Thesis (M.S.)--Boston University

This study aimed to determine how CMs used by surgical patients are managed in the hospital system by doctors and pharmacists and what patient and practitioner influences affect this management. Research design and method Five systematic reviews were conducted to investigate the peer-reviewed literature for information about Australians use of CM; overseas and Australian doctors and CM; surgical patients use of CM and safety information about CMs in surgery as a basis to design and conduct three surveys. Surveys of hospital doctors, pharmacists and surgical patients were used to obtain measurement of people's attitudes, perceptions, behaviours and usage of CMs. For healthcare practitioners, knowledge of complementary medicines (CMs), past training, current practice and interest in future practice of complementary therapies (CTs) and education was also investigated. Approximately 50% of surgical patients reported taking CMs in the 2 weeks prior to surgery and approximately 50% of these patients intended to continue use in hospital. The most commonly used CMs were: fish oil supplements, multivitamins, vitamin C and glucosamine supplements as well as some CMs considered to potentially increase bleeding risk or induce drug interactions. It was not uncommon for CMs to be used at the same time as prescription medicines. Most surgical patients in general self-prescribe their CMs or have them recommended by family and friends whereas medical practitioners were the main prescribers to cardiac surgery patients. Nearly 60% of patients using CMs in the 2 weeks prior to admission did not tell hospital staff about use. The main reason for non-disclosure was not being asked about use whereas fear of a negative response was rarely a concern. The most common sources of information surgery patients refer to were GPs, pharmacists and health food stores. Hospital doctors and pharmacists did not routinely refer to information sources about CMs safety. The majority of doctors and pharmacists did not routinely ask patients about CMs, or record usage information. They had little training and knowledge of the evidence of commonly used CMs and lacked confidence in dealing with CMs-related issues. Their attitude to CMs is moderately negative and many are wary of safety, efficacy and cost-effectiveness issues. The majority of practitioners considered some CTs as potentially useful, particularly acupuncture, massage and meditation whereas the medicinal CTs and chiropractic were considered potentially harmful. Most practitioners were interested in future education about CMs and CTs and some would consider practising CTs. Personal usage of CTs was low although there was substantial interest in receiving future treatment. Despite many strategically orientated initiatives developed in Australia to promote evidence based medicine (EBM) and quality use of medicines (QUM), it appears that CMs have been largely ignored and overlooked in the practice of Medicine and Pharmacy within the hospital system. Furthermore, it appears that in regards to CMs a 'don't ask, don't tell, don't know' culture exists within hospitals and that evidence based patient-centred care and concordance is not being achieved and potentially patient safety and wellbeing is being compromised.

Introduction: Surgical patients need knowledge to participate in their own care and to engage in self-care behaviour in the perioperative period which is important for their recovery. Patient education facilitates such knowledge acquisition and several methods can be used to facilitate it, for example, face-to-face education and brochures or using information technology such as website or computer games. Healthcare professionals have been slow to seize the possibilities that information technology has to offer within the field, including the use of serious games. To optimise patient education, the information is needed on the patients’ needs and preferences and what they think about the idea of using a serious game to learn about self-care. Aim: The overall aims of this thesis were to describe the knowledge expectations of surgical patients, to describe how surgical patients want to learn, and to explore the potential use of serious games in patient education. Methods: This thesis includes four studies that used both quantitative and qualitative data to describe aspects of patient learning in relation to surgery. Study I has a prospective and comparative design with survey data collected before surgery and before hospital