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Background. The application of evidence-based lifestyle interventions is suboptimal, but little is known what interventions are actually used. This study aimed to explore the range of lifestyle interventions used in Dutch ambulatory health care settings. Method. We conducted interviews (n = 67) in purposefully selected hospitals, general practices, and community care organizations. Interviews focused on identifying activities to help patients stop smoking, reduce alcohol consumption, increase physical activity, eat a healthy diet, and lose weight. We also asked who developed the interventions. All reported activities were registered and analyzed. Results. Four categories of health promotion activities emerged: giving advice, making referrals, offering counseling, and providing lifestyle interventions organized separately from the care process. In total, 102 lifestyle interventions were reported. Forty-five interventions were developed by researchers, of which 30 were developed by the Dutch Expert Center on Tobacco Control. Providers did not know the source of 31 interventions. Eighteen interventions were developed by the providers themselves, and eight were based on evidence-based guidelines. Conclusions. Health promotion activities seemed to be widely present in Dutch health care, in particular smoking cessation interventions. Although health care providers use many different interventions, replacing nontested for evidence-based interventions is required. [ABSTRACT FROM AUTHOR]

Background: The number of chronically ill patients increases every year. This is partly due to an unhealthy lifestyle. However, the frequency and quality of (evidence-based) health promotion activities conducted by Dutch general practitioners (GPs) and practice nurses (PNs) are limited. The aim of this pilot study was to explore which lifestyle interventions Dutch GPs and PNs carry out in primary care, which barriers and facilitators can be identified and what main topics are with respect to attitudes towards health promoting activities. These topic areas will be identified for a future, larger scale study. Method: This qualitative study consisted of 25 semi-structured interviews with sixteen GPs and nine PNs. ATLAS.ti was used to analyse the transcripts of the interviews. Results: All GPs and PNs said they discuss lifestyle with their patients. Next to this, GPs and PNs counsel patients, and/or refer them to other disciplines. Only few said they refer patients to specific lifestyle programs or interventions in their own practice or in the neighbourhood. Several barriers and facilitators were identified. The main topics as barriers are: a lack of patients' motivation to make lifestyle changes, insufficient reimbursement, a lack of proven effectiveness of interventions and a lack of overview of health promoting programs in their neighbourhood. The most cited facilitators are availability of a PN, collaboration with other disciplines and availability of interventions in their own practice. With respect to attitudes, six different types of GPs were identified reflecting the main topics that relate to attitudes, varying from 'ignorer' to 'nurturer'. The topics relating to PNs attitudes towards health promotion activities, were almost unanimously positive. Conclusion: GPs and PNs all say they discuss lifestyle issues with their patients, but the health promotion activities that are organized in their practice vary. Main topics that hinder or facilitate implementation are identified, including those that relate to attitudes of GPs and PNs. [ABSTRACT FROM AUTHOR]

Aims and objectives. To examine the psychometric properties of the Nurses' Observation Scale for Cognitive Abilities. Background. Nurses' Observation Scale for Cognitive Abilities is a behavioural rating scale comprising eight subscales that represent different cognitive domains. It is based on observations during contact between nurse and patient. Design. Observational study. Methods. A total of 50 patients from two geriatric wards in acute care hospitals participated in this study. Reliability was examined via internal consistency and inter-rater reliability. Construct validity of the Nurses' Observation Scale for Cognitive Abilities and its subscales were explored by means of convergent and divergent validity and post hoc analyses for group differences. Results. Cronbach's αs of the total Nurses' Observation Scale for Cognitive Abilities and its subscales were 0·98 and 0·66-0·93, respectively. The item-total correlations were satisfactory (overall > 0·4). The intra-class coefficients were good (37 of 39 items > 0·4). The convergent validity of the Nurses' Observation Scale for Cognitive Abilities against cognitive ratings (MMSE, NOSGER) and severity of dementia (Clinical Dementia Rating) demonstrated satisfactory correlations (0·59-0·70, p < 0·01), except for IQCODE (0·30, p > 0·05). The divergent validity of the Nurses' Observation Scale for Cognitive Abilities against depressive symptoms was low (0·12, p > 0·05). The construct validity of the Nurses' Observation Scale for Cognitive Abilities subscales against 13 specific neuropsychological tests showed correlations varying from poor to fair (0·18-0·74; 10 of 13 correlations p < 0·05). Conclusions. Validity and reliability of the total Nurses' Observation Scale for Cognitive Abilities are excellent. The correlations between the Nurses' Observation Scale for Cognitive Abilities subscales and standard neuropsychological tests were moderate. More conclusive results may be found if the Nurses' Observation Scale for Cognitive Abilities subscales were to be validated using more ecologically valid tests and in a patient population with less cognitive impairment. Relevance to clinical practice. Use of the Nurses' Observation Scale for Cognitive Abilities yields standardised, reliable and valid information about patient's cognitive behaviour in daily practice. The Nurses' Observation Scale for Cognitive Abilities aids in tailoring nursing interventions to patients' specific cognitive needs. We advocate the implementation of the Nurses' Observation Scale for Cognitive Abilities both in research and at geriatric units in acute care hospitals. [ABSTRACT FROM AUTHOR]

