The relationships between certified nursing assistants' voice behaviour and job satisfaction, work engagement and turnover intentions: A two-wave survey study

AIM

Whereas voice behaviour has been identified as a key precursor to safe and high-quality patient care, little is known about how voice relates to key workforce outcomes. This study aimed to investigate the relationships between certified nursing assistants' perceived promotive voice behaviour (speaking up with suggestions for future improvement) and prohibitive voice behaviour (speaking up about problems or potentially harmful situations) and their self-reported levels of job satisfaction, work engagement and turnover intentions.

DESIGN AND METHODS

Dutch certified nursing assistants were recruited for a two-wave survey study through non-random convenience sampling. The final sample contained 152 respondents. The data were analysed using multiple linear regression analyses. In all analyses, the dependent variable at time one was controlled for.

RESULTS

Certified nursing assistants' promotive and prohibitive voice behaviour at time one were found to be positively related to their level of job satisfaction at time two while controlling for job satisfaction at time one. No relationships with work engagement or occupational turnover intentions were found.

CONCLUSION

While previous research has found positive effects of voice on patient safety outcomes and team and organizational improvements in care organizations, we demonstrate that voice is also related to a key workforce outcome, that is, certified nursing assistants' job satisfaction.

IMPLICATIONS AND IMPACT

Recognizing the interplay between voice behaviour and job satisfaction underscores the importance of creating work environments where certified nursing assistants feel able and willing to make their voices heard-with ideas and suggestions, as well as information regarding problems and concerns.

PATIENT OR PUBLIC INVOLVEMENT

Three certified nursing assistants have contributed to the development of the survey.

From Integrated Care to Integrating Care: A Conceptual Framework of Behavioural Processes Underlying Effective Collaboration in Care

Introduction

At all levels, effective collaboration between actors with different backgrounds lies at the heart of integrated care. Much attention has been given to the structural features underlying integrated care, but even under structurally similar circumstances, the effectiveness of collaboration varies largely.

Theory and methods

Social and organizational psychological research shows that the extent to which collaboration is effective depends on actors' behaviours. We leverage insights from these two research fields and build a conceptual framework that helps untangle the behavioural processes underlying effective collaboration.

Results

We delineate that effective collaboration can be realized when actors (1) speak up about their interests, values, and perspectives (voice behaviour), (2) listen to the information that is shared by others, and (3) thoroughly process this information. We describe these behaviours and explain the motivations and conditions driving these. In doing so, we offer a conceptual framework that can be used to explain what makes actors collaborate effectively and how collaboration can be enhanced.

Discussion and conclusion

Fostering effective collaboration takes time and adequate conditions, fitting the particular context. As this context continuously changes, the processes and conditions require continuous attention. Integrated care, therefore, actually requires a carefully designed process of integrating care.

Improving the quality of care in nursing home organizations with urgent quality issues: design and effectiveness of a Dutch government-funded support programme

BACKGROUND

Various societal developments are currently challenging the ability of European nursing home organizations to meet quality standards. To support nursing home organizations throughout the Netherlands in quality improvement (QI), the Dutch government launched a nationwide programme in 2016 entitled 'Dignity and pride' (D&p). As part of this programme, participating nursing home organizations followed a tailored trajectory centred around intensive, on-site support from external expert coaches. For this study, we evaluated to what extent quality improvements were realized in the programme, paying particular attention to the role of the expert coaches.

METHODS

Thirty-six nursing home organizations were included. At the start of D&p, the majority of these organizations (78%) had major quality issues as determined by the Health Care Inspectorate. Information on quality of care at the start versus end of the programme was obtained from improvement plans and final evaluation reports. Quality of person-centred care (PCC) and resident safety were quantified using a standardized assessment tool based on national guidelines, with improvements analysed using two-sided paired-sample T-tests. In addition, semi-structured interviews were conducted with 14 coaches and 29 healthcare professionals, focusing on the greatest benefits of programme participation and on the added value of the expert coaches.

RESULTS

After completion of the programme, 60% of the organizations scored a 4 (= good) on PCC and resident safety, and none scored a 2 or less (average improvement on a 5-point scale for both themes: 1.9 points, p < 0.001). Interviewees confirmed that the quality of care had both improved and become more person-centred. The expert coaches were credited with substantially contributing to the QI process by offering an outsider's perspective, bringing in experience and expertise, and helping the organization stay committed and focused.