discharge from 290 patients with osteoarthritis undergoing knee arthroplasty. Data was collected on fulfilment of knowledge expectations and related factors. Study II is a cross-­‐sectional study in 104 patients with heart failure who had been scheduled for cardiac resynchronisation therapy (CRT) device implantation. Data was collected on knowledge expectations and related factors. In Study III the perceptions of 13 surgical patients towards novel and traditional methods to learn about post-operative pain management are explored in a qualitative interview study using content analysis. Study IV describes the development and evaluation of a serious game to learn about pain management with the participation of 20 persons recruited from the public. The game was developed by an interdisciplinary team following a structured approach. Data on the efficacy and usability of the game was collected in one session with questionnaires, observations and interviews. Results: Participants reported high knowledge expectations. Knowledge expectations were highest within the bio-physiological knowledge dimension on disease, treatment and complications and the functional dimension on how daily activities are affected, both of which include items on self-care. Most participants wanted to know about the possible complications related to the surgery procedure. In none of the knowledge dimensions the expectations of participants were fulfilled. Participants received most knowledge on the physical and functional issues and received least on the financial and social aspects of their illness. The main predictor of fulfilment of knowledge expectations was having access to knowledge in the hospital from doctors and nurses. Trust in the information source and own motivation to learn shaped how the participants thought about different learning methods. Although the participants were open to using novel learning methods such as websites or games they were also doubtful about their use and called for advice by healthcare professionals. To develop a serious game with the goal to learn about pain management, theories of self-care and adult learning, evidence on the educational needs of patients about pain management and principles of gamification were found useful. The game character is a surgical patient just discharged home from hospital who needs to attend to daily activities while simultaneously managing post-operative pain with different strategies. Participants who evaluated a first version of the serious game improved their knowledge and described usability of the game as high. They were positive towards this new learning method and found it suitable for learning about pain management after surgery in spite of some technical obstacles. Conclusions: Surgical patients have high knowledge expectations about all aspects of their upcoming surgery and although they prefer direct communication with healthcare professionals as a source for knowledge they might be open to try using more novel methods such as games. Preliminary short-­‐term results demonstrate that a serious game can help individuals to learn about pain management, and has the potential to improve knowledge. A careful introduction, recommendation, and support from healthcare professionals is needed for implementation of such a novel method in patient education. / Fræðsla gerir sjúklingum betur kleift að taka þátt í umönnun sinni sem er mikilvægt fyrir bata eftir skurðaðgerð. Sjúklingafræðslu má veita með ýmsum aðferðum, til dæmis munnlega, með bæklingum eða með því að nota upplýsingatækni á formi vefsíðna eða kennslutölvuleikja. Heilbrigðisstarfsfólk hefur verið lengi að tileinka sér möguleika upplýsingatækninnar í sjúklingafræðslu, þar með talið notkun kennslutölvuleikja. Þörf er á meiri þekkingu um fræðsluþarfir skurðsjúklinga en jafnframt um viðhorf sjúklinga til nýrra námsaðferða. Kennslutölvuleikir eru ein leið sem gæti gagnast sjúklingum en notagildi þeirra hefur lítið verið rannsakað. Meginmarkmið þessarar ritgerðar var að lýsa væntingum skurðsjúklinga til fræðslu, lýsa því hvernig þeir vilja læra og að kanna möguleika kennslutölvuleikja í sjúklingafræðslu. Ritgerðin samanstendur af fjórum rannsóknargreinum. Notuð vorumegindleg og eigindleg rannsóknargögn til að lýsa ýmsum hliðum náms einstaklinga sem fara í skurðaðgerð. Rannsókn I er framsýn samanburðarrannsókn sem gerð var á 290 sjúklingum með slitgigt sem gengust undir hnéliðskipti. Gögnum var safnað með spurningalistum fyrir skurðaðgerð og fyrir útskrift af sjúkrahúsi um uppfyllingu væntinga