Introduction: Care for the frail elderly is often provided by several professionals. Collaboration between them is essential, but remains difficult to achieve. Interprofessional education (IPE) can improve this collaboration. We developed a 9-hour IPE program for primary care professionals from 7 disciplines caring for the frail elderly, and aimed to establish whether the program improved professionals' interprofessional attitudes and attitudes toward collaboration, collaboration skills, and collaborative behavior. We also evaluated learners' reactions to the program. Methods: Before-after study, using the Interprofessional Attitudes Questionnaire (IAQ, score:1 to 7); Attitudes Toward Health Care Teams Scale (ATHCTS, score: 0 to 105); and Team Skills Scale (TSS, score:17 to 85). Additionally, semistructured interviews were conducted with 10 selected participants. Results: Participants' ( N = 80) overall interprofessional attitudes improved (IAQ baseline: 5.49; follow-up: 5.67, p = 0.001); attitudes toward geriatric teams did not change (ATHCTS baseline: 69.9; follow-up: 69.1, p = 0.32). Participants' self-reported team skills improved (TSS baseline: 45.7; follow-up: 48.1, p = 0.001). In the interviews, many interviewees reported increased collaboration with professionals of other disciplines due to the program. Interviewees considered the program's interprofessional nature and attending the program with local professionals important contributing factors to the experienced improvements in collaboration. However, they also noted that not all parts of the program had met the needs of all participating disciplines, due to differences in professional background and knowledge. Discussion: A brief IPE program can improve interprofessional attitudes, collaboration skills, and collaborative behavior. That such a program allows professionals to get acquainted with each other and each other's viewpoints appears to be as important as the educational content. [ABSTRACT FROM AUTHOR]

Aims and objectives. The objectives are: (1) to identify factors that influence the implementation of the guideline Triage in emergency departments [2004] in emergency departments in the Netherlands, and (2) to develop tailored implementation strategies for implementation of this guideline. Background. Guideline dissemination is no guarantee for guideline implementation. In 2004 the guideline Triage in Emergency Departments was disseminated in Dutch hospitals. Guideline revision was scheduled in 2008. Prior to the revision, factors which influenced the implementation of the guideline [2004] were studied to be addressed at the implementation of the revised guideline. Methods. This is an exploratory study using a qualitative design including: a questionnaire sent to all emergency departments in the Netherlands ( n = 108): four focus group interviews, including nurses and ward managers and in-depth interviews with ward managers and doctors. Based on the results, tailored implementation strategies and activities were suggested which target the identified influencing factors. Results. Various factors at individual, social context and organisational level were identified as influencing the implementation of the 2004 version of the guideline, namely: level of knowledge; insight and skills; work preferences; motivation and/or commitment; support; informed doctors; preliminary work and arrangements for implementation; description of tasks and responsibilities; workload and resources. Ward managers, nurses and doctors mentioned similar as well as different factors. Consequently, tailored implementation strategies and activities related to education, maintenance of change, motivation and consensus-building, information, organisation and facilitation were suggested. Conclusion. Nurses, ward managers and doctors broadly indicated similar influencing factors, although the importance of these factors differed for the different groups. For nurses, resistance and lack of resources are most important, ward managers mentioned culture and doctors the availability of doctors at the emergency department. Relevance to clinical practice. Insight into the barriers for implementation and tailoring implementation strategies to these barriers improves the implementation. [ABSTRACT FROM AUTHOR]

Background: Implementation of lifestyle interventions in patient care is a major challenge. Understanding factors that influence implementation is a first step in programs to enhance uptake of these interventions. A lifestyle-counseling intervention, Lively Legs, delivered by trained nurses, can effectively improve the lifestyle in patients with venous leg ulcers. The aim of this study was to identify factors that hindered or facilitated implementation of this intervention in outpatient dermatology clinics and in home care. Methods: A mixed-methods multiple case study in five purposefully selected healthcare settings in the Netherlands was conducted. Measurements to identify influencing factors before and after implementation of Lively Legs included interviews, focus groups, questionnaires, and nurses' registration. Analyses focused on qualitative data as the main data source. All data were compared across multiple cases to draw conclusions from the study as a whole. Results: A total of 53 patients enrolled in the Lively Legs program, which was delivered by 12 trained nurses. Barriers for implementation were mainly organizational. It was difficult to effectively organize reaching and recruiting patients for the program, especially in home care. Main barriers were a lack of a standardized healthcare delivery process, insufficient nursing time, and a lack of motivated nurses to deliver the program. Facilitating factors were nurse-driven coordination of care and a standardized care process to tie Lively Legs into, as this resulted in better patient recruitment and better program implementation. Conclusions: This study identified a range of factors influencing the implementation of a lifestyle-counseling program, mainly related to the organization of healthcare. Using a case study method proved valuable in obtaining insight into influencing factors for implementation. This study also shed light on a more general issue, which is that leg ulcer care is often fragmented, indicating that quality improvement is needed. [ABSTRACT FROM AUTHOR]

