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PubMed1999

Sharing cross-reactive groups of MHC class I improves long-term graft survival.

BACKGROUND: Renal transplant loss from chronic rejection remains substantial. To increase our understanding of this syndrome, we identified risk factors predicting late graft loss, with a special emphasis on the impact of human lymphocyte antigen (HLA) matching. METHODS: We studied all 654 cadaveric kidney transplants performed in our center between 1983 and 1996 that had survived for more than six months. Eighty-two transplants, lost because of chronic rejection, were used as the outcome variable. The influence of HLA mismatches and shares on long-term graft survival was evaluated at the level of private antigens and cross-reactive groups (CREG) of multiple histocompatibility complex (MHC) class I. HLA and other recipient, donors and transplant parameters were studied using univariate and multivariate Cox regression analysis. RESULTS: The cohort had a mean number of 1.9 HLA mismatches. Because of the homozygosity of HLA antigens, HLA mismatches were not reciprocal to shares. CREG and HLA-A-B mismatches had a relative risk for graft loss of 1.19 (95% CI, 0.97 to 1.45) and 1.05 (0.84 to 1.32) per mismatch. In contrast, the relative risk per shared CREG and broad HLA-A-B antigen was 0.76 (0.63 to 0.92) and 0.79 (0.61 to 1.03). Multivariate analysis revealed that individuals sharing less than four CREGs had a relative risk of 2.13 (1.29 to 3.75) for late graft loss. Other independent predictors were a recipient age of less than 50 years, relative risk 1.95 (1.02 to 3.71); a donor age of more than 50 years, relative risk 1.68 (1.01 to 2.80); acute rejection (vascular vs. no rejection), relative risk 3.52 (1.72 to 7.18); proteinuria (dipstick > 1+ vs. negative), relative risk 2.86 (1.29 to 6.35); and a serum creatinine concentration of more than 150 micromol/liter at six months, relative risk 3.41 (1.96 to 5.94). CONCLUSION: We identified several coexisting recipient-, donor-, and transplant-related risk factors for graft loss from chronic rejection. In this well-matched group of renal transplants, HLA mismatches and shares had a nonreciprocal relationship. Sharing of HLA antigens, especially CREG of MHC class I, was associated with improved long-term survival.

Adult↗
PubMed2003

[Shared decision making: an approach to strengthening patient participation in rehabilitation].

In this paper, the concept of Shared Decision Making, i. e. the participation of the patient regarding the selection of therapeutic goals and treatment options, is presented. The degree of patient participation in medical decisions varies widely across different models of the physician-patient relationship. According to the paternalistic model, the physician knows best what is in the patient's interest; patient participation is limited. This model clearly does not take into account patients' autonomy and desire for information appropriately. In contrast, the informative model claims that values are well-known to the patient while the physician's role is restricted to providing him with the necessary information. However, the assumption of fixed values may be challenged. Patients expect their doctors to be not only technical experts but also caring persons. In the interpretive model, the physician's task is to help the patient to identify and express his values. In the deliberative model, both physician and patient engage in an open discussion about the values the patient could and should pursue. The physician is allowed to present his own preferences, and conflicting values are discussed explicitly. Thus, the patient is empowered to choose between alternative preferences. This model forms the basis of shared decision making, which involves at least two participants who engage in a process of both mutual information and interactive discussion. Patient participation should result in a greater sense of personal control, more satisfaction with treatment, better compliance and transfer into the daily routine of disease management and, consequently, better outcomes. Although it is largely unknown whether these outcomes are achieved, indirect evidence may be gained from systematic reviews showing that a favourable physician-patient communication (i. e. allowing patients to express their information needs and concerns and to receive both information and emotional support) produced better outcomes regarding both mental and physical health. There are several barriers to shared decision making. No information exists regarding the degree to which physicians are interested in shared decision making. While there is ample evidence that patients' needs for information are high, patients' wishes for participation seem to vary widely, though. Both physicians and patients require the ability to make shared decisions. Structural restraints include time and institutional inflexibility. To conclude, shared decision making is a promising approach to enhance patient participation in rehabilitative care.

