Preceptors' considerations when entrusting professional activities to postgraduate nursing students: A qualitative study

BACKGROUND

Nurse-preceptors regularly struggle to evaluate students' readiness to take care of patients unsupervised, even with sophisticated workplace-based assessment tools. Preceptors' gut feelings are not always captured well, but are critical for judgement of readiness for learner entrustment with care tasks. Studies in medical education report features that clinicians consider important when trusting students with clinical responsibilities that might also apply in nursing.

OBJECTIVES

To unravel preceptors' considerations when entrusting professional activities to postgraduate nursing students. The findings may contribute to the improvement of workplace-based assessments and the training of preceptors.

METHODS

Thematic analysis of semi-structured interviews with sixteen nurse-preceptors from three postgraduate nursing specialisations in Dutch hospitals.

RESULTS

Three themes emerged: CONCLUSIONS: For preceptors of postgraduate nursing students, entrustment requires more than merely insight into objectively measurable competencies. Entrusting is accompanied by subjectivity related to what preceptors expected of students. These expectations are in line with suggested factors in the literature-capability, integrity, reliability, agency, and humility-considered before entrusting students with clinical responsibilities identified in medical training. Entrusting is also accompanied by what preceptors realise about their own role in entrustment decisions. Combining different information sources made assessment more transparent and the implicit more explicit.

Development of a microlearning intervention regarding nursing nutritional care for older adults: A multi-methods study

BACKGROUND

Nutritional care for older adults provided by hospital and home care nurses and nursing assistants is suboptimal. This is due to several factors including professionals' lack of knowledge and low prioritisation. Affecting these factors may promote nurses' and nursing assistants' behavioral change and eventually improve nutritional care. To increase the likelihood of successfully targeting these factors, an evidence-based educational intervention is needed.

OBJECTIVES

To develop an educational intervention for hospital and home care nurses and nursing assistants to promote behaviour change by affecting factors that influence current behaviour in nutritional care for older adults. In this paper, we describe the intervention development process.

DESIGN

A multi-methods approach using literature and expert input.

SETTINGS

Hospital and home care.

PARTICIPANTS

Older adults, nurses, nursing assistants, experts, and other professionals involved in nutritional care.

METHODS

The educational intervention was based on five principles: 1) interaction between intervention and users, 2) targeting users on both individual and team level, 3) supporting direct and easy transfer to the workplace, and continuous learning, 4) facilitating learning within an appropriate period, and 5) fitting with the context. Consistent with these principles, the research team focussed on developing a microlearning intervention and they established consensus on seven features of the intervention: content, provider, mode of delivery, setting, recipient, intensity, and duration.

RESULTS

The intervention consisted of 30 statements about nursing nutritional care for older adults, which nurses and nursing assistants were asked to confirm or reject, followed by corresponding explanations. These can be presented in a snack-sized way, this means one statement per day, five times a week over a period of six weeks through an online platform.

CONCLUSIONS

Based on a well-founded and comprehensive procedure, the microlearning intervention was developed. This intervention has the potential to contribute to nursing nutritional care for older adults.

Exploring nurse-sensitive patient outcomes in Dutch district nursing care: A survey study

There is a lack of evidence to guide district nurses in using nurse-sensitive patient outcomes as it is unclear how these outcomes are currently used in daily district nursing practice. Therefore, we aimed to explore (1) which nurse-sensitive patient outcomes are measured and how these outcomes are measured, (2) how district nurses use the outcomes to learn from and improve current practice and (3) the barriers and facilitators to using outcomes in current district nursing practice. An exploratory cross-sectional survey study was conducted. The survey was distributed online among nurses working for various district nursing care organisations across the Netherlands. The responses from 132 nurses were analysed, demonstrating that different instruments or questionnaires are available and used in district nursing care as outcome measures. The nurse-sensitive patient outcomes most often measured with validated instruments are pain using the Numeric Rating Scale or Visual Analogue Scale, delirium using the Delirium Observation Scale, weight loss using the Short Nutritional Assessment Questionnaire and caregiver burden using the Caregiver Strain Index or a Dutch equivalent. Falls and client satisfaction with delivered care are most often measured using unvalidated outcome measures. The other nurse-sensitive outcomes are measured in different ways. Outcomes are measured, reported and fed back to the nursing team multiple times and in various ways to learn from and improve current practice. In general, nurses have a positive attitude towards using nurse-sensitive outcomes in practice, but there is a lack of facilitation to support them. Because insight into how nurses can and should be supported is still lacking, exploring their needs in further research is desirable. Additionally, due to the high variation in the utilisation of outcomes in current practice, it is recommended to create more uniformity by developing (inter)national guidelines on using nurse-sensitive patient outcomes in district nursing care.

Impact of organizational context on patient outcomes in a proactive primary care program:a longitudinal observational study

BACKGROUND

The effectiveness of health care interventions is co-determined by contextual factors. Unknown is the extent of this impact on patient outcomes. Therefore, the aim of this study is to explore which characteristics of general practices are associated with patient outcomes in a proactive primary care program, the U-PROFIT 2.0.

METHODS

A longitudinal observational study was conducted from January 2016 till October 2017. Two questionnaires were send out, one to collect characteristics of general practices such as practice neighbourhood socio-economic status, general practice versus healthcare centre (involving multiple primary care professionals), and professional- frail older patient ratio per practice of general practitioners and practice nurses. Regarding delivering the program, the practice or district nurse who delivered the program, number of years since the start of the implementation, and choice of age threshold for frailty screening were collected. Patient outcomes collected by the second questionnaire and send to frail patients were daily functioning, hospital admissions, emergency department visits, and general practice out-of-hours consultations. Linear and generalized linear mixed models were used.

RESULTS

A total of 827 frail older people were included at baseline. Delivery of the program by a district nurse compared to a practice nurse was significantly associated with a decrease in daily functioning on patient-level (β = 2.19; P = < 0.001). Duration since implementation of 3 years compared to 9 years was significantly associated with less out-of-hours consultations to a general practice (OR 0.11; P = 0.001). Applying frailty screening from the age of 75 compared to those targeted from the age of 60 showed a significant increase in emergency visits (OR 5.26; P = 0.03).

CONCLUSION

Three associations regarding the organizational context 1) the nurse who delivered the program, 2) the number of years the program was implemented and 3) the age threshold for defining a frail patient are significant and clinically relevant for frail patients that receive a proactive primary care program. In general, contextual factors need more attention when implementing complex primary care programs which can result in better balanced choices to enhance effective proactive care for older people living in the community.

Predictors of district nursing care utilisation for community-living people in the Netherlands: an exploratory study using claims data

OBJECTIVE

To explore predictors of district nursing care utilisation for community-living (older) people in the Netherlands using claims data. To cope with growing demands in district nursing care, knowledge about the current utilisation of district nursing care is important.

SETTING

District nursing care as a part of primary care.

PARTICIPANTS

In this nationwide study, claims data were used from the Dutch risk adjustment system and national information system of health insurers. Samples were drawn of 5500 pairs of community-living people using district nursing care (cases) and people not using district nursing care (controls) for two groups: all ages and aged 75+ years (total N=22 000).

OUTCOME MEASURES

The outcome was district nursing care utilisation and the 114 potential predictors included predisposing factors (eg, age), enabling factors (eg, socioeconomic status) and need factors (various healthcare costs). The random forest algorithm was used to predict district nursing care utilisation. The performance of the models and importance of predictors were calculated.