ABSTRACT The present study explored the applicability of two brief evidence-based interventions to improve sleep quality in inpatient psychiatry. The study involved three comparable admission wards of a psychiatric hospital. Stimulus control was introduced at the first ward, and music-assisted relaxation at the second. At the third ward, no intervention was introduced. A mixed-method study was employed. We found that nurses share the opinion that both interventions can be applied, but patients are hard to motivate. They perceived the lack of available time, busyness at the ward, and the lack of cooperation of patients as the main obstacles. The perception of a successful implementation is correlated with the perception of gained attention for sleep problems, the perception of increased care options, and the impression of effectiveness. Qualitative data showed that the effectiveness of the interventions was compromised by operational issues, commitment issues, adaptation to contextual limitations, and conflicting individual beliefs. We concluded that music-assisted relaxation is applicable in inpatient psychiatry. The application of stimulus control met with insurmountable operational issues. The nursing team is a very important factor for the implementation of evidence-based interventions at ward level. The lack of a shared urge for change and responsibility for continuity are important factors contributing to failure. [ABSTRACT FROM AUTHOR]

Aims and objectives. The aim of this study was to evaluate the adherence to the 2004 guideline Triage in emergency departments three years after dissemination in Dutch emergency departments. Background. In 2004, a Dutch guideline Triage in emergency departments was developed. Triage is the first step performed by nurses when a patient arrives at an emergency department. It includes the prioritisation of patients to ensure that doctors see patients with the highest medical needs first. Although the national guideline was developed and disseminated in 2004, three years on there was no insight into the level of implementation of the guideline in practice. Design. A cross-sectional descriptive design. Methods. In February 2007, data were collected from ward managers and triage nurses at all emergency departments in the Netherlands ( n = 108), using a questionnaire that was based on the recommendations and performance indicators of the guideline. Results. In total, 79% of all 108 Dutch emergency departments responded. The main findings showed that over 31% of the emergency departments did not use a triage system. Emergency departments using the Manchester Triage System had a mean adherence rate of 61% of the guideline's recommendations and emergency departments using the Emergency System Index adhered to a mean of 65%. Conclusion. The guideline Triage in emergency departments was disseminated in 2004, but results from this study indicate that an improvement in adherence to this guideline is required. Relevance to clinical practice. Adherence to guidelines is important to standardise practice to ensure that patients receive the appropriate treatment and to improve quality of care. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study which examined the quality and quantity of care provided by health professionals to patients who relied with home parenteral nutrition. The authors reveal patients' satisfaction with the nutrition support team. They add that minimal attention was given to psychosocial problems of patients. They also mention the problem experienced by patients with the general practitioner's knowledge of home parenteral nutrition.

Objectives: A labour shortage in the dementia care sector is to be expected in the near future in the Netherlands and in many other European states. The objective of this study is to analyse why people quit or avoid jobs in dementia care. Method: An integrative analysis was used to study reports, articles, and Website information on the dementia care labour market. Results: The main reason for quitting a (dementia) care job was the lack of job satisfaction. Job satisfaction was reduced by a lack of appreciation and professionals' own dissatisfaction about the quality of care they were able to provide. Effects of staff training on job satisfaction, quality of dementia care, and patient functioning are promising. Conclusion: Job satisfaction is the main cause of quitting (dementia) care jobs. It might also be the key to solving problems in the dementia care labour market. Considering health-care workers as precious capital and taking adequate measures to enhance job satisfaction might contribute to a better image of dementia care. The following hypothesis has been derived from our results: enhancement of job satisfaction will prevent professional caregivers from quitting jobs and improve the quality of care and patient outcomes. [ABSTRACT FROM AUTHOR]

Title. Fatigue in patients with rheumatoid arthritis: British and Dutch nurses’ knowledge, attitudes and management. Aim. This paper is a report of a study conducted to compare the knowledge, attitudes and current management of rheumatoid arthritis-related fatigue in British and Dutch rheumatology nurses. Background. After pain, fatigue is the most important symptom for patients with rheumatoid arthritis, but little is known about the current management of this fatigue by healthcare professionals. Methods. A questionnaire was mailed in 2007 to rheumatology nurses who were members of British Health Professionals in Rheumatology ( N = 267) and the Dutch Society of Rheumatology Nurses ( N = 227). Descriptive statistics, independent samples t-test and Pearson chi-square tests were used for statistical analysis. Results. A total of 494 nurses returned questionnaires (response rate 48%). In general, their knowledge about rheumatoid arthritis fatigue was in accordance with the literature and all indicated a positive attitude towards assessing and managing rheumatoid arthritis-related fatigue. However, respondents reported contradictory views about managing fatigue. Although they believed that other team members could help patients, they seldom referred patients on to other professionals. Although nurses believed that other advice besides pacing and balance between activity and rest might help, they did not offer this to patients. Despite acknowledging that there is poor communication about fatigue between patients and nurses, respondents reported that it is patients rather than nurses who raise the issue of fatigue in consultations. Conclusion. British and Dutch rheumatology nurses are sympathetic but do not know how to manage rheumatoid arthritis-related fatigue. Strategies to support self-management for this fatigue, and to increase communication between healthcare professionals and patients, should be initiated to help improve patient outcomes for rheumatoid arthritis-related fatigue. [ABSTRACT FROM AUTHOR]