Choice Behavior↗
PubMed1985

The impact of cost sharing on emergency department use.

We studied the effect of insurance coverage on the use of emergency department services, using data from a national trial of cost sharing in health insurance. A total of 3973 persons below the age of 62 years were randomly assigned to fee-for-service health insurance plans with coinsurance rates of 0, 25, 50, or 95 per cent, subject to an income-related upper limit on out-of-pocket expenses. Persons with no cost sharing had emergency department expenses that were 42 per cent higher than those for persons on the 95 per cent plan (P less than 0.01) and about 16 per cent higher than those for persons with smaller amounts of cost sharing. Without cost sharing, emergency department visits for less serious diagnoses (e.g., abrasions) increased three times as much as did visits for more serious diagnoses (e.g., lacerations). After control for insurance, persons in the lower third of the income distribution had emergency department expenses that were 64 per cent higher than those in the upper third (P less than 0.001) and received a greater proportion of their ambulatory care in the emergency department. We conclude that the absence of cost sharing results in significantly greater emergency department use than does insurance with cost sharing. A disproportionate amount of the increased use involves less serious conditions.

Ambulatory Care↗
PubMed1995

As good as anyone: antenatal shared care at an inner Sydney hospital.

An exploratory survey design was used to assess satisfaction with antenatal care over a two-month period of women giving birth in an inner Sydney teaching hospital. Patients received obstetric services from private obstetricians, midwives, the hospital outpatient clinic, or 'shared care' between general practitioners and the outpatient clinic or birth centre. Insurance status and demographic information were collected across all groups. Shared care patients gave reasons why they chose that model of antenatal service. Ten per cent of women in the sample received shared care. Shared care patients were equally as satisfied as those in other modes of care in all but one factor--promptness of service (in which private obstetricians received higher ratings). They also judged shared care to have the advantages of being convenient, personal, and culturally appropriate. Significantly more patients in the shared care group were born overseas and they were less likely to hold private insurance. This paper discusses the results of the current study in the context of the Australian literature, explores some issues surrounding satisfaction research, and suggests further research arising from this work.

Australia↗
PubMed2005

Two HLA-B14 subtypes (B*1402 and B*1403) differentially associated with ankylosing spondylitis differ substantially in peptide specificity but have limited peptide and T-cell epitope sharing with HLA-B27.

The peptide specificity of HLA-B*1403, an allotype associated with ankylosing spondylitis (Lopez-Larrea, C., Mijiyawa, M., Gonzalez, S., Fernandez-Morera, J. L., Blanco-Gelaz, M. A., Martinez-Borra, J., and Lopez-Vazquez, A. (2002) Arthritis Rheum. 46, 2968-2971) was compared with those of the non-associated B*1402 and the prototypic disease-associated B*2705 allotypes. Although differing by a single residue (L156R), B*1402 and B*1403 shared only 32-35% of their peptide repertoires. Subtype-related differences observed in multiple peptide positions, including P3 and P7, were largely explained by a direct effect of the L156R change on peptide specificity. The HLA-B14 subtypes shared only approximately 3% of their peptide repertoires with B*2705. This was due to distinct residue usage at most positions, as revealed by statistical comparison of B*1402, B*1403, and B*2705-bound nonamers. Nevertheless, shared ligands between B*2705 and B*1403 were formally identified, although ligands common to B*2705 and B*1403, but absent from B*1402, were not found. Alloreactive T-cells were used as a tool to analyze epitope sharing among B*1402, B*1403, and B*2705. The percentage of cross-reactive T-cell clones closely paralleled peptide overlap, suggesting that shared ligands tend to maintain their antigenic features when bound to the different allotypes. Our results indicate that B*1403 and B*2705 can present common peptides. However, both the disparity of their peptide repertoires and the lack of binding features shared by these two allotypes, but not B*1402, argue against, although do not exclude, a mechanism of spondyloarthritis mediated by specific ligands of B*2705 and B*1403.