RESULTS

For the population of people aged 75+ years, most important predictors were older age, and high costs for general practitioner consultations, aid devices, pharmaceutical care, ambulance transportation and occupational therapy. For the total population, older age, and high costs for pharmaceutical care and aid devices were the most important predictors.

CONCLUSIONS

People in need of district nursing care are older, visit the general practitioner more often, and use more and/or expensive medications and aid devices. Therefore, close collaboration between the district nurse, general practitioner and the community pharmacist is important. Additional analyses including data regarding health status are recommended. Further research is needed to provide an evidence base for district nursing care to optimise the care for those with high care needs, and guide practice and policymakers' decision-making.

Hospital nurses' knowledge regarding older patients: a multicenter study

BACKGROUND

Nursing care in hospitals increasingly involves older adults. A nursing workforce able to care for the ageing population is therefore critical for ensuring quality older adult care. Gaining insight in the knowledge and attitudes of nurses regarding older patients in the Netherlands is needed to develop and increase the impact of education- and quality improvement programs which can positively influence nurses' knowledge and attitudes regarding older patients.

METHODS

A cross-sectional multicenter study was performed. Data was collected in ten tertiary medical teaching hospitals well spread across the Netherlands (89 wards, 2902 nurses). Knowledge levels were measured using the Knowledge about Older Patient-Quiz (KOP-Q), consisting of 30 true-false questions. Knowledge levels of registered nurses are compared with knowledge levels known from literature of first year nursing students; last year nursing students; nurses; and nurse specialist. Potential associated factors considered were: age; sex; education; experience; opinions and preferences. Opinion and preferences regarding working with older patients were measured by three questions: 1) which patient group nurses preferred to work with; 2) how nurses feel about the increase of older patients in the hospital; and 3) whether nurses find it difficult to care for older patients.

RESULTS

From all wards, a representative sample of 1743 registered hospital nurses working on all 89 wards participated. On all wards, a large range in knowledge levels is observed between nurses, with 37% of nurses presenting knowledge levels comparable with nursing student and 31% of nurses presenting knowledge levels comparable with nurse specialists. Knowledge is related to age (p < .001), work experiences (p < .001), preparatory secondary education (p < .001) and nurses education level (p = .012). A minority (12.5%) prefers working with older patients and most nurses do not find it difficult.

CONCLUSIONS

This study shows that there is a large diversity in knowledge levels of Dutch hospital nurses in every hospital, on every ward. A majority of nurses demonstrate negative opinions and preferences. This implies that older patients admitted can receive different levels of quality of care on the same day as nurses with different knowledge levels provide care during the various shifts. Findings demonstrate an urgent need for education programs with themes regarding essential care for older patients in the Netherlands.

Nurse-sensitive outcomes in district nursing care: A Delphi study

OBJECTIVES

To determine nurse-sensitive outcomes in district nursing care for community-living older people. Nurse-sensitive outcomes are defined as patient outcomes that are relevant based on nurses' scope and domain of practice and that are influenced by nursing inputs and interventions.

DESIGN

A Delphi study following the RAND/UCLA Appropriateness Method with two rounds of data collection.

SETTING

District nursing care in the community care setting in the Netherlands.

PARTICIPANTS

Experts with current or recent clinical experience as district nurses as well as expertise in research, teaching, practice, or policy in the area of district nursing.

MAIN OUTCOME MEASURES

Experts assessed potential nurse-sensitive outcomes for their sensitivity to nursing care by scoring the relevance of each outcome and the ability of the outcome to be influenced by nursing care (influenceability). The relevance and influenceability of each outcome were scored on a nine-point Likert scale. A group median of 7 to 9 indicated that the outcome was assessed as relevant and/or influenceable. To measure agreement among experts, the disagreement index was used, with a score of <1 indicating agreement.

RESULTS

In Delphi round two, 11 experts assessed 46 outcomes. In total, 26 outcomes (56.5%) were assessed as nurse-sensitive. The nurse-sensitive outcomes with the highest median scores for both relevance and influenceability were the patient's autonomy, the patient's ability to make decisions regarding the provision of care, the patient's satisfaction with delivered district nursing care, the quality of dying and death, and the compliance of the patient with needed care.

CONCLUSIONS

This study determined 26 nurse-sensitive outcomes for district nursing care for community-living older people based on the collective opinion of experts in district nursing care. This insight could guide the development of quality indicators for district nursing care. Further research is needed to operationalise the outcomes and to determine which outcomes are relevant for specific subgroups.

Hospital and home care nurses' experiences and perceptions regarding nutritional care for older adults to prevent and treat malnutrition: A cross-sectional study

AIMS AND OBJECTIVES

To gain insight into the experiences and perceptions of hospital and home care nurses regarding nutritional care for older adults to prevent and treat malnutrition.

BACKGROUND

In-depth knowledge about hospital and home care nurses' experiences and perceptions can contribute to optimise nutritional care for older adults across the care continuum between hospital and home to prevent and treat malnutrition.

DESIGN

Multicentre cross-sectional descriptive study.

METHOD

A validated questionnaire addressing malnutrition was used. A total of 1,135 questionnaires were sent to hospital and home care nurses. The STROBE statement was followed for reporting.

RESULTS

The response rate was 49% (n = 556). Of all the nurses, 37% perceived the prevalence of malnutrition among their care recipients between 10% and 25%. Almost 22% of the nurses neither agreed nor disagreed or disagreed with the statement that prevention of malnutrition is possible. More than 28% of the nurses reported that malnutrition is a small or no problem. Over 95% of the hospital nurses and 52.5% of the home care nurses stated they screened routinely for malnutrition. The nurses considered several interventions for treating malnutrition important. Over 81% of the nurses indicated they wanted to follow further training.

CONCLUSION

Most hospital and home care nurses perceived that nutritional care for older adults to prevent and treat malnutrition was important. A fair group of nurses, however, had the opposite perception.

RELEVANCE TO CLINICAL PRACTICE

Raising the awareness of all hospital and home care nurses about the importance of nutritional care for older adults is pivotal to increase the chance of successfully providing nursing nutritional care. Nurses should follow training for consolidation of nutritional care. Nurses are well-positioned to take a leadership role to improve continuity and quality of nutritional care across the care continuum between hospital and home.

Older Adults' and Their Informal Caregivers' Experiences and Needs regarding Nutritional Care Provided in the Periods before, during and after Hospitalization: A Qualitative Study

To enhance prevention and treatment of malnutrition in older adults before, during and after hospitalization, deeper understanding of older adults' and informal caregivers' perspective on nutritional care is important. One-time in-depth interviews were conducted with 15 older adults who had been discharged from hospital, and seven informal caregivers. We explored their experiences and needs regarding nutritional care provided in the periods before, during and after hospitalization. Five themes emerged from the data: (1) dietary intake, (2) food service during hospitalization, (3) nutrition-related activities, (4) whose job it is to give nutritional care, and (5) competing care priorities. Further, several opinions about nutritional issues were identified. Older adults and informal caregivers did not always experience optimal nutritional care. When discussing nutritional care, they mainly focused on the in-hospital period. When providing nutritional care and developing guidelines, older adults' and informal caregivers' perspective on nutritional care should be incorporated. Here, the periods before, during and after hospitalization should be taken into account equally.

Fidelity of primary care nurses' delivery of a behavioural change intervention enhancing physical activity in patients at risk of cardiovascular disease: an observational study

OBJECTIVE

To evaluate the fidelity of delivery of a nurse-led intervention to enhance physical activity in patients at risk for cardiovascular diseases, the Activate intervention, by assessing: (1) self-reported fidelity of delivery; (2) observed fidelity of delivery; (3) quality of delivery of the Activate intervention and (4) nurses' beliefs about their capability, motivation, confidence and effectiveness towards delivering the Activate intervention, including behavioural change techniques.