Aim. This paper reports a study exploring the role perceptions and current activities in evidence-based practice promotion of professional nurses’ associations in the Netherlands. Background. The promotion of evidence-based practice contributes to professional standards in nursing and good quality care for patients. As professional nurses’ associations can be key players in this process, the nature of their roles and current activities deserves to be explored. Methods. Roles and activities were explored for 43 professional nurses’ associations (83% of all national associations). Data were collected using interviews with the associations’ board members. Findings from the interviews were validated with those from an analysis of the associations’ policy reports and other publications in the previous 2 years. Results. Board members primarily thought that they had roles in the selection and distribution of evidence. The roles of participant ( n = 13) and performer ( n = 13) in selecting evidence, and those of facilitator ( n = 12), initiator ( n = 15) and performer ( n = 41) in the distribution of evidence were often addressed. A few respondents reflected on roles in generating evidence and implementing evidence-based practice in patient care. A majority of the associations was contemplating activities in the promotion of evidence-based practice. Specific activities for each of six relevant aspects in the promotion of evidence-based practice were found in fewer than five associations. Conclusion. Professional nurses’ association roles in the promotion of evidence-based practice need to be viewed in relation to the tasks to be accomplished, especially those of selecting and distributing evidence. Although many organizations expressed motivation, professional nurses’ associations have a long way to go in the promotion of evidence-based practice among their members. [ABSTRACT FROM AUTHOR]

Background Providing nursing teams with feedback on quality measurements is used as a quality improvement instrument in healthcare organizations worldwide. Previous research indicated contradictory results regarding the effect of such feedback on both nurses’ well-being and performance. Objectives Building on the Job Demands-Resources model this study explores: (1) whether and how nurses’ perceptions of feedback on quality measurements (as a burdening job demand or rather as an intrinsically or extrinsically motivating job resource) are respectively related to nurses’ well-being and performance; and (2) whether and how team reflection influences nurses’ perceptions. Design An embedded case study. Settings Four surgical wards within three different acute teaching-hospital settings in the Netherlands. Methods During a period of four months, the nurses on each ward were provided with similar feedback on quality measurements. After this period, interviews with eight nurses and the ward manager for each ward were conducted. Additionally, observational data were collected from three oral feedback moments on each of the participating wards. Results The data revealed that individual nurses perceive the same feedback on quality measurements differently, leading to different effects on nurses’ well-being and performance: 1) feedback can be perceived as a job demand that pressures nurses to improve the results on the quality measurements; 2) feedback can be perceived as an extrinsically motivating job resource, that is instrumental to improve the results on quality measurements; 3) feedback can be perceived as an intrinsically motivating job resource that stimulates nurses to improve the results on the quality measurements; and 4) feedback can be perceived neither as a job demand, nor as a job resource, and has no effect on nurses’ well-being and performance. Additionally, this study indicates that team reflection after feedback seems to be very low in practice, while our data also provides evidence that nursing teams using the feedback to jointly reflect and analyse their performance and strategies will be able to better translate information about quality measurements into corrective behaviours, which may result in more positive perceptions of feedback on quality measurements among individual nurses. Conclusions To better understand the impact of feedback to nursing teams on quality measurements, we should take nurses’ individual perceptions of this feedback into account. Supporting nursing teams in team reflection after them having received feedback on quality measurements may help in eliciting positive perceptions among nurses, and therewith create positive effects of feedback on both their well-being and performance. [ABSTRACT FROM AUTHOR]

Background: No-rinse disposable wash gloves are increasingly implemented in health care to replace traditional soap and water bed baths without proper evaluation of (cost) effectiveness. Objectives: To compare bed baths for effects on skin integrity and resistance against bathing and costs. Design: Cluster randomized trial. Setting: Fifty six nursing home wards in the Netherlands. Participants: Five hundred adult care-dependent residents and 275 nurses from nursing home wards. Methods: The experimental condition 'washing without water' consists of a bed bath with disposable wash gloves made of non-woven waffled fibers, saturated with a no-rinse, quickly vaporizing skin cleaning and caring lotion. The control condition is a traditional bed bath using soap, water, washcloths and towels. Both conditions were continued for 6 weeks. Outcome measures were prevalence of skin damage distinguished in two levels of severity: any skin abnormality/lesion and significant skin lesions. Additional outcomes: resistance during bed baths, costs. Results: Any skin abnormalities/lesions over time decreased slightly in the experimental group, and increased slightly in the control group, resulting in 72.7% vs 77.6% of residents having any skin abnormalities/lesions after 6 weeks, respectively (p = 0.04). There were no differences in significant skin lesions or resistance after 6 weeks. Mean costs for bed baths during 6 weeks per resident were estimated at €218.30 (95%CI 150.52-286.08) in the experimental group and €232.20 (95% CI: 203.80-260.60) in the control group (difference €13.90 (95%CI: 25.61-53.42). Conclusion: Washing without water mildly protects from skin abnormalities/lesions, costs for preparing and performing bed baths do not differ from costs for traditional bed bathing. Thus, washing without water can be considered the more efficient alternative. [ABSTRACT FROM AUTHOR]