Amino Acid Sequence↗
PubMed2001

Health literacy and shared decision making for prostate cancer patients with low socioeconomic status.

Quality of life (QOL) considerations are important in the treatment decision making process for prostate cancer patients. Although patient involvement in the treatment decision process has been encouraged, low health literacy can limit patient understanding of the complex information about treatments and their probable QOL outcomes and is a barrier to patient participation in the decision-making process. The objectives of the study were to evaluate (i) knowledge, level of satisfaction, and treatment preferences and intentions of men newly diagnosed with prostate cancer after participation in a CD-ROM shared decision making program; and (ii) the relationship between prostate cancer knowledge and health literacy. Thirty newly diagnosed prostate cancer patients from two Veteran's Administration (VA) hospitals in Chicago completed a demographic questionnaire and participated in an interactive CD-ROM shared decision making program. Subsequently, knowledge of prostate cancer, satisfaction with the information in the computer CD-ROM program, treatment preferences, and likelihood of following treatment preferences were assessed using interviewer-administered questionnaires. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). The Pearson correlation test was used to assess the relationship between health literacy and prostate cancer knowledge. The chi2 test and the Fischer exact test were used to evaluate relationships between patient demographics and other variables. More than three-quarters of the patients rated the information in the CD-ROM as "very satisfactory" (highest possible rating). Two-thirds of the patients (21 of 30) selected a treatment after participation in the CD-ROM program and 90.5% of these patients stated that they were very or somewhat likely to adhere to their selection. However, prostate cancer knowledge was variable, with one-third of the patients scoring 69.9% or lower. Participants' health literacy was equivalent to a 7th-8th grade reading level (mean = 57.1+/-10.9), and more than one-third of participants (36.7%) had lower than 9th grade literacy levels. Participants' prostate cancer knowledge was correlated with health literacy (Pearson correlation rhor = 0.65, rhop = 0.0001). Patients were satisfied with the interactive shared decision making CD-ROM program, and two-thirds of patients were able to select a preferred treatment based on the information presented in the program that they intended to follow. However, prostate cancer knowledge scores varied among participants after participation in the CD-ROM program, raising doubts that patients were adequately informed to make appropriate choices regarding their treatment. Lower prostate cancer knowledge scores corresponded to lower literacy scores, indicating that low literacy may have hindered patient understanding of the shared decision making program. The development of shared decision making tools should include collaborative efforts with the target population to improve the success of shared decision making programs among patients with low health literacy.

Aged↗
PubMed2004

In search of reflective behavior and shared understanding in ad hoc expert teams.

The work reported on here concentrates on virtual ad hoc expert teams for the integration of learning and working, as ad hoc teams seem to be one way to cope with complexity in a knowledge-intensive society. In order to let ad hoc teams learn and work together, group members require effective communication and shared understanding among each other. Two empirical studies were conducted to study collaborative learning and shared understanding, one exploratory study and one experiment. In the first study, it was explored how virtual design teams work and learn together. Based on conceptual ideas, collaborative learning and shared understanding were observed and assessed in a design team over a period of four months. It was concluded that shared understanding was suboptimal; mainly due to the effect that hardly any questions were raised and answered. The second study elaborates on the need to encourage question-answer patterns and reflective behavior in such teams. A tool was developed that supported questioning behavior. As it was hypothesized that this tool leads to better questioning behavior, which in turn results in more reflective behavior and in increased shared understanding, an experiment was conducted. In the exploratory study, as well as in the experimental study, the perceived shared understanding increased over time. However, in both studies suboptimal questioning behavior and little reflective activity were noticed. The main results of the two empirical studies are compared and discussed.

Adult↗
PubMed2000

Impact of interventions designed to increase market share and prescribing of fexofenadine at HMOs.