DESIGN

An observational study.

SETTING

General practices in the Netherlands.

PARTICIPANTS

Primary care nurses (n=20) from 16 general practices.

PRIMARY AND SECONDARY OUTCOME MEASURES

Nurses' self-reported fidelity was evaluated using checklists (n=282), and the observed fidelity and quality of delivery were examined using audiorecordings of consultations of the delivery of the Activate intervention (n=42). Nurses' beliefs towards delivering the intervention were assessed using questionnaires (n=72).

RESULTS

The self-reported fidelity was 88.1% and observed fidelity was 85.4%, representing high fidelity. The observed fidelity of applied behavioural change techniques was moderate (75.0%). The observed quality of delivery was sufficient and varied among nurses (mean 2.9; SD 4.4; range 0-4). Nurses' beliefs about their capability, motivation, confidence and effectiveness towards delivering the intervention increased over time.

CONCLUSIONS

Nurses delivered most intervention components as intended with sufficient quality. Nurses believed they were capable, motivated and confident to deliver the intervention. They believed the intervention was effective to increase patients' physical activity level. Despite the high fidelity and moderate fidelity of applied behavioural change techniques, the varying quality of delivery within and across nurses might have diluted the effectiveness of the Activate intervention.

TRIAL REGISTRATION NUMBER

NCT02725203.

Developing leadership in postdoctoral nurses: A longitudinal mixed-methods study

BACKGROUND

Postdoctoral nurses have an important role in advancing nursing by generating knowledge and building networks in research, practice, and education which requires effective leadership. Therefore, the Leadership Mentoring in Nursing Research programme for postdoctoral nurses was developed.

PURPOSE

This study was to evaluate expectations, experiences, and perceived influence of the leadership mentoring programme on leadership and professional development, professional identity, and research productivity of postdoctoral nurses.

METHODS

A longitudinal mixed-method study with a concurrent triangulation design was used with data collected through semistructured interviews and online surveys.

FINDINGS

The leadership mentoring programme was found to be valuable by the participants who described strengthened leadership and professional development and development of professional identities. Participants showed increased research productivity and many moved to new/higher positions.

DISCUSSION

The leadership mentoring programme was found to enhance the leadership and professional development of postdoctoral nurses and support them in their academic careers.

Implementation of an interprofessional collaboration in practice program: a feasibility study using social network analysis

BACKGROUND

Due to multimorbidity and geriatric problems, older people often require both psychosocial and medical care. Collaboration between medical and social professionals is a prerequisite to deliver high-quality care for community-living older people. Effective, safe, and person-centered care relies on skilled interprofessional collaboration and practice. Little is known about interprofessional education to increase interprofessional collaboration in practice (IPCP) in the context of community care for older people. This study examines the feasibility of the implementation of an IPCP program in three community districts and determines its potential to increase interprofessional collaboration between primary healthcare professionals caring for older people.

METHOD

A feasibility study was conducted to determine the acceptability and feasibility of data collection and analysis regarding interprofessional collaboration in network development. A questionnaire was used to measure the learning experience and the acquisition of knowledge and skills regarding the program. Network development was assessed by distributing a social network survey among professionals attending the program as well as professionals not attending the program at baseline and 5.5 months after. Network development was determined by calculating the number, reciprocity, value, and diversity of contacts between professionals using social network analysis.

RESULTS

The IPCP program was found to be instructive and the knowledge and skills gained were applicable in practice. Social network analysis was feasible to conduct and revealed a spill-over effect regarding network development. Program participants, as well as non-program participants, had larger, more reciprocal, and more diverse interprofessional networks than they did before the program.

CONCLUSIONS

This study showed the feasibility of implementing an IPCP program in terms of acceptability, feasibility of data collection, and social network analysis to measure network development, and indicated potential to increase interprofessional collaboration between primary healthcare professionals. Both program participants and non-program participants developed a larger, more collaborative, and diverse interprofessional network.

Early-Stage Feasibility of a Mobile Health Intervention (Copilot) to Enhance Exacerbation-Related Self-Management in Patients With Chronic Obstructive Pulmonary Disease: Multimethods Approach

Background

There is an emergence of mobile health (mHealth) interventions to support self-management in patients with chronic obstructive pulmonary disease (COPD). Recently, an evidence-driven mHealth intervention has been developed to support patients with COPD in exacerbation-related self-management: the Copilot app. Health care providers (HCPs) are important stakeholders as they are the ones who have to provide the app to patients, personalize the app, and review the app. It is, therefore, important to investigate at an early stage whether the app is feasible in the daily practice of the HCPs.

Objective

The aim of this study is to evaluate the perceived feasibility of the Copilot app in the daily practice of HCPs.

Methods

A multimethods design was used to investigate how HCPs experience working with the app and how they perceive the feasibility of the app in their daily practice. The feasibility areas described by Bowen et al were used for guidance. HCPs were observed while performing tasks in the app and asked to think aloud. The System Usability Scale was used to investigate the usability of the app, and semistructured interviews were conducted to explore the feasibility of the app. The study was conducted in primary, secondary, and tertiary care settings in the Netherlands from February 2019 to September 2019.

Results

In total, 14 HCPs participated in this study—8 nurses, 5 physicians, and 1 physician assistant. The HCPs found the app acceptable to use. The expected key benefits of the app were an increased insight into patient symptoms, more structured patient conversations, and more tailored self-management support. The app especially fits within the available time and workflow of nurses. The use of the app will be influenced by the autonomy of the professional, the focus of the organization on eHealth, costs associated with the app, and compatibility with the current systems used. Most HCPs expressed that there are conditions that must be met to be able to use the app. The app can be integrated into the existing care paths of primary, secondary, and tertiary health care settings. Individual organizational factors must be taken into account when integrating the app into daily practice.

Conclusions

This early-stage feasibility study shows that the Copilot app is feasible to use in the daily practice of HCPs and can be integrated into primary, secondary, and tertiary health care settings in the Netherlands. The app was considered to best fit the role of the nurses. The app will be less feasible for those organizations in which many conditions need to be met to use the app. This study provides a new approach to evaluate the perceived feasibility of mHealth interventions at an early stage and provides valuable insights for further feasibility testing.

Value of social network analysis for developing and evaluating complex healthcare interventions: a scoping review

OBJECTIVES

Most complex healthcare interventions target a network of healthcare professionals. Social network analysis (SNA) is a powerful technique to study how social relationships within a network are established and evolve. We identified in which phases of complex healthcare intervention research SNA is used and the value of SNA for developing and evaluating complex healthcare interventions.

METHODS

A scoping review was conducted using the Arksey and O'Malley methodological framework. We included complex healthcare intervention studies using SNA to identify the study characteristics, level of complexity of the healthcare interventions, reported strengths and limitations, and reported implications of SNA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews 2018 was used to guide the reporting.

RESULTS

Among 2466 identified studies, 40 studies were selected for analysis. At first, the results showed that SNA seems underused in evaluating complex intervention research. Second, SNA was not used in the development phase of the included studies. Third, the reported implications in the evaluation and implementation phase reflect the value of SNA in addressing the implementation and population complexity. Fourth, pathway complexity and contextual complexity of the included interventions were unclear or unable to access. Fifth, the use of a mixed methods approach was reported as a strength, as the combination and integration of a quantitative and qualitative method clearly establishes the results.

