. The health-oriented foundations of IM are in line with the recently posed concept that describes health as ”the ability to adapt and to self-manage”. Due to the shared underpinnings of both IM and the new concept of health, incorporation of this new concept of health may serve as a facilitator for the development and implementation of IM. From a practical viewpoint, working from an integrative care approach requires specific competences from healthcare providers, such as socio-communicative and self-reflective skills, and reflexivity towards a holistic perspective on health. Previous studies have shown that a Mind-Body Medicine (MBM) course can potentially foster these competences among future healthcare providers. This thesis intended to gain increased insight into the prerequisites and tools for implementation of IM. Therefore, in the first part it aimed to explore the attitudes and practice of IM among Dutch nurses and the support for the new dynamic concept of health as ”the ability to adapt and to self-manage” among main stakeholders within the Dutch healthcare community. Furthermore, in the second part it aimed to evaluate the possibilities of an MBM course among medical and nursing students as a tool to foster an integrative care approach. Methods Both quantitative and qualitative research designs were used. Attitudes and practice of IM were assessed in a semi-structured survey study among 355 Dutch nurses (study I). Support for the new concept of health was explored in a mixed method study, where in the first step data from interviews and focus-groups among 140 stakeholders were investigated by use of manifest content analysis, and in the second step a cross-sectional survey was performed among 1938 stakeholders to verify the findings of the first step (study II). The MBM course was evaluated by a controlled, quasi-experimental intervention study (74 participants / 61 controls among medical students and 47 participants / 64 controls among nursing students) in which validated questionnaires were used (study III). Furthermore, in-depth interviews with 11 medical and 15 nursing students were employed and analysed by a Phenomenological Hermeneutical method to obtain an in-depth understanding of the meaning of the MBM course for the participants (study IV). Findings Study I showed an overall positive attitude towards IM among nurses. Patient-centeredness and a focus on individuals’ own resources and responsibility to promote health met the most support among both nurses and other stakeholders. These elements were considered to be the main positive aspects of the new dynamic concept of health among stakeholders as well (study II). Use of evidence-based and safe complementary therapies and a healing environment received some support from the nurses, but lack of knowledge and lack of evidence seems to hinder further incorporation in the current healthcare practice (study I). Additionally, study II revealed that health was perceived to comprise six dimensions: bodily functions, mental functions &amp; perception, spiritual / existential dimension, quality of life, social and societal participation and daily functioning. In line with patients, nurses had a more broad conception of health in comparison to other healthcare professionals. Study III showed long-term beneficial effects of the MBM course on two dimensions of empathy (personal distress and empathic concern) among medical students, and on perceived stress and empathy (personal distress) among nursing students. Study IV brought forth that the MBM course can be understood as a pathway to inner awareness and a support to connecting with others as well as the outside world. The following themes were identified: “ability to be more present”, “an increased perception and awareness of self”, and “connecting on a deeper level with others”. Conclusion It can be concluded from the results in the first explorative part of this thesis that the observed positive attitudes and perceptions among healthcare professionals toward IM and the newly proposed health concept can serve as important facilitators for further implementation of IM within the Dutch healthcare system. Furthermore, the increased ability to deal with stress, improved empathic abilities and more openness toward different perspectives on health and new treatment options among medical and nursing students following a MBM course, as reported in the second part of this thesis, suggest that this course might be a suitable tool to foster an integrative care approach among future healthcare professionals. / IM (Integrativ Vård mer adekvat term på svenska) är ett vårdkoncept/vårdansats som mer fokuserar på patienters välmående och läkeprocesser än enbart deras sjukdom. IM överlämnar makten och utbildar individen till att själv bli aktiva i sin vård, den framhäver vikten av en god