The impact of interventions designed to shift prescribing from loratadine to fexofenadine at HMOs was studied. Pharmacy claims data for a six-month preintervention period at four HMOs were analyzed to identify all new and refill prescriptions for loratadine, fexofenadine, astemizole, and cetirizine. The interventions consisted of a mandatory lockout of loratadine in favor of fexofenadine (at HMO A), a voluntary switch to fexofenadine promoted through letters to both physicians and members (HMO B), and a voluntary switch promoted through letters to physicians only (HMO C). There was no intervention at HMO D. Pharmacy claims data for the six months after each intervention program was implemented were analyzed to determine changes in the market share and prescribing of the study drugs. After the intervention programs were implemented, the market share of fexofenadine increased from 18.9% to 65.2% at HMO A, from 14.8% to 21.0% at HMO B, and from 20.7% to 23.8% at HMO C. Loratadine's market share decreased from 62.3% to 8.7% at HMO A, from 67.5% to 58.6% at HMO B, and from 70.5% to 65.3% at HMO C. HMOs A, B, and C each had greater shifts in market share for fexofenadine and loratadine than the control HMO. Changes in prescribing followed a similar pattern for the 25 physicians at each HMO who had most frequently prescribed loratadine during the preintervention period. The average cost per antihistamine prescription decreased 22.3% at HMO A. Prescription costs continued to rise at HMOs B, C, and D. Mandating the use of fexofenadine produced a significant increase in its market share, reduced the cost of nonsedating antihistamines, and successfully influenced prescribing behavior. Voluntary programs had a more modest impact on market share and did not stop increases in prescription costs.

Analysis of Variance↗
PubMed2006

Obstacles to shared care for patients with dementia: a qualitative study.

BACKGROUND: All Primary Care Trusts in England were meant to have shared care protocols for antidementia medication use in place by 1 April 2004. Shared care of medical treatment in dementia depends upon early diagnosis, but under-recognition of and under-response to dementia appear widespread in general practice. AIM: To investigate the perceptions of specialists and generalists about the potential for shared care of people with dementia. DESIGN OF STUDY: Qualitative study with semistructured interviews. SETTING: Three inner-city and two rural areas. METHODS: Semistructured interviews were arranged at the participants' convenience and were tape-recorded and transcribed. Thematic analysis of the anonymized transcripts was undertaken and a case and cross-case analysis was performed. RESULTS: Thirty-nine GPs and 30 specialists were interviewed. Broad themes were reduced to following four key categories which appear to be layered over each other: therapeutic nihilism; risk reduction or avoidance; concerns about competency; and resources for shared care. CONCLUSION: Roles for primary and secondary care professionals are inappropriately distributed and require clearer definition. Resistance to shared care mostly comes from within general practice and reflects concerns about staffing, time constraints, lack of experience and confidence in making and disclosing a diagnosis. Developers of shared care protocols must dissect layered obstacles, addressing the issues of therapeutic nihilism, risk management and clinical competence.

Adult↗
PubMed2005

Do increases in the market share of managed care influence quality of cancer care in the fee-for-service sector?

BACKGROUND: Increases in the market share of managed care in an area are associated with decreases in expenditures in the fee-for-service sector (i.e., a spillover effect). Given concerns that these decreases in expenditures result from reductions in necessary care, we examined associations between increases in managed care market share and changes in the quality of care delivered to cancer patients in the fee-for-service sector. METHODS: We studied a population-based sample of fee-for-service Medicare beneficiaries aged 66 years or older who were diagnosed with breast (N = 41,394) or colorectal (N = 48,027) cancer during 1993-1999. We used fixed effects regression analysis of SEER cancer registry and Medicare claims data to assess whether county-level increases in the market share of managed care over time were associated with the quality of cancer care. All statistical tests were two-sided. RESULTS: Increases in the market share of managed care were not associated with most quality indicators, including receipt of surveillance mammography after diagnosis for patients with breast cancer (P = .83), receipt of radiation after breast-conserving surgery among women who underwent breast-conserving surgery (P = .16), receipt of adjuvant chemotherapy for patients with stage III colorectal cancer (P = .94), or surveillance colonoscopy after treatment for colorectal cancer (P = .39). Increases in the market share of managed care were associated with increased rates of surveillance carcinoembryonic antigen testing for colorectal cancer patients (P = .001). CONCLUSIONS: Increases in managed care market share had limited or no effect on the quality of care for cancer patients. Concerns that increases in managed care would have large negative spillover effects on the quality of cancer care appear to be unfounded; however, the potential for managed care to stimulate improved quality throughout the medical care system have not yet been realized.