Background: Many strategies have been designed and evaluated to address poor hand hygiene compliance. Unfortunately, well-designed economic evaluations of hand hygiene improvement strategies are lacking. Objective: To compare the cost-effectiveness of two successful implementation strategies for improving nurses' hand hygiene compliance and reducing hospital acquired infections (HAI's). Design and setting: A cost-effectiveness analysis alongside a cluster randomised controlled trial was conducted in 67 nursing wards of three hospitals in the Netherlands. The evaluation used a hospital perspective. Participants: All affiliated nurses of the nursing wards. Wards were randomly assigned to either the control group (n = 30) or the experimental group (n = 37). Methods: The control group received a state-of-the-art strategy including education, reminders feedback and optimising materials and facilities. The experimental group received a team and leaders-directed strategy which included all elements of the state-ofthe- art strategy supplemented with interventions aimed at the social context of teams and enhancing leadership. The most efficient implementation strategy was determined by the incremental costeffectiveness ratio per extra percentage of hand hygiene compliance gained and the incremental cost-effectiveness ratio per additional percentage reduction in the HAI rate. Bootstrap methods were used to determine confidence intervals for these incremental cost-effectiveness ratio's. Two scenarios of 15 and 30% were used to express the association between increased hand hygiene compliance and the reduction in HAIs. Results: The team and leaders-directed strategy was significantly more effective in improving hand hygiene compliance. The mean difference effect was 8.91% (95% CI, 0.75-17.06). This extra increase was achieved at an average cost of €5497 per ward. The incremental cost per extra percentage of hand hygiene gained on ward level was €622. The incremental cost per additional percentage reduction in the HAI rate on ward level was €2074 (30% scenario) and €4125 (15% scenario). Within the 30% scenario, there is a probability of 90% that the team and leaders-directed strategy is cost-effective and within the 15% scenario, there is a probability of 70% that the team and leaders-directed strategy is cost-effective. Conclusions: Optimising hand hygiene compliance through a team and leaders-directed strategy is cost-effective as compared to a state-of-the-art strategy. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The aim of the study is to give insight into facilitators and barriers in pain management in trauma patients in the chain of emergency care in the Netherlands. Patients and methods: A qualitative approach was adopted with the use of the implementation Model of Change of Clinical Practice. The chain of emergency care concerned prehospital Emergency Medical Services (EMS) and Emergency Departments (EDs). We included two EMS ambulance services and three EDs and conducted five focus groups and 10 individual interviews. Stakeholders and managers of organisations were interviewed individually. Focus group participants were selected based on availability and general characteristics. Transcripts of the audio recordings and field notes were analysed in consecutive steps, based on thematic content analysis. Each step was independently performed by the researchers, and was discussed afterwards. We analysed differences and similarities supported by software for qualitative analysis MaxQDA. Results: This study identified five concepts as facilitators and barriers in pain management for trauma patients in the chain of emergency care. We described the concepts of knowledge, attitude, professional communication, organisational aspects and patient input, illustrated with quotes from the interviews and focus group sessions. Furthermore, we identified whether the themes occurred in the chain of care. Knowledge deficits, attitude problems and patient input were similar for the EMS and ED settings, despite the different positions, backgrounds and educational levels of respondents. In the chain of care a lack of professional communication and organisational feedback occurred as new themes, and were specifically related to the organisational structure of the prehospital EMS and EDs. Conclusion: Identified organisational aspects stressed the importance of organisational embedding of improvement of pain management. However, change of clinical practice requires a comprehensive approach focused at all five concepts. We think a shift in attitudes is needed, together with constant surveillance and feedback to emergency care providers. Implementation efforts need to be aimed at the identified barriers and facilitators, tailored to the chain of emergency care and the multi-professional group of emergency care providers. [Copyright &y& Elsevier]