vårdande relation och använder alla tillämpliga evidensbaserade metoder. Den hälsofrämjande grunden i IM är i linje med ett nyligen utvecklat hälsobegrepp, som beskriver hälsa som ”en persons förmåga till att anpassa sig och hantera utmaningar”. Utifrån den liknande grunden och förutsättningarna hos IM och det nya hälsobegreppet så kan en integration av dem vara en understödjande faktor för utveckling och implementering av IM. Utifrån en praktisk synvinkel så innebär en integrativ vårdansats att den som vårdar måste inneha specifika kompetenser och förmågor relaterade till bland annat socio-kommunikativ och självreflektiv förmåga, såväl som en reflektiv öppenhet till ett holistiskt perspektiv på hälsa. Tidigare forskning har visat att en Mind-Body Medicine (MBM) kurs potentiellt kan understödja utveckling av dessa kompetenser bland framtida vårdare. Denna avhandling avsåg i första hand att uppnå ökad insikt i förutsättningar och verktyg för implementering av Integrativ Vård. Mer specifikt syftade den till att beskriva attityder till, och utövande av IM bland Nederländska sjuksköterskor, samt undersöka stödet för det nya dynamiska hälsobegreppet (”en persons förmåga till att anpassa sig och hantera utmaningar”) bland intressenter inom Nederländsk Hälso- och Sjukvård. Vidare i andra hand, avsåg avhandlingen också att utvärdera förutsättningarna för att använda en MBM kurs som ett verktyg till att understödja och fostra ett mer integrativt förhållningssätt bland läkar- och sjuksköterskestudenter. Metod Både kvantitativ såväl som kvalitativ forskningsdesign tillämpades. Attityder till, och utövande av IM undersöktes i en semistrukturerad enkätstudie bland 355 Nederländska sjuksköterskor (studie I). Stödet för det nya hälsobegreppet undersöktes i en studie som genomfördes med mixad design, där i det första steget data från individuella- och fokusgruppintervjuer bland 140 intressenter genomgick en manifest innehållsanalys, och i det andra steget genomfördes en tvärsnittsstudie bland 1938 intressenter för att validera fynden från det första steget (Studie II). MBM kursen utvärderades i en kontrollerad, kvasi-experimentell interventionsstudie (71 deltagare/61 kontroller bland läkarstudenter, och 47 deltagare/64 kontroller bland sjuksköterskestudenter) med validerade frågeformulär (Studie III). Vidare även i en Fenomenologisk-Hermeneutisk ansats via individuella intervjuer med 11 läkar- och 15 sjuksköterskestudenter för att uppnå en djupare förståelse över MBM kursens betydelse för deltagarna (Studie IV). Fynd I studie I framkom att sjuksköterskorna övergripande hade en positiv attityd till IM. Patientcentrering och fokus på individens resurser, samt deras egna ansvar för att arbeta hälsofrämjande var områden som hade mest stöd bland både sjuksköterskor och andra intressenter. Dessa element ansågs också av intressenterna vara den mest positiva aspekten av det nya dynamiska hälsobegreppet (Studie II). Användandet av evidensbaserade komplementärmedicinska metoder och hälsofrämjande miljöer stöddes till viss del av sjuksköterskorna men brist på kunskap och brist på evidens förefaller vara hinder för integration i nuvarande vårdpraxis (Study I). I studie II framkom att begreppet hälsa uppfattades som att bestå i sex olika dimensioner; ”kroppslig funktion”, ”mental funktion och perception”, ”spirituell/existentiell dimension”, ”livskvalitet”, ”social-samhällelig inklusion” samt ”daglig funktion”. I samklang med patienter, så hade sjuksköterskor en bredare syn på hälsa än andra hälsoprofessioner. I studie III framkom långsiktiga positiva effekter av att delta i MBM kursen avseende i två dimensioner av empatisk förmåga (Personal distress och Empatic concern) bland läkarstudenterna, samt avseende upplevd stressnivå (perceived stress) och empati (personal distress) bland sjuksköterskestudenterna. I studie IV framkom att MBM kursen kan ses som ”en väg till inre medvetenhet och stöd till att knyta an till andra och den omgivande världen” vidare identifierades temana: ”en förmåga till en mer medveten närvaro”, ”en ökad uppfattningsförmåga och inre medvetenhet” samt ”att knyta an till andra människor på en djupare nivå”. Slutsats Utifrån resultaten i avhandlingens explorativa (I, II) del är slutsatsen att de observerade positiva attityderna, och uppfattningarna bland vårdgivare avseende IM och det nyutvecklade hälsobegreppet kan ses som viktiga facilitatorer för ytterligare implementering av IM i det Nederländska hälso- och sjukvårdssystemet. Vidare, den ökade förmågan att hantera stress, utveckla empatisk förmåga och mer öppenhet för nya perspektiv på hälsa och behandlingsalternativ hos läkar- och sjuksköterskestudenter efter deltagande i en MBM kurs (implementeringsdelen i denna avhandling, III, IV), stöttar antagandet att kursen kan ses som ett användbart verktyg för att understödja en mer integrativ vårdansats bland framtida vårdpersonal. / <p>Vid tidpunkten för disputationen var följande delarbeten opublicerade: delarbete 3 i tryck, delarbete 4 inskickat.</p><p>At the time of the doctoral defence the following papers were unpublished: paper 3 in press, paper 4 submitted.</p>