Aged↗
PubMed2004

Frequency of bed sharing and its relationship to breastfeeding.

Bed sharing has been promoted as facilitating breastfeeding but also may increase risks for sudden, unexpected infant deaths. This prospective cohort study was performed to determine the prevalence of adult and infant bed sharing and its association with maternal and infant characteristics. Demographic data were collected from 10,355 infant-mother pairs at birth hospitals in Eastern Massachusetts and Northwest Ohio, and follow-up data were collected at 1, 3, and 6 months by questionnaire. Associations with bed sharing were estimated using odds ratios and 95% confidence intervals from multiple logistic regression models while adjusting for confounding variables. At 1, 3, and 6 months, 22%, 14%, and 13% of infant-mother pairs shared a bed, respectively. On multivariate analysis, race/ethnicity and breastfeeding seemed to have the strongest association with bed sharing. These factors need to be considered in any comprehensive risk to benefit analysis of bed sharing.

Adolescent↗
PubMed1992

The impact of the UNOS mandatory sharing policy on recipients of the black and white races--experience at a single renal transplant center.

The impact of the United Network for Organ Sharing mandatory sharing policy on a large transplant center procuring kidneys primarily from caucasians while serving a pool of prospective recipients composed mainly of blacks is described. This policy requires that all 6-antigen-matched and phenotypically identical donor kidneys be shipped to the appropriately matched recipients. The study consisted of 49 kidneys from 25 cadaveric donors; one kidney was unusable. In general, the 33 recipients of the mandatorily shared kidneys were caucasian (94%), unsensitized (70%), and first-time transplants (73%). Allograft survival for the 24 first-time recipients was 100% (mean graft survival = 11.3 months). Of the 9 regraft kidneys, 2 have failed (mean graft survival = 11.9 months) due to chronic rejection. In comparison, the 16 paired kidneys transplanted into non-6-antigen-matched recipients exhibited a 1-year graft survival of 80% versus 92% for the 33 recipients of mandatorily shared kidneys (P = 0.01). These 16 recipients were composed of more blacks (38%), fewer regrafts (6%), and most were unsensitized (75%). All 25 cadaveric donors were caucasians with very common HLA types. Thus, kidneys provided by the UNOS mandatory sharing policy had excellent allograft survival, and the recipients were largely unsensitized caucasians receiving their first kidney. The low number of blacks receiving allografts under this policy may be due to two factors. First, the histocompatibility differences between black recipients and the primarily caucasian cadaveric donor pool limit the number of kidneys available to blacks. Secondly, blacks do not have access to the best-matched kidneys, in part due to few black donors, their best source for well-matched kidneys. Thus, the mandatory sharing program is of clear benefit to the recipients of these well-matched kidneys; however, for a local program servicing a waiting list composed of 64% blacks the policy has been of limited value. In contrast, over 50% of local cadaveric transplants are into black recipients in a waiting time of 197 days, one third the national average for blacks. In conclusion, this study supports efforts to improve graft survival through matching but emphasizes the need to broaden our efforts in all areas of research and organ procurement to serve the entire recipient population, regardless of race.

Black People↗
PubMed2000

National sharing of cadaveric isolated intestinal allografts for human transplantation: a feasibility study.