CONCLUSION

SNA is a widely applicable method that can be used in different phases of complex intervention research. SNA can be of value to disentangle and address the level of complexity of complex healthcare interventions. Furthermore, the routine use of SNA within a mixed method approach could yield actionable insights that would be useful in the transactional context of complex interventions.

Medication self-management: Considerations and decisions by older people living at home

BACKGROUND

Medication self-management is complicated for older people. Little is known about older persons' considerations and decisions concerning medication therapy at home.

OBJECTIVE

(s): To explore how older people living at home self-manage their medication and what considerations and decisions underpin their medication self-management behavior.

METHODS

Semi-structured interviews with consenting participants (living at home, aged ≥65, ≥5 different prescription medications daily) were recorded and transcribed with supporting photographs. Content was analyzed with a directed approach and presented according to three phases of medication self-management (initiation, execution, and discontinuation).

RESULTS

Sixty people were interviewed. In the initiation phase, participants used different techniques to inform healthcare professionals and to fill and check prescriptions. Over-the-counter medication was seldom discussed, and potential interactions were unknown to the participants. Some participants decided to not start treatment after reading the patient information leaflets for fear of side effects. In the execution phase, participants had various methods for integrating the use of new and chronic medication in daily life. Usage problems were discussed with healthcare professionals, but side effects were not discussed, since the participants were not aware that the signs and symptoms of side effects could be medication-related. Furthermore, participants stored medication in various (sometimes incorrect) ways and devised their own systems for ordering and filling repeat prescriptions. In the discontinuation phase, some participants decided to stop or change doses by themselves (because of side effects, therapeutic effects, or a lack of effect). They also mentioned different considerations regarding medication disposal and disposed their medication (in)correctly, stored it for future use, or distributed it to others.

CONCLUSIONS

Participants' considerations and decisions led to the following: problems in organizing medication intake, inadequate discussion of medication-related information with healthcare professionals, and incorrect and undesirable medication storage and disposal. There is a need for medication self-management observation, monitoring, and assistance by healthcare professionals.

Optimizing patients' functional status during daily nursing care interventions: A systematic review

Patients often experience a functional decline due to physical inactivity during illness. Nurses can influence the physical activity of patients while assisting them with activities of daily living. The purpose of this study was to identify effective interventions that are embedded in daily nursing care (irrespective of care setting) that aim to optimize the functional status of patients by increasing their physical activity. A systematic review was performed and reported following the preferred reporting items for systematic reviews and meta‐analyses. PubMed, CINAHL, and Cochrane were searched for studies from January 2002 to March 2019. The critical appraisal tools from the Joanna Briggs Institute were used to assess the risk of bias in individual studies. Study characteristics, intervention key components, and reported effects of included studies were extracted, summarized narratively, and compared. Twenty studies, evaluating nine different interventions were included. In these interventions, eight key components were identified. Four components were included in all six interventions with a positive effect on mobility, physical activity, or functional status. These components were: assessment of patient's functionality; goal setting with the patient; establishment of an individualized plan; and engagement of patients in physical and daily activity. The effects were limited due to the risk of bias in the studies, small sample sizes, limited clinical meaning of the effects, and variability of the adherence to the interventions. Multicomponent interventions were the most promising to enhance the functional status of patients. Future research should evaluate these interventions using research methods aiming at producing more rigorous evidence.

Trends in Risk of Limitations in Instrumental Activities of Daily Living Over Age in Older Persons With and Without Multiple Chronic Conditions

Background

To investigate trends over age by comorbidity status for the risk of limitations in individual activities of daily living for community-living older persons.

Methods

A longitudinal population-based study was conducted in 9,319 community-living Dutch persons aged 60 years and older. Self-reported multiple chronic conditions (MCC) and nine instrumental activities of daily livings (IADLs) were assessed in 15 studies of the Dutch National Care for the Elderly Program (TOPICS-MDS). Risks of limitations in IADLs, odds ratios (per 5 years), and rate ratios (per 5 years) were calculated with mixed logistic and negative binomial regression models with age as the underlying timescale, stratified by number of MCC (no, 1–2, ≥ 3 MCC), and corrected for confounders.

Results

At inclusion, the number of IADL limitations was highest for the “≥3 MCC” group (2.00 interquartile range [1.00–4.00]) and equal for “no MCC” or “1–2 MCC” (1.00 interquartile range [0.00–2.00]). Trends of individual IADLs depicted a higher risk in IADL limitation with increasing age over 2 years of follow-up, except for handling finances for the “no MCC” group. The longitudinal age effect on IADL limitations varied subject to MCC, being strongest for the “no MCC” group for most IADLs; grooming and telephone use were almost unaltered by age and MCC.

Conclusion

We observed a decline in IADL functioning with increasing age over 2 years of follow-up in persons with and without MCC. The impact of MCC on IADL decline varied per IADL activity.

User-Centered Design of a Mobile Health Intervention to Enhance Exacerbation-Related Self-Management in Patients With Chronic Obstructive Pulmonary Disease (Copilot): Mixed Methods Study

Background

Adequate self-management skills are of great importance for patients with chronic obstructive pulmonary disease (COPD) to reduce the impact of COPD exacerbations. Using mobile health (mHealth) to support exacerbation-related self-management could be promising in engaging patients in their own health and changing health behaviors. However, there is limited knowledge on how to design mHealth interventions that are effective, meet the needs of end users, and are perceived as useful. By following an iterative user-centered design (UCD) process, an evidence-driven and usable mHealth intervention was developed to enhance exacerbation-related self-management in patients with COPD.

Objective

This study aimed to describe in detail the full UCD and development process of an evidence-driven and usable mHealth intervention to enhance exacerbation-related self-management in patients with COPD.

Methods

The UCD process consisted of four iterative phases: (1) background analysis and design conceptualization, (2) alpha usability testing, (3) iterative software development, and (4) field usability testing. Patients with COPD, health care providers, COPD experts, designers, software developers, and a behavioral scientist were involved throughout the design and development process. The intervention was developed using the behavior change wheel (BCW), a theoretically based approach for designing behavior change interventions, and logic modeling was used to map out the potential working mechanism of the intervention. Furthermore, the principles of design thinking were used for the creative design of the intervention. Qualitative and quantitative research methods were used throughout the design and development process.

Results

The background analysis and design conceptualization phase resulted in final guiding principles for the intervention, a logic model to underpin the working mechanism of the intervention, and design requirements. Usability requirements were obtained from the usability testing phases. The iterative software development resulted in an evidence-driven and usable mHealth intervention—Copilot, a mobile app consisting of a symptom-monitoring module, and a personalized COPD action plan.

Conclusions

By following a UCD process, an mHealth intervention was developed that meets the needs and preferences of patients with COPD, is likely to be used by patients with COPD, and has a high potential to be effective in reducing exacerbation impact. This extensive report of the intervention development process contributes to more transparency in the development of complex interventions in health care and can be used by researchers and designers as guidance for the development of future mHealth interventions.

The Leadership Mentoring in Nursing Research Program for Postdoctoral Nurses: A Development Paper

PURPOSE

The Dutch Nursing Science Faculties developed the Leadership Mentoring in Nursing Research program, which aims to increase the cadre of nurse scientists, strengthen nursing research within universities, and improve the career development of postdoctoral nurses. The purpose of this article was to describe the development of the leadership and mentoring program to foster its replication and to present a formative program evaluation.

DESIGN

The leadership mentoring program was developed using a three-step procedure: a systematic review of the literature on successful leadership programs was conducted; theoretical underpinnings were identified and input; and feedback was solicited from national and international experts and changes made, resulting in the final program, which was executed from February 2016-2018.