Background: Delirium is a serious and frequent psycho-organic disorder in critically ill patients. Reported incidence rates vary to a large extent and there is a paucity of data concerning delirium incidence rates for the different subgroups of intensive care unit (ICU) patients and their short-term health consequences. Objectives: To determine the overall incidence and duration of delirium, per delirium subtype and per ICU admission diagnosis. Furthermore, we determined the short-term consequences of delirium. Design: Prospective observational study. Participants and setting: All adult consecutive patients admitted in one year to the ICU of a university medical centre. Methods: Delirium was assessed using the Confusion Assessment Method-ICU three times a day. Delirium was divided in three subtypes: hyperactive, hypoactive and mixed subtype. As measures for short-term consequences we registered duration of mechanical ventilation, re-intubations, incidence of unplanned removal of tubes, length of (ICU) stay and in-hospital mortality. Results: 1613 patients were included of which 411 (26%) developed delirium. The incidence rate in the neurosurgical (10%) and cardiac surgery group (12%) was the lowest, incidence was intermediate in medical patients (40%), while patients with a neurological diagnosis had the highest incidence (64%). The mixed subtype occurred the most (53%), while the hyperactive subtype the least (10%). The median delirium duration was two days [IQR 1–7], but significantly longer (P <0.0001) for the mixed subtype. More delirious patients were mechanically ventilated and for a longer period of time, were more likely to remove their tube and catheters, stayed in the ICU and hospital for a longer time, and had a six times higher chance of dying compared to non-delirium ICU patients, even after adjusting for their severity of illness score. Delirium was associated with an extended duration of mechanical ventilation, length of stay in the ICU and in-hospital, as well as with in-hospital mortality. Conclusions: The delirium incidence in a mixed ICU population is high and differs importantly between ICU admission diagnoses and the subtypes of delirium. Patients with delirium had a significantly higher incidence of short-term health problems, independent from their severity of illness and this was most pronounced in the mixed subtype of delirium. Delirium is significantly associated with worse short-term outcome. [Copyright &y& Elsevier]

Abstract: Objective: Investigating the effectiveness of the Lively Legs program for promoting adherence with ambulant compression therapy and physical exercise as well as effects on leg ulcer recurrence. Design: A randomized controlled trial. Setting: Eleven outpatient clinics for dermatology in the Netherlands participated in the study. Patients: 184 patients attending the outpatient clinic with leg ulcers based dominantly on a venous aetiology. Randomization was stratified by centre, age, sex and aetiology (purely venous or mixed). Intervention: The intervention group received additionally to usual care, lifestyle counselling according to the Lively Legs program, the control group received care as usual. Patient behaviour on physical activity (IPAQ), adherence to compression therapy and wound status were assessed every 6 months during a follow-up period of 18 months. Data analysis was based on the intention to treat principle, using a generalized linear model with additive link function and Bernouilli distributions. Effects on recurrence were analyzed after the first ulcer had healed using proportional hazard regression. Results: The results showed an increase in adherence with compression therapy in both groups, with no significant difference between the groups. The intervention group performed significantly better on conducting leg exercises (p <0.01) and 10min walks at five days a week (p <0.01). There was no difference on reaching 30min of walking on 5 days a week. The intervention group had less wound days (p <0.01), time till recurrence did not differ significantly (p =0.07). Conclusion: The Lively Legs program effectively increased the use of leg exercises and walking behaviour, and decreased wound time, however it did not significantly enhance use of compression stockings. Non significant effects regarding secondary outcomes may relate to the frailty of the sample. [Copyright &y& Elsevier]

Abstract: Background: Patient care guidelines are usually implemented one at a time, yet patients are at risk for multiple, often preventable, adverse events simultaneously. Objective: The SAFE or SORRY? programme targeted three adverse events (pressure ulcers, urinary tract infections and falls) and was successful in reducing the incidence of these events. This article explores the process of change and describes the effect on the preventive care given. Design: Separate data on preventive care were collected along the cluster randomised trial, which was conducted between September 2006 and November 2008. Settings: Ten hospital wards and ten nursing home wards. Participants: We monitored nursing care given to adult patients with an expected length of stay of at least five days. Methods: The SAFE or SORRY? programme consisted of the essential recommendations of guidelines for pressure ulcers, urinary tract infections and falls. A multifaceted implementation strategy was used to implement this multiple guidelines programme. Data on preventive care given to patients were collected in line with these guidelines and the difference between the intervention and the usual care group at follow-up was analysed. Results: The study showed no overall difference in preventive pressure ulcer measures between the intervention and the usual care group in hospitals (estimate=6%, CI: −7–19) and nursing homes (estimate=4%, CI: −5–13). For urinary tract infections, even statistically significantly fewer hospital patients at risk received preventive care (estimate=19%, CI: 17–21). For falls in hospitals and nursing homes, no more patients at risk received preventive care. Conclusion: Though the SAFE OR SORRY? programme effectively reduced the number of adverse events, an increase in preventive care given to patients at risk was not demonstrated. These results seem to emphasise the difficulties in measuring the compliance to guidelines. More research is needed to explore the possibilities for measuring the implementation of multiple guidelines using process indicators. [Copyright &y& Elsevier]