CONCLUSIONS

Our study results suggest that the D&p programme was associated with improved quality of care in nursing home organizations with urgent quality issues. However, offering on-site tailored support through a nationally coordinated, government-funded programme is both time- and labour-intensive, and therefore not feasible in every healthcare setting. Nevertheless, the findings provide valuable insights for future QI support strategies.

Exploring crucial programme characteristics and group mechanisms of an empowerment programme for certified nursing assistants-A qualitative study

Aims

To identify crucial programme characteristics and group mechanisms of, and lessons learned from hindrances in an empowerment programme for certified nursing assistants and contribute to the development of similar programmes in other care settings.

Design

Exploratory qualitative study.

Methods

Between May 2017 and September 2020, we used in‐depth interviews and participant observations to study four groups participating in an empowerment programme for certified nursing assistants (N = 44).

Results

We identified three crucial empowerment‐enhancing programme characteristics: (1) inviting participants to move outside their comfort zone of caregiving; (2) stimulating the use of untapped talents, competencies and interests; (3) supporting the rediscovery of participants' occupational role and worth. Crucial group mechanisms encompassed learning from and with each other, as well as mechanisms of self‐correction and self‐motivation. Hindrances included a perceived lack of direction, and a lack of organizational support and facilitation.

Conclusion

We showed the significance of creating an inviting and stimulating environment in which participants can explore and function in ways they otherwise would not. Likewise, we identified how this can help participants learn from, critically correct and motivate one another.

Impact

The programme under study was uniquely aimed to empower certified nursing assistants. Our insights on crucial programme characteristics and group mechanisms may benefit those who develop empowerment programmes, but also policymakers and managers in supporting certified nursing assistants and other nursing professions in empowerment endeavours. Such empowerment may enhance employee retention and make occupational members more likely to address challenges affecting their occupational group and the long‐term care sector.

A sector-wide response to national policy on client-centred care and support: a document analysis of the development of a range of instruments to assess clients' experiences in the care and support for people with (intellectual) disabilities

Background

Client-centred care serves as the foundation for healthcare policy. Indeed, various instruments for assessing clients’ experiences of care and support are increasingly used to provide insights into the quality, and client-centred nature, of the care and support provided, which, in turn, aids the development of subsequent improvements. The unique characteristics of care and support for people with intellectual disabilities (ID), such as the need for both lifelong and life-wide care and support across all aspects of clients’ lives, led to an initiative within Dutch ID care to jointly develop a range of instruments to assess the experiences of clients receiving ID care and support. Individual clients’ experiences and suggestions for improvement, which are embedded in clients’ care plan cycles, constitute the foundation of this Range of Instruments. This paper provides a unique, bottom-up, exhaustive account of the process of developing the Range of instruments used to assess the experiences of clients in the field of Dutch ID care.

Methods

Relevant documents at three levels (i.e. 1) national documents, such as policy papers and governmental reports, 2) documents and reports from the Dutch Association of Healthcare Providers for People with Disabilities (VGN) along with minutes from the meetings of the expert Committee who assessed the instruments, and 3) correspondence between the Committee and developers as well as the forms used in the assessment process for each instrument) were qualitatively analysed by two researchers who had no affiliation with the development of the Range of instruments used to assess clients’ experiences in ID care and support. All of the documents were inductively coded using a thematic analytical approach. Informants who were either currently or previously involved in the development of these instruments were asked to provide clarification over the documents themselves and to explain the context in which they were produced.

Results

The development of the range of instruments can be classified into four phases, namely: 1) supporting the bottom-up development of initiatives to assess clients’ experiences, 2) focusing on learning and further development, 3) stimulating exchange between the developers and users of the instruments and the Committee responsible for assessing them, and 4) further development in response to the changing times and new landscape.

Conclusions

The range of instruments were found to be appropriate for a variety of clients in ID care and support, specifically in terms of assessing their individual experiences and gaining insight into their suggestions for improvement, and effective in terms of collaboratively improving the quality of ID care and support. In so doing, these instruments potentially provide an avenue through which clients’ experiences can be embedded in the process of ID care and support. Other specific features in the development of these instruments, namely their incremental adoption, ongoing evaluation and strong practice orientation, were also found to be suitable for other care contexts’ attempts to respond to the top-down policy objectives of client-centeredness and translating outcomes into direct care practice.