UNLABELLED: Most isolated intestinal graft losses are immunological. We conducted a pilot study to evaluate the feasibility of national sharing of HLA no-mismatch allografts for cadaveric isolated intestinal transplantation. METHODS: UNOS data were analyzed in a theoretical model. Part I: All solid organ donors between 1/95-8/97 who would have met criteria for bowel donation were considered potential donors for all recipients who actually received isolated intestinal transplants during this period. We then determined how many donor intestines could have been directed to no-mismatch candidates had national sharing been in place. Donor exclusion criteria were CMV+ donors to CMV- recipients, hemodynamic instability, age >50, size mismatch (donor weight greater than recipient), and obesity. Mean and median waits for transplants, as well as theoretical mean and median waits for transplants that would have occurred given national sharing, were calculated. Part II: We estimated, based on registry graft survival data, the number of intestinal transplants necessary to demonstrate a no-mismatch graft survival advantage at 2 years. RESULTS: Part I: Although no actual cadaveric no-mismatch transplant was performed, 12-17% of patients could have received no-mismatch allografts had sharing been in place, using various donor acceptance criteria. The impact on waiting time was variable. Part II: Accepting a 15% rate of no-mismatch cases and a survival advantage of 10% at 2 years, 793 transplants would be required to prove an advantage to HLA matching at P<0.05. If the graft survival advantage were 20% at 2 years, the time to show significance would be approximately 5 years. Using early acute rejection as an endpoint could require fewer transplants (93), and only a few years to complete the study. CONCLUSIONS: National sharing of cadaveric isolated intestinal allografts is feasible. Median waits would not be significantly increased. The time necessary to prove graft survival advantage would be considerable, but a difference in the rate of acute rejection could be seen within 2 years. Additionally, a national sharing arrangement might improve the overall outcome of isolated intestinal transplantation.

Cadaver↗
PubMed2002

Sensitized patients require sharing of highly matched kidneys.

BACKGROUND: Improved HLA matching can allow for renal transplantation in sensitized patients. United Network for Organ Sharing (UNOS) is currently considering removing the points awarded for HLA matching. METHOD: Twenty-six transplant centers shared kidneys, according to the algorithm: A, UNOS mandatory 0-mismatch (MM) share; B, UNOS mandatory 0-mm payback; C, 0 - B,Dr-MM; PRA> or = 40%; ROP tray negative; D, 0-B,Dr-MM; panel reactive antibodies (PRA) <40%; E, 0-B,Dr payback; F, local use. RESULTS: A total of 354 patients received transplants through the program and were compared with 6492 control patients. There was a significantly greater primary nonfunction rate in sensitized patients in spite of similar length cold ischemia time. Blacks were not significantly disadvantaged by the HLA matching requirements of the program. White recipients were favored by the matching program to the detriment of race group "other." Women were more frequently found in the sensitized groups but were not favored by sharing. Retransplant patients and patients with current PRA > or = 40% were favored by the sharing program. Sharing for HLA match does not improve graft survival at 1, 2, 3 years. CONCLUSIONS: (1). Elimination of suboptimal HLA matching by UNOS will probably not adversely affect 1-, 2-, and 3-year graft survival; (2). Removing the consideration for HLA matching will result in fewer transplant opportunities for highly sensitized patients such as retransplants and currently sensitized patients.

Adult↗
PubMed2006

A clinical report of adverse health effects due to bed sharing in two children with spinal cord injury and traumatic brain injury.

This paper explores the possibility that bed sharing may carry particular risks for children with special healthcare needs (CSHCN). Two cases of CSHCN who may have sustained adverse health effects from bed sharing are described. These two case reports indicate that CSHCN may be particularly susceptible to risks associated with bed sharing. Healthcare providers for CSHCN may need to inquire about patients' sleeping arrangements and, when bed sharing is acknowledged, provide counseling regarding the potential risks and benefits. They may need to monitor more closely for adverse events when bed sharing is a factor and should consider reporting health problems that may have occurred in concurrence with bed sharing.

Beds↗
PubMed2000

A qualitative evaluation of shared leadership barriers, drivers and recommendations.