Abstract: Background: Patient care guidelines are usually implemented one at a time, yet patients are at risk for multiple, often preventable, adverse events simultaneously. Objective: This study aimed to test the effect of the SAFE or SORRY? programme on the incidence of three adverse events (pressure ulcers, urinary tract infections and falls). This paper describes Part I of the study: the effect on the incidence of adverse events. Design: A cluster randomised trial was conducted between September 2006 and November 2008. After a three-month baseline period the intervention was implemented followed by a nine-month follow-up period. Settings: Ten wards from four hospitals and ten wards from six nursing homes were stratified for institute and ward type and then randomised to intervention or usual care group. Participants: During baseline and follow-up, patients (≥18 years) with an expected length of stay of at least five days, were asked to participate. Methods: The SAFE or SORRY? programme consisted of the essential recommendations of guidelines for the three adverse events. A multifaceted implementation strategy was used for the implementation: education, patient involvement and feedback on process and outcome indicators. The usual care group continued care as usual. Data were collected on the incidence of adverse events and a Poisson regression model was used to estimate the rate ratio of the adverse events between the intervention and the usual care group at follow-up. Results: At follow-up, 2201 hospital patients with 3358 patient weeks and 392 nursing home patients with 5799 patient weeks were observed. Poisson regression analyses showed a rate ratio for the development of an adverse event in favour of the intervention group of 0.57 (95% CI: 0.34–0.95) and 0.67 (95% CI: 0.48–0.99) for hospital patients and nursing home patients respectively. Conclusion: This study showed that implementing multiple guidelines simultaneously is possible, which is promising. Patients in the intervention groups developed 43% and 33% fewer adverse events compared to the usual care groups in hospitals and nursing homes respectively. Even so, more research is necessary to underline these results. Trial registration: clinicaltrials.gov, number NCT00365430. [Copyright &y& Elsevier]

Background: In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce mortality from sepsis, was launched. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, effective implementation remains troublesome and no recommendations concerning the role of nurses are given. Objectives: To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback. Design and setting: A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the Netherlands. Participants: Adult patients (≥16 years old) visiting the ED because of a known or suspected infection to whom two or more of the extended systemic inflammatory response syndrome (SIRS) criteria apply. Methods: We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis: measure serum lactate within 6h, obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine for urinalysis and culture, start antibiotics within 3h, and hospitalize or discharge the patient within 3h. Results: A total of 825 patients were included in the study. Compliance with the complete bundle significantly improved from 3.5% at baseline to 12.4% after our entire implementation program was put in place. The completion of four of six individual elements improved significantly, namely: measure serum lactate (improved from 23% to 80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from 49% to 67%), and start antibiotics within 3h (from 38% to 56%). The mean number of performed bundle elements improved significantly from 3.0 elements at baseline to 4.2 elements after intervention [1.2; 95% confidence interval=0.9–1.5]. Conclusions: Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback. [Copyright &y& Elsevier]

Abstract: Background: Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy. Objectives: The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses. Design: A cluster randomised trial was conducted between September 2006 and July 2008. Settings: Ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward. Participants: All nurses from participating wards. Methods: A knowledge test measured nurses’ knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately. Results: After correction for baseline, the mean difference between the intervention and the control group on hospital nurses’ knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: −0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10–0.81). For the other two topics there was no statistically significant effect. Nursing home nurses’ knowledge did neither improve (0 points, CI: −0.35 to 0.35) overall, nor for the separate subjects. Conclusion: The educational intervention improved hospital nurses’ knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is needed. Trial registration: ClinicalTrials.gov ID [NCT00365430]. [Copyright &y& Elsevier]

Previous studies on the effects of providing feedback about quality improvement measures to nurses show mixed results and the factors explaining the variance in effects are not yet well-understood. One of the factors that could explain the variance in outcomes is how nurses perceive the feedback. It is not the feedback per se that influences nurses, and consequently their performance, but rather the way the feedback is perceived. This article aims to enhance our understanding of Human Resource attributions and employee engagement and burnout in a feedback environment. An in-depth study of nurses' attributions about the 'why' of feedback on quality measurements, and its relation to engagement and burnout, was performed. A convergent mixed-methods, multiple case study design was used. Evidence was drawn from four comparable surgical wards within three teaching hospitals in the Netherlands that volunteered to participate in this study. Nurses on each ward were provided with oral and written feedback on quality measurements every two weeks, over a four month period. After this period, an online survey was distributed to all the nurses (n = 184) on the four participating wards. Data were collected from 91 nurses. Parallel to the survey, individual, semi-structured face-to-face interviews were conducted with eight nurses and their ward manager in each ward, resulting in interview data from 32 nurses and four ward managers. Results show that nurses – both as a group and individually – make varying attributions about their managers' purpose in providing feedback on quality measurements. The feedback environment is associated to nurses' attributions and these attributions are related to nurses' burnout. By showing that feedback on quality measurements can be attributed differently by nurses and that the feedback environment plays a role in this, the study provides an interesting mechanism for explaining how feedback is related to performance. Implications for theory, practice and future research are discussed. [ABSTRACT FROM AUTHOR]