It takes three to tango: An ethnography of triadic involvement of residents, families and nurses in long-term dementia care

Background

Researchers often stress the necessity and challenge of integrating the positionings of residents, family members and nurses in order to realize each actor's involvement in long‐term dementia care. Yet most studies approach user and family involvement separately.

Aim

To explain how productive involvement in care provision is accomplished in triadic relationships between residents, family members and nurses.

Methods

An ethnographic study of identity work, conducted between 2014 and 2016 in a Dutch nursing home.

Findings

We identify four ideal‐typical identity positionings performed by nurses through daily activities. The findings reveal how their identity positionings were inseparable from those of the residents and family members as they formed triads. Congruent, or ‘matching’, identity positionings set the stage for productive involvement. Our systematic analysis of participants' identity work shows how—through embedded rights and responsibilities—their positionings inherently shaped and formed the triadic types and degrees of involvement observed within these relationships.

Discussion and conclusion

This study both unravels and juxtaposes the interrelatedness of, and differences between, the concepts of user and family involvement. Accordingly, our findings display how residents, family members and nurses—while continuously entangled in triadic relationships—can use their identity positionings to accomplish a variety of involvement activities. To mirror and optimize the implementation of user and family involvement, we propose a rights‐based and relational framework based on our findings.

Patient or public contribution

Conversations with and observations of residents; feedback session with the Clients' Council.

The Journey Towards Community-Based Dementia Care: The Destination, Roadmap, Guide, Tour Group and the Conditions

In their paper, Morton-Chang et al. (2016) discuss how aging societies are struggling and trying to cope with the rapidly increasing numbers of persons living with dementia (PLWD). In that sense, the Canadian case is not unique. On the contrary, it is very similar to other developing countries. Therefore, it is worthwhile to reflect from another country's perspective on this unprecedented societal development. In this paper, I will consider the challenge of dealing with increasing numbers of PLWD from the European and, in particular, Dutch perspectives. Whereas, MortonChang et al. pose the question: "How do we get there from here?" I will address the issues of what the "there" should be and how we get there from my European/Dutch perspective. I will provide my view on how the roadmap can be drawn, who needs to be on the tour, who might be the guide and what conditions need to be in place to arrive at the desired destination.

Citizens as Active Participants in Integrated Care: Challenging the Field's Dominant Paradigms

Policy makers, practitioners and academics often claim that care users and other citizens should be 'at the center' of care integration pursuits. Nonetheless, the field of integrated care tends to approach these constituents as passive recipients of professional and managerial efforts. This paper critically reflects on this discrepancy, which, we contend, indicates both a key objective and an ongoing challenge of care integration; i.e., the need to reconcile (1) the professional, organizational and institutional frameworks by which care work is structured with (2) the diversity and diffuseness that is inherent to pursuits of active user and citizen participation. By identifying four organizational tensions that result from this challenge, we raise questions about whose knowledge counts (lay/professional), who is in control (local/central), who participates (inclusion/exclusion) and whose interests matter (civic/organizational). By making explicit what so often remains obscured in the literature, we enable actors to more effectively address these tensions in their pursuits of care integration. In turn, we are able to generate a more realistic outlook on the opportunities, limitations and pitfalls of citizen participation.

[Symposium The future of informal care]

Due to the reform of long term care in 2015, there is growing concern about whether groups at risk receive the care they need. People in need of care have to rely more on help from their social network. The increased need for informal care requires resilience and organizational skills of families, but also of volunteers, professionals and employers. What does this mean for the provision of informal care in the next decennia? The symposium 'The future of informal care', organized on January 26 2017 by the National Institute for Social Research and the Institute for Societal Resilience of the Vrije Universiteit, addressed possible answers to this question. In her inaugural speech Alice de Boer discussed social inequality as possible determinant and outcome of informal care. Some conclusions:Until 2050 the absolute number of 75-plus doubled to about 3 million persons, but the number of informal caregivers will decrease. In addition to the importance of social and economic resources (the 'have & have-nots'), the ability to arrange care (the 'can & can-nots') gains importance.Almost half of the older employers provides informal care just before retirement. Flexibility in working hours and work location facilitates combining work and care, but about half of the employers indicates that partial retirement and working at home are no options.Informal caregivers and professionals often provide care from comparable perspectives and identities. Addressing similarities rather than differences improves their chances for collaboration.The number of adult children providing household care to older parents increased between 2002 and 2014. This suggests an increase in family solidarity, but current reform policies may increase the gender inequality in caregiving families.Spouses and children remain primary caregivers in the future, preferably supported by many different types of caregivers. Not everybody has the capabilities to organize and direct such a large care network.Providing informal care increases the risk for overburden and absence at work or education. Informal caregivers at risk remain, also in the future, women, spouses, migrants, and younger carers.