FINDINGS

A 2-year leadership and mentoring program for postdoctoral nurses working in research was developed and executed. Ten fellows completed the program and worked on their leadership development, developed their own research programs, and established research collaborations. Formative evaluations showed that the fellows highly valued the program sessions. We have learned several key lessons on how to structure, implement, and evaluate the leadership and mentoring program.

CONCLUSIONS

Through the leadership and mentoring program, the fellows are immersed in concerted leadership development focusing on the academic leadership role. Formative evaluations showed that the program was valued by the fellows and that several key lessons were learned.

CLINICAL RELEVANCE

Through the leadership and mentoring program, 10 postdoctoral nurses strengthened their leadership in research and will further develop their role in healthcare research, clinical practice, and education.

Effectiveness of the nurse-led Activate intervention in patients at risk of cardiovascular disease in primary care: a cluster-randomised controlled trial

Background

To understand better the success of self-management interventions and to enable tailoring of such interventions at specific subgroups of patients, the nurse-led Activate intervention is developed targeting one component of self-management (physical activity) in a heterogeneous subgroup (patients at risk of cardiovascular disease) in Dutch primary care.

Aim

The aim of this study was to evaluate the effectiveness of the Activate intervention and identifying which patient-related characteristics modify the effect.

Methods

A two-armed cluster-randomised controlled trial was conducted comparing the intervention with care as usual. The intervention consisted of four nurse-led behaviour change consultations within a 3-month period. Data were collected at baseline, 3 months and 6 months. Primary outcome was the daily amount of moderate to vigorous physical activity at 6 months. Secondary outcomes included sedentary behaviour, self-efficacy for physical activity, patient activation for self-management and health status. Prespecified effect modifiers were age, body mass index, level of education, social support, depression, patient provider relationship and baseline physical activity.

Results

Thirty-one general practices (n = 195 patients) were included (intervention group n = 93; control group n = 102). No significant between-group difference was found for physical activity (mean difference 2.49 minutes; 95% confidence interval -2.1; 7.1; P = 0.28) and secondary outcomes. Patients with low perceived social support (P = 0.01) and patients with a low baseline activity level (P = 0.02) benefitted more from the intervention.

Conclusion

The Activate intervention did not improve patients’ physical activity and secondary outcomes in primary care patients at risk of cardiovascular disease. To understand the results, the intervention fidelity and active components for effective self-management require further investigation.

Trial registration: ClinicalTrials.gov NCT02725203.

POTENTIAL CLINICAL CONSEQUENCES OF ADMINISTRATIVE ISSUES REGARDING MEDICATION IN HOME CARE PATIENTS

Home care professionals observe drug-related problems (DRPs) as administrative problems (e.g. inconsistent registration of (changes in) drug prescription) and side effects which may have clinical consequences for older patients. This study aims to determine the potential clinical impact of administrative problems. A retrospective descriptive study was performed, using reports of home care professionals of the eHOME system (system that assist monitoring/reporting DRPs). Administrative problems of a one year period were assessed by three experts on potential discomfort/clinical deterioration using a 3-point scale. 309 DRPs of 120 out of 451 patients (age ≥65) were assessed. Problems involved undelivered medication administration record lists (n=103,33.3%), inconsistent registration of drug prescription (n=188,60.9%) and insufficient drug delivery (n=18,5.8%). 58.2% of the DRPs had the potential to cause moderate to severe discomfort or clinical deterioration. The results underlines the importance of the observation function of home care professionals and the need to improve pharmaceutical administration issues.

NURSES’ OPINIONS AND BELIEFS ABOUT MALNUTRITION IN OLDER ADULTS: A CROSS-SECTIONAL STUDY

Malnutrition in older adults is a frequent and major problem. Despite the fact that nurses have an essential role in nutritional care, they fail to ensure appropriate delivery in preventing and treating malnutrition. For improvement, it is necessary to understand the perspective of nurses about malnutrition. The aim of this study was to gain insight into nurses’ opinions and beliefs about malnutrition in older adults. A cross-sectional study was conducted where nurses working in different health care settings were asked to fill in a survey with twelve questions regarding different aspects of malnutrition. Nurses (n = 557) frequently observe malnutrition in older care recipients, and they consider this as a serious health problem. They believe that prevention and treatment of malnutrition is important and they see screening of malnutrition as a relevant nursing activity. They also consider nutritional care as multidisciplinary. Nurses state their need for education to give adequate nutritional care. Nurses’ opinions and beliefs about malnutrition in older adults is positive, which enhances nurses’ behavior to give sufficient nutritional care to older adults. To gain more benefit in improving nursing activities within nutritional care for older adults, more education is needed targeting nurse professionals and nurse students.

CHANGING NURSES’ BEHAVIOR TOWARD NUTRITIONAL CARE WITH A SNACK-SIZED LEARNING INTERVENTION

Nurses play an important role in the prevention and treatment of malnutrition in older adults. However, research shows that nurses lack the motivation to give adequate nutritional care. In order to change this motivation a learning intervention about nutrition in older adults targeted at nurses would be desirable. The aim of this study was to assess the development, validation, and reliability of a learning intervention about nutrition in older adults. The results show that this learning intervention has a good construct and content validity, and is psychometrically sound. Questions of the learning intervention can be presented at once or in a snack-sized way, where the questions are presented over a period of time. This learning intervention can be used for developers of similar interventions, and as part of educating programs for nursing professionals and nursing students about nutritional care for older adults.

A PROACTIVE CARE PROGRAM FOR FRAIL OLDER PEOPLE LIVING AT HOME: A 2-YEAR EVALUATION

This study presents the long-term evaluation and impact of a proactive primary care program that aims to reduce acute healthcare consumption and preservation of daily functioning of frail older people living at home. For nine years the program has been adapted and evaluated. We present the results of our implementation study with two-year follow-up. 53 general practices (GP) participated. They provided care to approximately 35000 people aged 65 years and older. Data was extracted from routine primary care data, hospital data and social care data from the municipality. Important outcomes were: number of GP visits, house visits by GP, out-of-hours primary care visits, emergency room (ER) visits, hospital admission, social support, self-sufficiency and wellbeing. After implementing the program, a significant reduction in acute visits (ER and out-of-hour visits) was observed. GP contacts and visits were also significantly increased. The program was well perceived by professionals.

Patients' perspectives on the COPD-GRIP intervention, a new nursing care intervention for COPD

Background

The nurse-led chronic obstructive pulmonary disease-Guidance Research on Illness Perception (COPD-GRIP) intervention was developed to incorporate illness perceptions into COPD care with the intention to improve the health-related quality of life of COPD patients. This individualized intervention focuses on identifying, discussing and evaluating illness perceptions and consists of three consultations with a practice nurse. The aim of this study is to explore patients’ experiences regarding the COPD-GRIP intervention.

Methods

A qualitative interview study nested in a cluster randomized trial in primary care. One-time semi-structured individual interviews with COPD patients who were guided with the COPD-GRIP intervention were conducted. During data collection, the constant comparative approach was used. All interviews were recorded, transcribed, anonymized and uploaded to MAXQDA. To identify themes, the transcripts were independently coded by two researchers.

Results

Sixteen patients were interviewed. All patients were positive and experienced an additional value of the COPD-GRIP intervention in different areas. Three main themes were identified and show that taking part in this intervention made the patients feel ‘listened to and acknowledged’, improved their awareness of the disease and its management and helped them to make lifestyle changes. Some patients suggested that the individualized care plan could be improved and to start the intervention immediately after being informed of the COPD diagnosis. All patients recommended this intervention.