Submitted by Eunice Novais (enovais@uepg.br) on 2017-09-13T17:21:23Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Juliano del Gobo.pdf: 1561259 bytes, checksum: 02e8d1aff033d933d126130c2027b7d7 (MD5) / Made available in DSpace on 2017-09-13T17:21:23Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Juliano del Gobo.pdf: 1561259 bytes, checksum: 02e8d1aff033d933d126130c2027b7d7 (MD5) Previous issue date: 2017-06-14 / A Organização Mundial da Saúde (OMS) utiliza o termo MAC ou, simplesmente, Medicina Tradicional (MT) para nomear um amplo universo de conhecimentos, atitudes e práticas, baseadas em teorias, crenças e experiências advindas de diferentes culturas, utilizadas para a manutenção da saúde, prevenção, diagnóstico, recuperação ou tratamento de doença física ou mental. As MAC/MT estão presentes na agenda internacional da OMS desde o final da década de 1970 e junto dela um conjunto variado de condições tem lhe possibilitado maior valorização e legitimidade no campo oficial da saúde. Este cenário tem estimulado a implantação de políticas nacionais de MAC/MT em todo o mundo. Em 2006, o Brasil seguiu essa tendência mundial e publicou a Política Nacional das Práticas Integrativas e Complementares (PNPIC), quando apresentou um conjunto de objetivos e diretrizes para implementação de práticas e sistemas terapêuticos associados às MAC/MT no Sistema Único de Saúde (SUS). A presente dissertação é resultado de estudo de natureza qualitativa e quantitativa, e analisou a inserção das MAC no SUS. Teve por objetivos descrever e refletir sobre o surgimento e o desenvolvimento da PNPIC, do ponto de vista das conferências nacionais de saúde (CNS) realizadas entre 1986 e 2015. De forma mais específica, objetivou sistematizar e analisar deliberações de conferências que versaram sobre o tema; e por fim, dimensionar relações e tensionamentos entre indivíduos e grupos diante da inserção de novas práticas no campo da saúde. O percurso metodológico foi organizado por meio da triangulação de técnicas e fontes, a partir das seguintes etapas: análise documental dos relatórios das conferências realizadas entre 1986 e 2011; participação e observação de atividades e discussões que trataram do tema das MAC/PICs na 15ª CNS (2015); a realização de entrevistas com sujeitos significativos participantes desta etapa nacional. Dos resultados de pesquisa: a análise documental destacou os cenários políticos de cada conferência e as propostas sobre as MAC/PICs aprovadas. Foram organizadas tabelas de dados sobre a quantidade de propostas e sobre a terminologias utilizada para se referir às MAC/PICs em cada etapa. Concluiu-se que o surgimento e desenvolvimento da PNPIC ocorreu em meio a duas tendências: a primeira, mais progressista e voltada para a construção de um novo modelo de atenção à saúde, organizado de forma multiprofissional, pautado na promoção e manutenção da saúde e no combate à medicalização da vida; a segunda tendência identificada é mais conservadora, inserida na lógica da organização do modelo assistencial vigente e submetida à hierarquia biomédica. A pesquisa de campo identificou um movimento organizado para dar visibilidade e fortalecer as PICs na 15ªCNS; da mesma forma identificou resistências ao seu desenvolvimento em três planos: no plano corporativo, no plano científico e no plano econômico. O conteúdo das entrevistas confirmou os dados empíricos e de forma complementar revelou a dinâmica do que se chamou de ‘espaço interno das PICs’, onde ocorrem relações de articulação e disputa entre os agentes que militam no campo. / The World Health Organization (WHO) uses the term CAM or simply Traditional Medicine to name a wide range of knowledge, attitudes and practices, based on theories, beliefs and experiences Health, prevention, diagnosis, recovery or treatment of physical or mental illness.CAM/MT have been on the international agenda of the WHO since the late 1970s, and with it a varied set of conditions has enabled it to gain greater value and legitimacy in the official health field. This scenario has stimulated the implementation of national CAM/MT policies around the world. In 2006, Brazil followed this worldwide trend and published the National Policy on Integrative and Complementary Practices (PNPIC), when it presented a set of objectives and guidelines for the implementation of therapeutic practices and systems associated with CAM/MT in the Unified Health System. The present dissertation is the result of a qualitative and quantitative study, and analyzed the insertion of CAM into SUS. Its objectives were to