til fræðslu og tengda þætti. Rannsókn II er þversniðsrannsókn með þátttöku 104 sjúklinga með hjartabilun sem voru á leið í aðgerð til að fá ígræddan sérstakan hjartagangráð (e. cardiac resynchronisation therapy (CRT)). Gögnum var safnað með spurningalistum, fyrir ígræðsluna, um væntingar til fræðslu og tengda þætti. Rannsókn III er eigindleg rannsókn með þátttöku 13 sjúklinga sem nýlega höfðu farið í liðskiptaaðgerð eða hjartaskurðaðgerð. Gögnum var safnað með viðtölum þar sem sjúklingar lýstu viðhorfum sínum til nýrra og hefðbundinna aðferða til að læra um verkjameðferð eftir  skurðaðgerð. Gögnin voru greind með innihaldsgreiningu. Rannsókn IV lýsir þróun og mati á kennslutölvuleik til að læra um verkjameðferð eftir skurðaðgerð, með þátttöku 20 sjálfboðaliða. Leikurinn var þróaður af þverfaglegum hópi hjúkrunarfræðinga og tölvunarfræðinga. Gagnsemi og notagildi leiksins voru metin með spurningalistum, áhorfi og viðtölum. Þátttakendur höfðu miklar væntingar til fræðslu. Væntingar voru mestar á sviði lífeðlisfræði um atriði er sneru að sjúkdómi, meðferð og fylgikvillum og á sviði færni um áhrif veikinda á daglegar athafnir. Bæði sviðin fela í sér atriði um sjálfsumönnun. Flestir þátttakendur vildu fá fræðslu um mögulega fylgikvilla skurðaðgerðar. Væntingar voru ekki uppfylltar á neinu þekkingarsviði þó best á sviði lífeðlisfræði og færni en síst er vörðuðu fjárhag og félagslegan stuðning í tengslum við veikindi. Væntingar voru best uppfylltar meðal þeirra sem höfðu góðan aðgang að fræðslu á spítalanum frá hjúkrunarfræðingum og læknum. Viðhorf þátttakenda til mismunandi námsaðferða mótaðist af trausti á fræðslumiðli og eigin áhugahvöt. Þátttakendur voru opnir fyrir notkun nýjunga á borð við vefsíður og kennslutölvuleiki en jafnframt nokkuð tortryggnir og töldu mikilvægt að fá ráðleggingar og aðstoð heilbrigðisstarfsfólks við slíka notkun. Kenningar um sjálfsumönnun og nám fullorðinna, aðferðir leikjahönnunar og tiltæk þekking á fræðsluþörfum sjúklinga um verkjameðferð voru notaðar til grundvallar við hönnun kennslutölvuleiksins. Persóna leiksins er nýlega útskrifuð af sjúkrahúsi eftir skurðaðgerð og þarf að sinna daglegum athöfnum jafnframt því að meðhöndla verki sína. Þátttakendur rannsóknarinnar sem lögðu mat á kennsluleikinn bættu þekkingu sína og töldu nothæfni leiksins mikla. Þeir voru jákvæðir gagnvart þessari nýju námsaðferð og fannst hún henta vel til að læra um verkjameðferð eftir skurðaðgerð þrátt fyrir nokkra  tæknilega örðugleika. Sjúklingar hafa miklar væntingar til fræðslu fyrir skurðaðgerð. Þeir kjósa helst að leita þekkingar hjá heilbrigðisstarfsfólki en eru þó opnir fyrir að prófa nýjungar eins og kennslutölvuleiki. Fyrstu niðurstöður sýndu að kennslutölvuleikur getur hjálpað einstaklingum að læra um verkjameðferð. Við innleiðingu nýjunga innan sjúklingafræðslu er vönduð kynning, meðmæli og stuðningur af hálfu heilbrigðisstarfsfólks mikilvægur fyrir viðtökur sjúklinga. / <p>The online version is a corrected version of the printed thesis. Download the errata list in order to see thecorrections.</p>

Submitted by JÚLIO HEBER SILVA (julioheber@yahoo.com.br) on 2016-11-24T17:44:53Z No. of bitstreams: 2 Dissertação - Luciana Marya Gusmão Tartuce - 2016.pdf: 2825829 bytes, checksum: fe4eb785221991a505a52e87e318ad9a (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Jaqueline Silva (jtas29@gmail.com) on 2016-11-28T17:52:09Z (GMT) No. of bitstreams: 2 Dissertação - Luciana Marya Gusmão Tartuce - 2016.pdf: 2825829 bytes, checksum: fe4eb785221991a505a52e87e318ad9a (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2016-11-28T17:52:09Z (GMT). No. of bitstreams: 2 Dissertação - Luciana Marya Gusmão Tartuce - 2016.pdf: 2825829 bytes, checksum: fe4eb785221991a505a52e87e318ad9a (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-10-27 / The changing profile of morbidity and mortality points to an increase in both life expectancy of human beings and the growing prevalence of chronic degenerative diseases, such as cancer. Regarding the impact that both diagnosis and treatment, especially, surgical one, have on patients, their families, and social environment, it is worth caring about the overall health (OH) and Quality of Life (QOL) as perceived by the individual. The main objective of this study was to assess health-related QOL among patients undergoing surgeries for gastrointestinal cancer who were treated in a surgery clinic of a school hospital. It is a descriptive exploratory quantitative study, carried out with 31 patients, mostly women, from the capital of