Impact of the Fukushima accident on tritium, radiocarbon and radiocesium levels in seawater of the western North Pacific Ocean: A comparison with pre-Fukushima situation

Tritium, radiocarbon and radiocesium concentrations in water column samples in coastal waters offshore Fukushima and in the western North Pacific Ocean collected in 2011-2012 during the Ka'imikai-o-Kanaloa (KoK) cruise are compared with other published results. The highest levels in surface seawater were observed for ¹³⁴Cs and ¹³⁷Cs in seawater samples collected offshore Fukushima (up to 1.1 Bq L^-1), which represent an increase by about three orders of magnitude when compared with the pre-Fukushima concentration. Tritium levels were much lower (up to 0.15 Bq L^-1), representing an increase by about a factor of 6. The impact on the radiocarbon distribution was measurable, but the observed levels were only by about 9% above the global fallout background. The ¹³⁷Cs (and similarly ¹³⁴Cs) inventory in the water column of the investigated western North Pacific region was (2.7 ± 0.4) PBq, while for ³H it was only (0.3 ± 0.2) PBq. Direct releases of highly contaminated water from the damaged Fukushima NPP, as well as dry and wet depositions of these radionuclides over the western North Pacific considerably changed their distribution patterns in seawater. Presently we can distinguish Fukushima labeled waters from global fallout background thanks to short-lived ¹³⁴Cs. However, in the long-term perspective when ¹³⁴Cs will decay, new distribution patterns of ³H, ¹⁴C and ¹³⁷Cs in the Pacific Ocean should be established for future oceanographic and climate change studies in the Pacific Ocean.

Modelling of marine radionuclide dispersion in IAEA MODARIA program: Lessons learnt from the Baltic Sea and Fukushima scenarios

State-of-the art dispersion models were applied to simulate (137)Cs dispersion from Chernobyl nuclear power plant disaster fallout in the Baltic Sea and from Fukushima Daiichi nuclear plant releases in the Pacific Ocean after the 2011 tsunami. Models were of different nature, from box to full three-dimensional models, and included water/sediment interactions. Agreement between models was very good in the Baltic. In the case of Fukushima, results from models could be considered to be in acceptable agreement only after a model harmonization process consisting of using exactly the same forcing (water circulation and parameters) in all models. It was found that the dynamics of the considered system (magnitude and variability of currents) was essential in obtaining a good agreement between models. The difficulties in developing operative models for decision-making support in these dynamic environments were highlighted. Three stages which should be considered after an emergency, each of them requiring specific modelling approaches, have been defined. They are the emergency, the post-emergency and the long-term phases.

Iodine-129, Iodine-127 and Cesium-137 in seawater from the North Sea and the Baltic Sea

In this study, new data are presented for the iodine isotopes (¹²⁷I, ¹²⁹I and their isotopic ratios) and Cesium (¹³⁷Cs) in water samples of the North Sea and the Baltic Sea in 2005 and 2009. This study supplements and extends the study of Michel et al. (2012). Iodine isotopes were separated from their matrix by using an anion exchange method and were determined by applying ICP-MS and AMS. ¹³⁷Cs in seawater was determined after cesium ion exchange procedure enrichment by gamma-spectrometry. The concentrations of ¹²⁷I in seawater of the North and Baltic Sea are fairly constant in each Sea with averages of (44 ± 2) and (21 ± 1) ng g^-1, respectively, depending on the salinity. However, large variations of ¹²⁹I concentrations in these areas were detected, which decreased along the French, Belgian, Dutch, German, and Danish shores. ¹²⁹I/¹²⁷I isotope ratios in the Baltic Sea are about 10 times lower than in the North Sea in 2009. The highest isotopic ratios (2.7 × 10^-6) was detected in the English Channel east of the nuclear reprocessing plant at Cap de la Hague. The results confirm the result of our early study that the sources of ¹²⁹I in the North Sea are primarily the nuclear reprocessing facilities at Sellafield (UK) and La Hague (F), and that in the Baltic Sea the inflow of water from North Sea through the Danish Straits dominates the occurrence of ¹²⁹I. In 2009, the activity concentration of ¹³⁷Cs was at least 6 times higher in the Baltic Sea (37 Bq m^-3) than in the North Sea (5.9 Bq m^-3), due to release of ¹³⁷Cs from sediments in the Baltic Sea, which were contaminated by the Chernobyl accident and - to a minor degree - the atmospheric explosions of atomic bombs. The results are discussed by comparing the results of our previous work and the current study demonstrating the continuing disequilibrium of ¹²⁹I/¹²⁷I atomic ratio in the environmental compartments.