Conclusion

The results of this study indicate that patients acknowledge that the COPD-GRIP intervention is a useful and promising tool for providing individualized COPD care.

Patients' experiences with a behaviour change intervention to enhance physical activity in primary care: A mixed methods study

Objective

To explore the experiences of patients at risk for cardiovascular disease in primary care with the Activate intervention in relation to their success in increasing their physical activity.

Methods

A convergent mixed methods study was conducted, parallel to a cluster-randomised controlled trial in primary care, using a questionnaire and semi-structured interviews. Questionnaires from 67 patients were analysed, and semi-structured interviews of 22 patients were thematically analysed. Experiences of patients who had objectively increased their physical activity (responders) were compared to those who had not (non-responders). Objective success was analysed in relation to self-perceived success.

Results

The questionnaire and interview data corresponded, and no substantial differences among responders and non-responders emerged. Participating in the intervention increased patients’ awareness of their physical activity and their physical activity level. Key components of the intervention were the subsequent support of nurses with whom patients’ have a trustful relationship and the use of self-monitoring tools. Patients highly valued jointly setting goals, planning actions, receiving feedback and review on their goal attainment and jointly solving problems. Nurses’ support, the use of self-monitoring tools, and involving others incentivised patients to increase their physical activity. Internal circumstances and external circumstances challenged patients’ engagement in increasing and maintaining their physical activity.

Conclusion

Patients experienced the Activate intervention as valuable to increase and maintain their physical activity, irrespective of their objective change in physical activity. The findings enable the understanding of the effectiveness of the intervention and implementation in primary care.

Trial registration

ClinicalTrials.gov NCT02725203.

Development process of a mobile electronic medical record for nurses: a single case study

Background

With the growing shortage of nurses, labor-saving technology has become more important. In health care practice, however, the fit with innovations is not easy. The aim of this study is to analyze the development of a mobile input device for electronic medical records (MEMR), a potentially labor-saving application supported by nurses, that failed to meet the needs of nurses after development.

Method

In a case study, we used an axiomatic design framework as an evaluation tool to visualize the mismatches between customer needs and the design parameters of the MEMR, and trace these mismatches back to (preliminary) decisions in the development process. We applied a mixed-method research design that consisted of analyzing of 118 external and internal files and working documents, 29 interviews and shorter inquiries, a user test, and an observation of use. By factoring and grouping the findings, we analyzed the relevant categories of mismatches.

Results

The involvement of nurses during the development was extensive, but not all feedback was, or could not be, used effectively to improve the MEMR. The mismatches with the most impact were found to be: (1) suboptimal supportive technology, (2) limited functionality of the app and input device, and (3) disruption of nurses’ workflow. Most mismatches were known by the IT department when the MEMR was offered to the units as a product. Development of the MEMR came to a halt because of limited use.

Conclusion

Choices for design parameters, made during the development of labor-saving technology for nurses, may conflict with the customer needs of nurses. Even though the causes of mismatches were mentioned by the IT department, the nurse managers acquired the MEMR based on the idea behind the app. The effects of the chosen design parameters should not only be compared to the customer needs, but also be assessed with nurses and nurse managers for the expected effect on the workflow.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0726-3) contains supplementary material, which is available to authorized users.

Nurses' perceptions towards the delivery and feasibility of a behaviour change intervention to enhance physical activity in patients at risk for cardiovascular disease in primary care: a qualitative study

Background

Self-management support is widely accepted for the management of chronic conditions. Self-management often requires behaviour change in patients, in which primary care nurses play a pivotal role. To support patients in changing their behaviour, the structured behaviour change Activate intervention was developed. This intervention aims to enhance physical activity in patients at risk for cardiovascular disease in primary care as well as to enhance nurses’ role in supporting these patients. This study aimed to evaluate nurses’ perceptions towards the delivery and feasibility of the Activate intervention.

Methods

A qualitative study nested within a cluster-randomised controlled trial using semistructured interviews was conducted and thematically analysed. Fourteen nurses who delivered the Activate intervention participated.

Results

Three key themes emerged concerning nurses’ perceptions of delivering the intervention: nurses’ engagement towards delivering the intervention; acquiring knowledge and skills; and dealing with adherence to the consultation structure. Three key themes were identified concerning the feasibility of the intervention: expectations towards the use of the intervention in routine practice; perceptions towards the feasibility of the training programme; and enabling personal development.

Conclusions

Delivering a behaviour change intervention is challenged by the complexity of changing nurses’ consultation style, including acquiring corresponding knowledge and skills. The findings have increased the understanding of the effectiveness of the Activate trial and will guide the development and evaluation of future behaviour change interventions delivered by nurses in primary care.

Trial registration

ClinicalTrials.gov NCT02725203.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0888-1) contains supplementary material, which is available to authorized users.

Comparisons of Knowledge of Dutch Nursing Students and Hospital Nurses on Aging

BACKGROUND

Although there is a growing population of older adults admitted to hospitals, the literature demonstrates knowledge deficits of nurses regarding older patients. This study investigated knowledge levels of both nursing students and RNs about older hospitalized patients in relation to their educational level and work experience.

METHOD

First- and final-year vocational and bachelor nursing students, and associate degree and bachelor degree nurses working in the hospital setting with 0 to 5 years, 6 to 15 years, and more than 15 years of experience, have completed the Knowledge about Older Patients-Quiz (KOP-Q). The KOP-Q has a clearly described theoretical base finding its origin in knowledge regarding nursing care for older patients and shows good content and construct validity.

RESULTS

A substantial proportion of participants in all groups demonstrated insufficient knowledge about older patients. A difference in knowledge exists among nurses with different educational qualifications, and a link between years of experience and higher knowledge levels of nurses is found.

CONCLUSION

Throughout the nursing career, basic care topics in relation to care for older patients should play a key role in basic nursing education programs, as well as for continuing education programs provided in hospitals for nurses. J Contin Educ Nurs. 2018;49(2):84-90.

The Effectiveness of a PRoactive Multicomponent Intervention Program on Disability in Independently Living Older People: A Randomized Controlled Trial

BACKGROUND

There is an increase in functional limitations and a decline in physical and mental well-being with age. Very few effective lifestyle interventions are available to prevent adverse outcomes such as disability in (pre-) frail older people. The effectiveness of an interdisciplinary multicomponent intervention program to prevent disability in older people in the community was tested.

METHOD

A randomized controlled trial (RCT) with a one-year follow-up was conducted in the Netherlands. Community-dwelling pre-frail older people aged 65 years and over were invited to participate. Frailty was measured with the Groningen Frailty Indicator (GFI) and categorized into non-frail (GFI=0), pre-frail (GFI = 1-3) and frail (GFI ≥ 4). The intervention program consisted of four components: a medication review, physical fitness, social skills, and nutrition.

OUTCOMES

The primary outcome was activity of daily living (ADL) measured with the Katz-6. Secondary outcomes were quality of life (SF-12) and healthcare consumption such as hospital admission, nursing home admission and primary care visits. Additional outcomes measured in the intervention group were physical fitness, Instrumental Activities of Daily Living (IADL), muscle strength, walking speed, functional capacity, mobility, feelings of depression and loneliness and nutritional status. The data were collected at baseline, after each intervention component and at a 12-month follow-up. An intention to treat analysis was used.