Goiás, aged between 60 and 69 years old, catholic, married, retired, with elementary level of education, predominantly diagnosed with colorectal cancer, all of them treated at the Surgery Clinic of the HC/UFG. The instruments used were: Socio-demographic Questionnaire, QSG, WHOQOL-bref and EORTC QLQ-C30. The socio-demographic data and diagnosis were assessed regarding its frequency and average. The WHOQOL-bref, EORTC QLQ-C30 and QSG were assessed according to their manuals and guidelines. The data collected was organized in the SPSS 18.0 statistical program. The quality of life was considered to be regular in two moments (30 and 60 postoperative days), being the Physical domain the most affected. As for the overall health, the QSG showed some effect in the sleep disturbance factor in the 30-day assessment, and in the 60-day assessment all factors were considered normal. The correlation between the factors of OH and the EORTC QOL scores C-30 showed positive and significant impact in all dimensions: the better overall health, the better QOL. However, in the correlation of the OH and the QOL assessed through the WHOQOL-Bref, there was only significant and positive correlation between OH and the Physical Dimensions and the environment. It is concluded that assessing the QOL of sick people is a complex process due to the characteristics of subjectivity and multidimensionality involved, making it necessary the use of valid and reliable instruments. The surgical procedure has brought benefits to the participants of this study, however qualitative methodologies could be added to the understanding of the meanings as assigned by the sick people, with similar experiences of cancer treatment, to several factors of their QOL and their OH, throughout the follow-up. Thus, the evaluation of the perception of QOL and the OH can be inserted in clinical practice and regular care of sick people. / A mudança do perfil de morbi-mortalidade aponta aumento da expectativa de vida do ser humano e crescimento da prevalência das doenças crônico-degenerativas, tais como o câncer. Considerando o impacto que este diagnóstico e seu tratamento, principalmente o cirúrgico, exercem sobre o enfermo e seu meio social e familiar, há de se preocupar com a Saúde Geral (SG) e a Qualidade de Vida (QV) percebida pelo indivíduo. O objetivo geral do estudo foi avaliar a qualidade de vida relacionada à saúde de pacientes operados por câncer do aparelho gastrointestinal assistidos na clínica cirúrgica de um hospital universitário. Trata-se de um estudo descritivo, exploratório e quantitativo, realizado com 31 pacientes, em sua maioria mulheres, provenientes da capital de Goiás, com faixa etária entre 60 e 69 anos, casados, aposentados, católicos, nível de escolaridade fundamental, com diagnóstico predominante de câncer colorretal, atendidos na clínica cirúrgica do HC/UFG. Os instrumentos utilizados foram: Questionário Sociodemográfico, QSG, WHOQOL-bref e EORTC QLQ-C30. Os dados sociodemográficos e o diagnóstico foram computados em sua frequência e média. O WHOQOL-bref, o EORTC QLQ-C30 e QSG foram avaliados de acordo com seus manuais de recomendação. Os dados coletados foram sistematizados no programa estatístico SPSS, versão 18.0. A qualidade de vida foi considerada regular nos dois momentos avaliados (30 e 60 dias pós-cirúrgico), sendo o domínio Físico o mais afetado. Quanto à saúde geral, o QSG apontou comprometimento no fator distúrbio do sono na avaliação de 30 dias, sendo que na avaliação de 60 dias todos os fatores já estavam dentro da normalidade. A correlação entre os fatores de SG e escores de QV da EORTC C-30 mostrou haver impacto positivo e significativo em todas as dimensões: quanto melhor avaliada a saúde geral, melhor foi avaliada a QV. Contudo, na correlação da SG e a QV avaliada por meio do WHOQOL-Bref, apenas houve correlação significativa e positiva entre SG e as Dimensões Física e Meio Ambiente. Concluiu-se que avaliar a QV de enfermos é um processo complexo pelas características de subjetividade e multidimensionalidade envolvidas, fazendo-se necessário o uso de instrumentos válidos e confiáveis. O procedimento cirúrgico trouxe benefícios aos participantes deste estudo sendo que metodologias qualitativas poderiam ser acrescidas para a compreensão dos sentidos atribuídos pelos enfermos, com vivências similares de tratamento do câncer, aos diversos fatores de sua QV e de sua SG, ao longo do follow-up. A avaliação da percepção da QV e da SG pode ser inserida na prática clínica e nos cuidados regulares dos enfermos.