Shared leadership is a management model based on the shared governance philosophy. Assumes those individuals or teams performing tasks are best equipped to provide meaningful improvement. The changing image of the current leadership model is one that resides in relationships rather than with a singular person. The key concepts are accountability, partnership, equity, and ownership. When shared leadership was initiated at St Joseph's Health Care, London, Ontario, in 1998, there was a commitment by management and staff to ensure that it was successfully implemented. In order to determine areas for improvement in the implementation process, continual evaluation is necessary. Reports from various staff members, prior to the project, indicated that the shared leadership implementation plan had not been fully realised. Therefore, a qualitative evaluation project, utilising focus groups and interviews, was completed. The purpose of the study was to identify the drivers, as well as the barriers affecting the implementation process. Several recommendations for improving the process were determined by the participants of the study. The result of the project was a collection of four themes, common to the discussions of barriers, drivers and recommendations. The internalisation of the concepts specific to the shared leadership model was found to be vital. The effectiveness of the council framework, including the council structure, processes and membership was also important. Communication of outcomes arising from the council was crucial. The final theme to be identified included those Humanistic Needs that addressed the relationship aspects of this model. Furthermore, the relationship between these themes was explored in the context of the external forces affecting the shared leadership model.

Data Collection↗
PubMed2005

Shared Care, elder and family member skills used to manage burden.

AIM: The aim of this paper is to further develop the construct of Shared Care by comparing and contrasting it to related research, and to show how the construct can be used to guide research and practice. BACKGROUND: While researchers have identified negative outcomes for family caregivers caused by providing care, less is known about positive aspects of family care for both members of a family dyad. Understanding family care relationships is important to nurses because family participation in the care of chronically ill elders is necessary to achieve optimal outcomes from nursing interventions. A previous naturalistic inquiry identified a new construct, Shared Care, which was used to describe a family care interaction that contributed to positive care outcomes. METHODS: A literature review was carried out using the databases Medline, CINAHL, and Psych-info and the keywords home care, care receiver, disability, family, communication, decision-making and reciprocity. The results of the review were integrated to suggest how Shared Care could be used to study care difficulties and guide interventions. RESULTS: The literature confirmed the importance of dyad relationships in family care. Shared Care extended previous conceptualizations of family care by capturing three critical components: communication, decision-making, and reciprocity. Shared Care provides a structure to expand the conceptualization of family care to include both members of a care dyad and account for positive and negative aspects of care. CONCLUSIONS: The extended view provided by the construct of Shared Care offers practitioners and scholars tools to use in the context of our ageing population to improve the effectiveness of family care relationships.

Aged↗
PubMed2004

District nursing--sharing an understanding by being present. Experiences of encounters with people with serious chronic illness and their close relatives in their homes.

BACKGROUND: In the homecare setting, district nurses assume a heavy responsibility and are involved in a variety of care activities. They view themselves as having a central role in care at home that centres on the development of a relationship with those who are ill and their families. AIM: The aim of this study was to elucidate the meaning of district nurses experiences of encounters with people with serious chronic illness and their close relatives in their homes. A purposive sample of 10 district nurses (female) was interviewed using a narrative approach. METHOD: To achieve the aim, a phenomenological hermeneutic interpretation inspired by the philosophy of Ricoeur was used to interpret the interview text. RESULTS: This study proposes that district nurses' experiences of encounters with people with serious chronic illness and their close relatives in their homes can be understood as district nurses being welcomed into the ill people's privacy, to share their intimacy and their understanding of being ill. This close relationship enables them to alleviate and to console the suffering and loneliness caused by illness. This is expressed in the three themes: being in a close relationship, sharing an understanding and weaving a web of protection. CONCLUSION: It seems that by being entirely present, in a close relationship, district nurses share the experiences of illness and through interpretation of the whole persons' expressions; they share an understanding of this illness experience. In this close relationship, at the home of the ill people and their close relatives, district nurses are available to alleviate people's suffering and loneliness caused by illness. RELEVANCE TO CLINICAL PRACTICE: This study reveals the need to be entirely present in encounters between the district nurses and people with serious chronic illness and their close relatives. This relation makes it possible to establish a shared understanding of the illness experience. Being aware of the importance of this shared understanding within a relationship, will increase the health care personnel's possibility to alleviate and console those suffering of illness. This proposed interpretation could be useful for reflection of care interventions, in education and supervision of district nurses.

Chronic Disease↗