The Journey towards Community-Based Dementia Care: The Destination, Roadmap, Guide, Tour Group and The Conditions

In their paper, Morton-Chang et al. (2016) discuss how aging societies are struggling and trying to cope with the rapidly increasing numbers of persons living with dementia (PLWD). In that sense, the Canadian case is not unique. On the contrary, it is very similar to other developing countries. Therefore, it is worthwhile to reflect from another country's perspective on this unprecedented societal development. In this paper, I will consider the challenge of dealing with increasing numbers of PLWD from the European and, in particular, Dutch perspectives. Whereas, Morton-Chang et al. pose the question: "How do we get there from here?" I will address the issues of what the "there" should be and how we get there from my European/Dutch perspective. I will provide my view on how the roadmap can be drawn, who needs to be on the tour, who might be the guide and what conditions need to be in place to arrive at the desired destination.

Integrated community-based dementia care: the Geriant model

This article gives an in-depth description of the service delivery model of Geriant, a Dutch organization providing community-based care services for people suffering from dementia. Core to its model is the provision of clinical case management, embedded in multidisciplinary dementia care teams. As Geriant's client group includes people from the first presumption of dementia until they can no longer live at home, its care model provides valuable lessons about how different mechanisms of integration are flexibly put to use if the complexity of clients" care needs increases. It showcases how the integration of services for a specific sub-population is combined with alignment of these services with generalist network partners. After a detailed description of the programme and its results, this article builds on the work of Walter Leutz for a conceptual discussion of Geriant's approach to care integration.

A comparison of marine radionuclide dispersion models for the Baltic Sea in the frame of IAEA MODARIA program

Four radionuclide dispersion models have been applied to simulate the transport and distribution of (137)Cs fallout from Chernobyl accident in the Baltic Sea. Models correspond to two categories: box models and hydrodynamic models which solve water circulation and then an advection/diffusion equation. In all cases, interactions of dissolved radionuclides with suspended matter and bed sediments are included. Model results have been compared with extensive field data obtained from HELCOM database. Inventories in the water column and seabed, as well as (137)Cs concentrations along 5 years in water and sediments of several sub-basins of the Baltic, have been used for model comparisons. Values predicted by the models for the target magnitudes are very similar and close to experimental values. Results suggest that some processes are not very relevant for radionuclide transport within the Baltic Sea, for instance the roles of the ice cover and, surprisingly, water stratification. Also, results confirm previous findings concerning multi-model applications.

Communities as co-producers in integrated care

Integrated care has become too much a professionals' concept, in research and theory development, as well as in practice, especially in high-income countries. The current debate on integrated care is dominated by norms and values of professionals, while most of the care is provided by non-professionals. The paradigms of integrated care for people with complex needs need to be reconsidered. It is argued that non-professional care and care by local communities need to be incorporated as a resource and a co-producer of care. It seems fair to assume that the community as such can take a more prominent role in organising and delivering health and long-term care. This implies redefining professional and non-professional responsibilities and boundaries. The boundary between public and private space is losing its significance, as is the distinction between formal and non-formal care. It also requires renegotiating and transforming organisational boundaries. This has consequences for legislation, funding and professional qualifications, as well as for management and governance. It challenges current professional identities as well as identities of service users, their informal carers and citizens. It may also require new types of funding, including non-monetary currencies, time-sharing and social impact bonds. The challenge is that big, that it needs to be addressed at its smallest scale: the citizen in his social network and local community, being co-producer of really integrated care.