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CNPQ / The medication reconciliation process (RIM) have great impact in preventing adverse events and errors related to drugs and is a formal process of obtaining a complete and accurate listing of household medication that is compared to the hospital prescription list. The discrepancies found during this process can cause harm to patients. This becomes more serious when polymedicated patients, using three or more medications at home, undergo surgical procedure of urgency. OBJECTIVE. Evaluate occurrence of discrepancies in the pharmacotherapy of surgical patients at a hospital in the state of Sergipe. METHODOLOGY. This was an observational study of descriptive exploratory, cross-sectional study between August and November 2014, to assess the occurrence of discrepancies in the pharmacotherapy of patients admitted to the surgical hospital admission. Polymedicated patients were considered those who used three or more drugs. In the initial interview we consider as sources of information the patient himself, the companion, the domestic use of drugs led to hospitalization and consultation of the record. Discrepancies were classified as unintentional variation among the drugs used before admission and the prescribed medication list after surgery may be: failure of drugs, differences in dose, differences in the frequency / schedule of administration, duplicity therapy and interaction between medications. The data were tabulated and analyzed. RESULTS. No período do estudo 422 pacientes foram admitidos no internamento pós-cirúrgico. Desses, 80 (19%) atenderam ao critério de inclusão, composto por 43 (53,8%) mulheres e 37 (46,3%) homens, com média de idade 64,14 anos ± 17,0. O motivo de internação mais prevalente foi amputação de membro inferior ou superior 33 (41,3%); a média de medicamentos do domicílio foi 4,7 ± 1,9. Foi encontrado um total de 444 discrepâncias, com uma média por paciente de 5,5 ± 2,78, as mais prevalentes foram interação, que representou mais da metade de todas as discrepâncias identificadas, 53,4% (n=237) e a omissão que constituiu 25,7% (n=114). Foram realizadas 106 intervenções e apenas n=15 (14,2%) foram aceitas. CONCLUSION. Polymedicated patients undergoing surgery require special care since they are under the care of medical specialists focused on meeting the reason for his hospitalization. The study suggests that the discrepancies found may represent high risk for safety of these patients, a more effective process of identification of home therapy is necessary when the patient is subjected to hospitalization; some comorbidities are related to the large number of medications. Thus, actions to promote patient safety in hospital admission and reduce medication errors should be practiced. / O processo de reconciliação de medicamentos (RM) tem grande impacto na prevenção de eventos adversos e erros relacionados a medicamentos e consiste num processo formal de obtenção de uma lista completa e precisa dos medicamentos do domicílio que é comparada com a lista de prescrição hospitalar. As discrepâncias encontradas durante esse processo podem causar danos aos pacientes. Isso se torna mais grave quando pacientes polimedicados, em uso de três ou mais medicamentos no domicílio, são submetidos a procedimento cirúrgico de urgência. OBJETIVO. Avaliar ocorrência de discrepâncias na farmacoterapia de pacientes cirúrgicos em um hospital do Estado de Sergipe. METODOLOGIA. Foi realizado um estudo observacional do tipo exploratório descritivo, de delineamento transversal entre Agosto e Novembro de 2014, para avaliação da ocorrência de discrepâncias na farmacoterapia de pacientes admitidos no internamento cirúrgico do hospital. Foram considerados pacientes polimedicados, aqueles que faziam