RESULTS

In total, there were 290 participants, and 217 (74.8%) completed the study. The mean age was 74 (SD: 7.2), most were pre-frail (59.9%), the majority were female (55.2%), and the individuals were not living alone (61.4%). After the 12-month follow-up, the median Katz-6 score did not change significantly between the two groups; adjusted Odds Ratio (OR) = 0.96 (95% Confidence Interval (CI): 0.39-2.35, p-value 0.92). No statistically significant differences were observed between the groups for quality of life and healthcare consumption. Among the participants in the intervention group, IADL (Friedman's test p <=0.04, X2 =6.50), walking speed (Friedman's test p <0.001, X2 =19.09) and functional capacity (Friedman's test p <0.001, X2 =33.29) improved significantly after the one-year follow-up. Right-hand grip strength improved immediately after completion of the intervention (Wilcoxon signed-rank test p=0.00, z= -3.39) but not after the 12-month follow-up.

CONCLUSION

The intervention program did not significantly improve daily functioning, quality of life and healthcare consumption among (pre) frail community-dwelling older persons at the one-year follow-up. Participants in the intervention group experienced improvements in walking speed, functional capacity and instrumental activities of daily living. More research is needed to better understand why may benefit and how to identify the target population.

Unravelling complex primary-care programs to maintain independent living in older people: a systematic overview

OBJECTIVES

Complex interventions are criticized for being a "black box", which makes it difficult to determine why they succeed or fail. Recently, nine proactive primary-care programs aiming to prevent functional decline in older adults showed inconclusive effects. The aim of this study was to systematically unravel, compare, and synthesize the development and evaluation of nine primary-care programs within a controlled trial to further improve the development and evaluation of complex interventions.

STUDY DESIGN AND SETTING

A systematic overview of all written data on the nine proactive primary-care programs was conducted using a validated item list. The nine proactive primary-care programs involved 214 general practices throughout the Netherlands.

RESULTS

There was little or no focus on the (1) context surrounding the care program, (2) modeling of processes and outcomes, (3) intervention fidelity and adaptation, and (4) content and evaluation of training for interventionists.

CONCLUSIONS

An in-depth analysis of the context, modeling of the processes and outcomes, measurement and reporting of intervention fidelity, and implementation of effective training for interventionists is needed to enhance the development and replication of future complex interventions.

The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care

The new COPD-GRIP (Chronic Obstructive Pulmonary Disease - Guidance, Research on Illness Perception) intervention translates evidence regarding illness perceptions and health-related quality of life (HRQoL) into a nurse intervention to guide COPD patients and to improve health outcomes. It describes how to assess and discuss illness perceptions in a structured way. This study aimed to assess the effectiveness of the intervention in primary care. A cluster randomised controlled trial was conducted within 30 general practices and five home-care centres, including 204 COPD patients. 103 patients were randomly assigned to the intervention group and 101 patients to the usual-care group. To assess differences, repeated multilevel linear mixed modelling analyses were used. Primary outcome was change in health status on the Clinical COPD Questionnaire (CCQ) at 9 months. Secondary outcomes were HRQoL, daily activities, health education impact and changes in illness perceptions. There was no significant difference between the groups in the CCQ at 9 months. We found a significant increase in health-directed behaviour at 6 weeks (p=0.024) and in personal control (p=0.005) at 9 months in favour of the intervention group. The COPD-GRIP intervention, practised by nurses, did not improve health status in COPD patients in primary care. However, the intervention has benefits in improving the ability to control the disease and health-related behaviours in the short term. Therefore, taking illness perceptions into account when stimulating healthy behaviours in COPD patients should be considered. Further study on influencing the health status and HRQoL is needed.

Self-management behaviors to reduce exacerbation impact in COPD patients: a Delphi study

Background

Little is known about which self-management behaviors have the highest potential to influence exacerbation impact in COPD patients. We aimed to reach expert consensus on the most relevant set of self-management behaviors that can be targeted and influenced to maximize reduction of exacerbation impact.

Materials and methods

A 2-round Delphi study was performed using online surveys to rate the relevance and feasibility of predetermined self-management behaviors identified by literature and expert opinion. Descriptive statistics and qualitative analyses were used.

Results

An international expert panel reached consensus on 17 self-management behaviors focusing on: stable phase (n=5): pharmacotherapy, vaccination, physical activity, avoiding stimuli and smoking cessation; periods of symptom deterioration (n=1): early detection; during an exacerbation (n=5): early detection, health care contact, self-treatment, managing stress/anxiety and physical activity; during recovery (n=4): completing treatment, managing stress/anxiety, physical activity and exercise training; and after recovery (n=2): awareness for recurrent exacerbations and restart of pulmonary rehabilitation.

Conclusion

This study has provided insight into expert opinion on the most relevant and feasible self-management behaviors that can be targeted and influenced before, during and after an exacerbation to exert the highest magnitude of influence on the impact of exacerbations. Future research should focus at developing more comprehensive patient-tailored interventions supporting patients in these exacerbation-related self-management behaviors.

Cost-Effectiveness of a Proactive Primary Care Program for Frail Older People: A Cluster-Randomized Controlled Trial

BACKGROUND

A proactive integrated approach has shown to preserve daily functioning among older people in the community. The aim is to determine the cost-effectiveness of a proactive integrated primary care program.

METHODS

Economic evaluation embedded in a single-blind, 3-armed, cluster-randomized controlled trial with 12 months' follow-up in 39 general practices in the Netherlands. General practices were randomized to one of 3 trial arms: (1) an electronic frailty screening instrument using routine medical record data followed by standard general practitioner (GP) care; (2) this screening instrument followed by a nurse-led care program; or (3) usual care. Health resource utilization data were collected using electronic medical records and questionnaires. Associated costs were calculated. A cost-effectiveness analysis from a societal perspective was undertaken. The incremental cost per quality-adjusted life-year was calculated comparing proactive screening arm with usual care, and screening plus nurse-led care arm with usual care, as well as the screening arm with screening plus nurse-led care arm.

RESULTS

Out of 7638 potential participants, 3092 (40.5%) older adults participated. Whereas effect differences were minor, the total costs per patient were lower in both intervention groups compared with usual care. The probability of cost-effectiveness at €20,000 per QALY threshold was 87% and 91% for screening plus GP care versus usual care and for screening plus nurse-led care compared to usual care, respectively. For screening plus nurse-led care vs screening plus standard GP care, the probability was 55%.

CONCLUSION

A proactive screening intervention has a high probability of being cost-effective compared to usual care. The combined intervention showed less value for money.

The Knowledge-about-Older-Patients - Quiz (KOP-Q) for nurses: Cross-cultural validation between the Netherlands and United States of America

BACKGROUND

The Knowledge about Older Patients-Quiz (KOP-Q) is designed as a unidimensional scale measuring knowledge of hospital nurses about older patients. Furthermore, the KOP-Q measures a second unidimensional construct, certainty of hospital nurses about their knowledge. The KOP-Q is developed and validated in the Netherlands. Whether the KOP-Q can be used in other countries is unknown given the cultural and language differences.

OBJECTIVES

Investigate the level of measurement invariance of the KOP-Q between the Netherlands and United States of America (USA).

DESIGN

A multicenter international cross-sectional design.

SETTINGS

Four general hospitals in the Netherlands and four general hospitals in the USA.

PARTICIPANTS

Nurses from the Netherlands (n=201) and the USA (n=130) were invited to participate by email from the ward manager, distributing flyers and present messages on the online hospital communication boards. Questions of the KOP-Q were completed online.

METHOD

The level of measurement invariance (configural, metric or scalar invariance) across countries was tested by running increasingly constrained structural equation models, and testing whether these models fitted the data.