describe and reflect on the emergence and development of the PNPIC from the point of view of the National Health Conferences held between 1986 and 2015. More specifically, it aimed to systematize and analyze deliberations of conferences that dealt with the theme ; And finally, to dimension relationships and tensions between individuals and groups in view of the insertion of new practices in the field of health. The methodological course was organized through the triangulation of techniques and sources, from the following stages: documentary analysis of the reports of the conferences held between 1986 and 2011; Participation and observation of activities and discussions that dealt with CAM/PICs in the 15th CNS; The conduct of interviews with significant subjects participating in this national stage. Of the research results: the documentary analysis highlighted the political scenarios of each conference and the proposals on the approved CAM/PICs. Tables of data were organized on the number of proposals and on the terminology used to refer to the CAM/PICs at each stage. It was concluded that the emergence and development of the PNPIC occurred in two tendencies: the first, more progressive and focused on the construction of a new model of health care, organized in a multiprofessional way, based on the promotion and maintenance of health and Combating the medicalization of life; The second trend identified is more conservative, inserted in the logic of the organization of the current care model and submitted to the biomedical hierarchy. The field research identified an organized movement to give visibility and strengthen the PICs in the 15ªNS; In the same way identified resistance to its development in three planes: in the corporate plane, in the scientific plane and in the economic plane. The content of the interviews confirmed the empirical data and, in a complementary way, revealed the dynamics of what was called the 'internal space of PICs', where articulation and dispute relations occur among the agents who work in the field.

Weight loss among HIV-infected African American women (AAW), results in the fall of the cluster of differentiation (CD4) cell count and an increase in the viral load. There are 48,126 HIV-infected AAW who reported weight loss within the first year. AAW who report more than 10% weight loss within the first year progress to AIDS due to a deficiency in micronutrients and poor linkage to care. The phenomenon that occurs with individuals living with HIV does not necessarily occur among individuals who have cancer, heart disease, or some other life-threatening illness, and this phenomenon indicates a direct threat to the individual's physical, mental, and social survival beyond the effects of chronic diseases. Using the health belief model in this study helped emphasize the physical change that occurs during weight loss among HIV-infected AAW. The research questions addressed if there was a direct correlation between the use of micronutrients and the decrease in weight, decrease in CD4 cell count, and the increase in viral load. The results of the multilinear regression revealed there was direct correlation between the use of micronutrients and the increase/maintain in weight, an increase in CD4 cell count, and a decrease in the viral load, thus promoting the need for more research and funding. The need to educate HIV-infected AAW on the use of micronutrients was evident. Providing research to providers on changes in standard of care for HIV-infected AAW would allow for an increase in the social, economic, and personal impact on the way an individual approaches care and treatment to prevent the progress to AIDS.

Due to the demanding structure of caring for a child with a life-threatening disease (LTD), parents experience psychosocial distress. Studies have shown that stress in parents of children with LTDs can be increased by unmet needs or fragmented care and may be mitigated by coordinated and comprehensive care. Limited literature exists about unmet needs of parents of children with LTDs and the barriers they encounter to accessing mental health resources within pediatric palliative care (PPC) programs. This research study applied quantifiable descriptive methods including a purposive sample of ninety-eight (98) PPC and other pediatric practitioners through the distribution of anonymous online surveys in order to examine unmet needs for mental health resources as they relate to parents of children with LTDs who experience psychological distress exacerbated from psychosocial stressors of care giving. Influenced by Andersen’s predisposing, enabling, and need factors, this study found that PPC practitioners perceived parents encountering waitlists and/or denials when referred to community mental health resources as demonstrating resistance against seeking help.