Detection of Fukushima Daiichi nuclear power plant accident radioactive traces in Monaco

Daily air monitoring of radionuclides in the Principality of Monaco (43°73'N, 7°43'E) after the Fukushima Daiichi nuclear power plant accident showed that only Iodine-131 ((131)I) and Caesium isotopes ((134)Cs and (137)Cs) were detected. The peak of (131)I varied and reached its maximum between March 29th and April 5th, meanwhile both peaks of (134)Cs and (137)Cs arrived later and attained a maximum between April 1st and 4th. Their maximum activity concentrations in air were 354, 30, and 37 μBq m(-3) respectively. The (134)Cs to (137)Cs activity ratio was close to 1, which is different from that one observed after the Chernobyl accident (around 0.54). Up to 95% of caesium isotopes were washed out by wet scavenging during 27-28th of March, where the maximum deposition rates of (134)Cs and (137)Cs (13.7 and 19.1 mBq m(-2) day(-1), respectively) were observed. The significant input of (134)Cs and (137)Cs into the Mediterranean seawater column (30 m depth) was detected later, on the 24th of May. Radioisotopes of caesium and iodine were found far above the applied detection limits, but still with no concern for harmful radiation exposure and public health. The contamination gradually decreased in air and activity concentrations returned to background values after one or two months.

Iodine-129 and iodine-127 in European seawaters and in precipitation from Northern Germany

In order to obtain a comprehensive survey on the consequences of the marine (129)I discharges from the European reprocessing plants La Hague and Sellafield, the distribution of (129)I and (127)I in surface waters of the North Sea, the English Channel, the Irish Sea, and the Northeast Atlantic was studied using accelerator mass spectrometry for (129)I and ICP-MS for (127)I. Samples of seawater were taken in the German Bight in May, September, and November 2005 and in the entire North Sea and the English Channel in August 2005. Further samples were obtained from the Irish Sea in June and August 2006 and from Arctic waters between Spitsbergen and Southern Norway in September 2005. (129)I is a conservative tracer in seawater. The concentrations of (127)I are relatively constant with exceptions of coastal areas with high biological activity and of areas influenced by influx from rivers and the Baltic Sea. The variability of the (129)I/(127)I isotopic ratios is exclusively determined by admixture of (129)I released from the reprocessing facilities Sellafield and La Hague to the seawater. The (129)I/(127)I ratios were between 4 × 10(-9)and 3 × 10(-6): at least 3 orders of magnitude higher than the natural equilibrium isotopic ratio 1.5 × 10(-12). (129)I/(127)I ratios of a few times 10(-10) were only found in seawater from the Indian Ocean and from the Pacific at Hawaii. Comparison of the results obtained for seawater with those of a measurement of airborne iodine species and with iodine isotopes in precipitation in Northern Germany demonstrates the transfer of (129)I and (127)I from the sea into the atmosphere and the dominating role of the marine discharges for the atmospheric fallout of (129)I in Western Europe. The results are discussed with the goal to estimate the relevance of the marine discharges for the contamination of the continental areas.

Dementia care: linear links and networks

The consequences of dementia, for both patients and primary caregivers, are formidable. Primary caregivers are often overburdened or are significantly at risk for becoming overburdened. How do we meet this substantial and complex social challenge, which is as yet insufficiently recognized? We must start looking for new forms of care and support, for more goal-oriented care while maintaining humane values. The problem of dementia demands that we follow more leads: new treatments and interventional care, greater use of technology, new divisions of labour among professionals and more empowerment of primary care. At issue is the organization of physical and social environments for patients with dementia that closely meet their needs. The road toward this goal is long and complicated, but a start has been made in the Netherlands.

The primary care physician and Alzheimer's disease: an international position paper

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Managing effective partnerships in older people's services

The integration of older people's services is a challenge to all countries with an ageing population. Although it is widely acknowledged that acute care, long-term care, social care, housing, leisure, education and other services should all operate in a more 'joined-up manner', achieving this in practice remains extremely difficult. Against this background, the European Union (EU) Care and Management of Services for Older People in Europe Network (CARMEN) project set out to explore the management of integrated care in 11 EU countries. Summarising key themes from the project, this paper explores the management of integrated care, the skills required, the mechanisms which aid successful integrated approaches, and future research priorities. Although very challenging, the concept of integrated care is still a promising way forward when seeking to meet the challenges of an ageing society.