RESULTS

Both the knowledge and certainty construct of the KOP-Q proved unidimensional in the Netherlands and USA sample. Test results of the measurement invariance across the Netherlands and USA indicated a stable, partial scalar invariance (15 items full scalar invariance) for the knowledge items and full scalar invariance for the certainty items.

CONCLUSIONS

The KOP-Q shows to function uniformly across both language groups and can therefore be used to assess nurses' knowledge and their certainty about this knowledge which can be important for educational and/or quality improvement programs in the USA. Furthermore, the KOP-Q is suitable to make comparisons between the Netherlands and the USA using latent variable models. Before the KOP-Q can be used in other countries, cross-cultural tests should again be performed.

Patient Characteristics Associated With a Successful Response to Nurse-Led Care Programs Targeting the Oldest-Old: A Comparison of Two RCTs

BACKGROUND

To improve the effectiveness of community-based care programs, especially those targeting the oldest-old population (80+), data are needed that elucidate those factors associated with a successful response to the intervention. Two comparable nurse-led care programs have been evaluated in two large randomized controlled trials (RCTs), one in Switzerland and one in the Netherlands.

AIMS

To identify common patient characteristics that are related to a successful response to proactive nurse-led care, we explored if and to what extent, identical factors were present in both study populations.

METHODS

A secondary data analysis using trial data from the intervention group of both RCTs was conducted. The study sample consisted 461 older adults, 230 from the U-PROFIT trial (the Netherlands) and 231 from the HPC trial (Switzerland). The mean age of the total sample was 85.1 years (SD 3.7). The UPROFIT intervention, delivered by registered nurses, included a frailty assessment and a comprehensive geriatric assessment (CGA) at home followed by an individualized evidence-based care plan, care coordination, and follow-up. The HCP intervention was delivered by advanced practice nurses consisting of four home visits and three phone calls, and was guided by the principles of health promotion, empowerment, partnership, and family-centeredness. A successful response was defined as "stable" or "no decline" in daily functioning at follow-up. Daily functioning was measured with 13 items of activities of daily living and instrumental activities of daily living. Multivariate logistic regression models were applied to calculate the association between individual characteristics and a successful response.

RESULTS

Almost half of the participants in the U-PROFIT trial (50.9%), and two-thirds (65.7%) of the participants in the HCP trial had a successful response at follow-up. Fewer comorbidities and a better self-rated health had the strongest predictive value for benefiting from the intervention (OR = 0.83 [95% CI 0.66-1.03], and OR = 1.5 [95% CI 0.92-2.45]), respectively.

LINKING EVIDENCE TO ACTION

Two large RCTs demonstrated that a preventive nurse-led care program can preserve daily functioning in the oldest-old population. Older people with few comorbidities and higher self-rated health had a higher likelihood of a positive outcome. Unraveling the characteristics associated with a successful response provides important information for further refining and targeting an intervention to obtain maximum effectiveness. More effort is needed to modify interventions for the oldest-old with multiple morbidities and low levels of education.

Barriers and carriers: a multicenter survey of nurses' barriers and facilitators to monitoring of nurse-sensitive outcomes in intensive care units

Aim

To identify nurses’ barriers and facilitators to monitoring of nurse‐sensitive outcomes in intensive care units (ICUs), and to explore influential nurse characteristics and work environment factors.

Design

A cross‐sectional survey in three Dutch ICUs between October 2013 ‐ June 2014.

Methods

A questionnaire with questions regarding facilitators and three types of barriers: knowledge, attitude and behaviour. The Dutch Essentials of Magnetism II was used to examine work environments.

Results

All 126 responding nurses identified pressure ulcers and patient satisfaction as outcomes that are nurse‐sensitive and nurses’ full responsibility. Lack of time (behaviour) was perceived as the most prominent barrier, followed by unfamiliarity with mandatory indicators (knowledge), and unreliability of indicators as benchmark data (attitude). Education and clear policies were relevant facilitators. Of nurse characteristics, only regularity of shifts was related to perceived attitude related barriers. The work environment factor “clinical autonomy” was potentially associated with behaviour related barriers.

HELP! Problems in executing a pragmatic, randomized, stepped wedge trial on the Hospital Elder Life Program to prevent delirium in older patients

Background

A pragmatic, stepped wedge trial design can be an appealing design to evaluate complex interventions in real-life settings. However, there are certain pitfalls that need to be considered. This paper reports on the experiences and lessons learned from the conduct of a cluster randomized, stepped wedge trial evaluating the effect of the Hospital Elder Life Program (HELP) in a Dutch hospital setting to prevent older patients from developing delirium.

Methods

We evaluated our trial which was conducted in eight departments in two hospitals in hospitalized patients aged 70 years or older who were at risk for delirium by reflecting on the assumptions that we had and on what we intended to accomplish when we started, as compared to what we actually realized in the different phases of our study. Lessons learned on the design, the timeline, the enrollment of eligible patients and the use of routinely collected data are provided accompanied by recommendations to address challenges.

Results

The start of the trial was delayed which caused subsequent time schedule problems. The requirement for individual informed consent for a quality improvement project made the inclusion more prone to selection bias. Most units experienced major difficulties in including patients, leading to excluding two of the eight units from participation. This resulted in failing to include a similar number of patients in the control condition versus the intervention condition. Data on outcomes routinely collected in the electronic patient records were not accessible during the study, and appeared to be often missing during analyses.

Conclusions

The stepped wedge, cluster randomized trial poses specific risks in the design and execution of research in real-life settings of which researchers should be aware to prevent negative consequences impacting the validity of their results. Valid conclusions on the effectiveness of the HELP in the Dutch hospital setting are hampered by the limited quantity and quality of routine clinical data in our pragmatic trial. Executing a stepped wedge design in a daily practice setting using routinely collected data requires specific attention to ethical review, flexibility, a spacious time schedule, the availability of substantial capacity in the research team and early checks on the data availability and quality.

Trial registration

Netherlands Trial Register, identifier: NTR3842. Registered on 24 January 2013.

Psychometric evaluation of the Signs of Depression Scale with a revised scoring mechanism in stroke patients with communicative impairment

OBJECTIVES

To investigate (1) the diagnostic value of the Signs of Depression Scale (SODS) in a Likert scale format and (2) whether the Likert scale improves the diagnostic value compared with the original dichotomous scale.

DESIGN

Cross-sectional multicentre study.

SETTING

One general and one university hospital in the Netherlands.

SUBJECTS

A total of 116 consecutive hospitalized stroke patients, of whom 53 were patients with communicative impairment.

MAIN MEASURES

Depression was diagnosed with the Composite International Diagnostic Interview (CIDI) administered to the patients' relatives. The Barthel Index (BI) was used as an external validator.

RESULTS

The correlation between the CIDI and the SODS-Likert or the SODS was small ( r_b = 0.18), and the correlation between the Barthel Index and the SODS-Likert ( r_s = -0.30) or the SODS ( r_s = -0.33) was moderate. For both instruments, the discriminatory power for diagnosing depression when compared with the CIDI was best at a cut-off score of ⩾2. The internal consistency of the SODS-Likert was acceptable (α = 0.69) and slightly higher than that of the SODS (α = 0.57). The inter-rater reliability of the SODS-Likert and the SODS was acceptable (intraclass correlation coefficient (ICC) 0.66 and ICC 0.80, respectively). The clinical utility was rated good.

CONCLUSION

The diagnostic value of the SODS did not improve using a Likert scale format. However, the diagnostic value of the original dichotomous SODS is reasonable for the initial mood assessment of stroke patients with communicative impairment.