The shift in health care and nursing philosophy and practice from a holistic approach to a highly technological, cure-oriented approach has been attributed to effective pharmaceuticals made to prolong life. Recently medical professionals have shifted their focus to a combination of spiritual healing and medicine. Hospice care in particular have taken a key interest in integrating spirituality within their health care. The problem is that due to the complications in defining spirituality and appropriate training and education of spirituality within nursing curriculum, assessing patients' spiritual distress may be difficult for many hospice nurses which may be at a loss when attempting to integrate spirituality within their practice. This study used a phenomenological approach to explore the infusion of spirituality in nursing practice and the hospice nurses perceptions of assessing spiritual distress needs of terminally ill patients. Frankl's existential theory and Kubler- Ross's stages of grief theory framed the study. Participants included 8 hospice nurses working in a Pacific Northwestern state. Face-to-face interviews were conducted to explore the essence of the experience of integrating spirituality as well as their views and concerns regarding assessment instruments used to assess spiritual distress. Data was analyzed for content themes. The study found that spiritual courses were merged into hospice nursing as a teaching unity making it difficult for hospice nurses in a Pacific Northwestern State to fully grasp the concept of spirituality. Further findings suggested that only a handful of schools had spiritual nursing as an independent course. The study may impact social change by informing the advancement of hospice nurses and hospice administrators in the practice of including spirituality within healthcare and integrating extensive existential support training within nurses' curriculum.

Background: Interest in alternatives to hormone therapy (HT) for menopausal symptoms increased following its association with serious health risks. In terms of phytotherapeutic interventions, while traditional use supports a range of herbs for treating menopausal symptoms, evidence from rigorous scientific trials is limited, and has largely focused on the phytoestrogenic plants. Because of some safety concerns over long-term use of isoflavones, the present study focused on two non-estrogenic herbs, Hypericum perforatum and Vitex agnus-castus, also employed in this context in the Anglo-American and European traditions. Both herbs have shown effectiveness for the alleviation of symptoms of premenstrual syndrome (PMS), which is reported to be more severe during the perimenopause, and may account for many of the so-called 'menopausal symptoms' at this time. Research on menopausal vasomotor symptoms is prone to substantial placebo responses. There has been much interest in increasing our understanding of the placebo response with a view to controlling it in clinical research and harnessing it in clinical practice. Methods & Results: A double-blind, randomised controlled trial (RCT), with a 16-week treatment phase, was conducted on 100 late-perimenopause and early postmenopause women. The herbal combination (Hypericum and Vitex) was not found to be superior to placebo for any of the endpoints - daily weighted flushing scores, overall menopausal symptoms (on the Greene Climacteric Scale) and depression (on the Hamilton Depression Inventory). However, significant improvements across the treatment phase were observed in both arms for all of these outcome measures. No significant change was found for either group on the Utian quality of life scale. The effects of the herbal combination were also examined on PMS-like symptoms in the small sub-population of late-perimenopausal women, and found to be superior to placebo for total PMS-like symptoms and the sub-clusters, PMS-D (depression) and PMS-C (cravings). The active treatment group also showed significant improvements on PMS-A (anxiety) and PMS-H (hydration), although these effects were not superior to placebo. Predictors of the placebo response were investigated and found to include study-entry anxiety for the outcome measures of flushing, depression and overall menopausal symptoms, and improvement during non-treatment run-in for depression and overall symptoms. Because no difference had been found between 'active' and placebo groups in the menopause RCT, it was hypothesised that the same predictors would predict the response to the study treatment. However, low anxiety was significantly associated with improvement in this group. None of the other variables that predicted the placebo response was relevant to the study treatment response. This finding is discussed with reference to the possibility that 'drug' effects and placebo effects are not necessarily additive, and that the same magnitude of effect in both arms might not necessarily imply activity via the same pathways. Conclusions: This research contributes to the growing body of scientific knowledge about evidence-based complementary therapies that informs the community, health-care providers and regulatory authorities. The findings may facilitate identification of potential placebo responders in future research. The need for more research in the area of mechanisms of placebo versus active responses is supported.