Sensitizing capacity and residual allergenicity of hydrolyzed cow's milk formulae: results from a murine model

BACKGROUND

Cow's milk allergy is the most common cause of clinically relevant adverse reactions to food in infants and children. Partially and extensively hydrolyzed formulae are used for the therapy and prevention of cow's milk allergy. However, the immunogenic potency of hydrolyzed cow's milk formulae to induce and/or enhance the allergic phenotype in vivo is still under debate. The aim of this study was to assess the sensitizing capacity and residual allergenicity of various partially and extensively hydrolyzed cow's milk formulae in a murine model of cow's milk allergy.

METHODS

BALB/c mice were immunized with either a cow's milk formula or various partially and extensively hydrolyzed formulae. Immediate cutaneous hypersensitivity reactions and allergen-specific antibody production were assessed.

RESULTS

Although immunization with cow's milk resulted in 12/13 cases in a positive skin test response to intradermal injection of cow's milk formulae, only 1 mouse showed a positive skin test to one of the partially hydrolyzed formulae, and none showed positive reactions to other partially hydrolyzed formulae, any of the extensively hydrolyzed formulae, phosphate-buffered saline or the amino acid formula. However, 6 of 8 mice showed positive skin tests when immunized with partially hydrolyzed formulae and with one of the extensively hydrolyzed formulae.

CONCLUSIONS

The residual allergenic potential is markedly reduced in many hydrolyzed formulae, but most of the formulae investigated could induce an allergic immune response in BALB/c mice. Our murine model seems to be suitable to investigate the sensitizing capacity of hydrolyzed formulae and to differentiate even between extensively hydrolyzed formulae.

Anthropogenic radioactivity in the Arctic Ocean--review of the results from the joint German project

The paper presents the results of the joint project carried out in Germany in order to assess the consequences in the marine environment from the dumping of nuclear wastes in the Kara and Barents Seas. The project consisted of experimental work on measurements of radionuclides in samples from the Arctic marine environment and numerical modelling of the potential pathways and dispersion of contaminants in the Arctic Ocean. Water and sediment samples were collected for determination of radionuclide such as 137Cs, 90Sr, 239 + 240Pu, 238Pu, and 241Am and various organic micropollutants. In addition, a few water and numerous surface sediment samples collected in the Kara Sea and from the Kola peninsula were taken by Russian colleagues and analysed for artificial radionuclide by the BSH laboratory. The role of transport by sea ice from the Kara Sea into the Arctic Ocean was assessed by a small subgroup at GEOMAR. This transport process might be considered as a rapid contribution due to entrainment of contaminated sediments into sea ice, following export from the Kara Sea into the transpolar ice drift and subsequent release in the Atlantic Ocean in the area of the East Greenland Current. Numerical modelling of dispersion of pollutants from the Kara and Barents Seas was carried out both on a local scale for the Barents and Kara Seas and for long range dispersion into the Arctic and Atlantic Oceans. Three-dimensional baroclinic circulation models were applied to trace the transport of pollutants. Experimental results were used to validate the model results such as the discharges from the nuclear reprocessing plant at Sellafield and subsequent contamination of the North Sea up the Arctic Seas.

Chernobyl nuclide record from a North Sea sediment trap

Nuclides liberated by explosion and subsequent fire at Chernobyl No. 4 reactor on 26 April 1986, travelled to Western Europe with lower tropospheric air masses. They reached the northern Alps and Paris on 30 April, southern Great Britain on 2 May, the southern North Sea on 3 May, and the northern North Sea on 3 May and again on 8 May. Levels of deposited activity varied by a factor of 30 or more over distances less than 100 km because of variability of rainfall. A sediment trap deployed 222-m-deep in the North Sea off Bergen recorded the onset and magnitude of the deposition of Chernobyl nuclides. The trap collected 13 samples between 24 April and 21 September 1986. The flux of nuclides adsorbed to particles sinking from surface waters to sediments started less than ten days after contaminated air reached the site. Maximum specific activity occurred on 16-27 May for 137Cs, 134Cs, 106Ru and 103Ru, and on 8-20 June for 144Ce, 95Nb and 95Zr. The highest activity was found for 103Ru. The highest total specific activity of these nuclides in depositing sediments reached 670,000 Bq kg-1, and the highest total activity flux for one day amounted to 50 Bq m-2.