uso de três ou mais medicamentos. Na entrevista inicial consideramos como fontes de informação o próprio paciente, o acompanhante, os medicamentos de uso domiciliar levados a internação e a consulta ao prontuário. As discrepâncias foram classificadas como qualquer variação não intencional entre os medicamentos utilizados antes da admissão e a lista de medicamentos prescrita após a intervenção cirúrgica podendo ser: omissão de medicamentos, diferenças na dose, diferenças na frequência/horário de administração, duplicidade terapêutica e interação entre medicamentos. Os dados obtidos foram tabulados e analisados. RESULTADOS. No período do estudo 422 pacientes foram admitidos no internamento pós-cirúrgico. Desses, 80 (19%) atenderam ao critério de inclusão, composto por 43 (53,8%) mulheres e 37 (46,3%) homens, com média de idade 64,14 anos ± 17,0. O motivo de internação mais prevalente foi amputação de membro inferior ou superior 33 (41,3%); a média de medicamentos do domicílio foi 4,7 ± 1,9. Foi encontrado um total de 444 discrepâncias, com uma média por paciente de 5,5 ± 2,78, as mais prevalentes foram interação, que representou mais da metade de todas as discrepâncias identificadas, 53,4% (n=237) e a omissão que constituiu 25,7% (n=114). Foram realizadas 106 intervenções e apenas n=15 (14,2%) foram aceitas. CONCLUSÃO. Os pacientes polimedicados submetidos a cirurgia requerem cuidados especiais uma vez que estão sob cuidados de médicos especialistas focados no atendimento do motivo do seu internamento. O estudo sugere que as discrepâncias encontradas podem representar alto risco para segurança desses pacientes, sendo necessário um processo mais efetivo de identificação da terapia domiciliar quando o paciente é submetido a internação; algumas comorbidades estão relacionadas ao elevado número de medicamentos em uso. Assim, ações que promovam a segurança do paciente na admissão hospitalar e reduzam os erros de medicamentos devem ser praticadas.

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Abstrakt Bakgrund: Vårdmiljön på operations- och intensivvårdsavdelningen är avancerad och högteknologisk. Att vara patient och behöva vårdas på sjukhus innebär att komma till en främmande miljö med risk att förlora kontroll över sig själv och behöva överlämnas till andra. Förhållandet mellan patient, vårdpersonal, närstående, teknik, omgivning samt omvärld anses vara avgörande för hur patienten kommer att uppleva vårdmiljön.  Syfte: Att beskriva patienters upplevelser av vårdmiljön på operations- och intensivvårdsavdelning. Metod: Systematisk litteraturstudie med induktiv och kvalitativ ansats. Analysen utfördes genom att syntetisera och summera innehållet i 17 kvalitativa primärstudier.  Resultat: Resultatet består av 3 huvudteman och 8 underteman. Tema nr 1: Att vara patient i en främmande och teknisk vårdmiljö - patienternas förändrade upplevelser av sig själva, att befinna sig mellan fantasi och verklighet, att ha och inte kontroll över sin situation samt familjens betydelse för patienternas upplevelser. Tema nr 2: Patienternas upplevelser av rädsa - att vara rädd samt rädsla mot existensen. Tema nr 3: Personalens betydelse för patienternas upplevelser - att vara väl eller icke väl omhändertagen samt att behandlas som subjekt eller objekt.  Slutsats: Patienternas upplevelser av vårdmiljön på operations- och intensivvårdsavdelningen beskrevs som både positiva och negativa, betryggande och skrämmande men var framförallt individuella. Relationen med vårdpersonalen och att som patient känna sig väl omhändertagen samt att bli bemött och behandlad med respekt, där patientens integritet och individualitet låg till grund för vårdandet, var den viktigaste aspekten i patienternas möte med vården.

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