Background: Previous studies on the effects of providing feedback about quality improvement measures to nurses show mixed results and the factors explaining the variance in effects are not yet well-understood. One of the factors that could explain the variance in outcomes is how nurses perceive the feedback. It is not the feedback per se that influences nurses, and consequently their performance, but rather the way the feedback is perceived., Objectives: This article aims to enhance our understanding of Human Resource attributions and employee engagement and burnout in a feedback environment. An in-depth study of nurses' attributions about the 'why' of feedback on quality measurements, and its relation to engagement and burnout, was performed., Design and Methods: A convergent mixed-methods, multiple case study design was used. Evidence was drawn from four comparable surgical wards within three teaching hospitals in the Netherlands that volunteered to participate in this study. Nurses on each ward were provided with oral and written feedback on quality measurements every two weeks, over a four month period. After this period, an online survey was distributed to all the nurses (n = 184) on the four participating wards. Data were collected from 91 nurses. Parallel to the survey, individual, semi-structured face-to-face interviews were conducted with eight nurses and their ward manager in each ward, resulting in interview data from 32 nurses and four ward managers., Results: Results show that nurses - both as a group and individually - make varying attributions about their managers' purpose in providing feedback on quality measurements. The feedback environment is associated to nurses' attributions and these attributions are related to nurses' burnout., Conclusions: By showing that feedback on quality measurements can be attributed differently by nurses and that the feedback environment plays a role in this, the study provides an interesting mechanism for explaining how feedback is related to performance. Implications for theory, practice and future research are discussed., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Brief admission (BA) is a widely used intervention for patients with a borderline personality disorder but it has not yet clearly defined and still lacks clear operational standards. To fully develop this intervention, the relevant components need to be identified and clearly documented., Objective: To obtain consensus on the components of BA as a crisis intervention for patients with a borderline personality disorder., Design: Modified Delphi study., Results: Consensus of 100% was reached for the components: "BA plan must be developed together with the patient"; "The BA intervention should be mentioned in the care plan for the patient"; "Not all behavior on the part of the patient has to be accepted during a BA"; and "The BA can only be offered together with treatment by a community care professional.", Conclusion: Consensus on the components of BA was reached for 82 of the 90 components. This indicates a substantial degree of agreement on what BA should entail.

Aim: The purpose of this study was to determine construct validity of the Dutch Essentials of Magnetism II © instrument, designed to assess nursing practice environments, using hypotheses testing., Background: Reduction in hospital length of stay and the number of inpatient beds increases care intensity. Educational levels and numbers of nursing staff in hospitals, however, do not match this increase, resulting in a strain on quality of care and patient safety. A possible answer to existing concerns about quality of care may be the creation of a productive and healthy practice environment, as this has an impact on the quality of care. Therefore, areas requiring improvement of the practice environment have to be defined., Design: A cross-sectional, correlational study design., Method: We determined construct validity with hypotheses testing by relating the Dutch Essentials of Magnetism II to the Dutch Practice Environment Scale of the Nursing Work Index. We formulated 15 hypotheses prior to data-analysis; 10 related to convergent validity and five related to discriminant validity. Data were collected from qualified nurses (N = 259) on nine randomly selected hospital wards from March to April 2012., Results: Response rate was 47% (n = 121). Total scores of both instruments are strongly correlated (r = 0·88). In total, 12 of 15 hypotheses (80%) were confirmed and three were rejected., Conclusion: The D-EOMII has satisfactory construct validity for measuring the nursing practice environment in hospitals and can be used by nurses, managers, health policy makers, hospitals and governments to assess and identify processes and relationships that are in need of improvement., (© 2017 John Wiley & Sons Ltd.)

Background: Although frail older people can be more reluctant to become involved in clinical decision making, they do want professionals to take their concerns and wishes into account. Discussing goals can help professionals to achieve this., Objective: To describe the development of a two-step method for discussing goals with frail older people in primary care and professionals' first experiences with it., Methods: The method consisted of (i) an open-ended question: If there is one thing we can do for you to improve your situation, what would you like? if necessary, followed by (ii) a bubble diagram with goal subject categories. We reviewed the goals elaborated with the method and surveyed professionals' (primary care nurses and social workers) experiences, using questions concerning time investment, reasons for not formulating goals, and perceived value of the method., Results: One hundred and thirty-seven community-dwelling frail older people described 173 goals. These most frequently concerned mobility (n = 43; 24.9%), well-being (n = 52; 30.1%) and social context (n = 57; 32.9%). Professionals (n = 18) were generally positive about the method, as it improved their knowledge about what the frail older person valued. Not all frail older people formulated goals; reasons for this included being perfectly comfortable, not being used to discussing goals or cognitive problems limiting their ability to formulate goals., Conclusions: This two-step method for discussing goals can assist professionals in gaining insight into what a frail older person values. This can guide professionals and frail older people in choosing the most appropriate treatment option, thus increasing frail older people's involvement in decision making., (© 2013 John Wiley & Sons Ltd.)

Objectives: Adherence to prehospital guidelines and protocols is suboptimal. Insight into influencing factors is necessary to improve adherence. The aim of this study was to identify factors that influence ambulance nurses' adherence to a National Protocol Ambulance Care (NPAC)., Methods: A questionnaire was developed using the literature, a questionnaire and expert opinion. Ambulance nurses (n=452) from four geographically spread emergency medical services (EMSs) in the Netherlands were invited to fill out the questionnaire. The questionnaire included questions on influencing factors and self-reported adherence., Results: Questionnaires were returned by 248 (55%) of the ambulance nurses. These ambulance nurses' adherence to the NPAC was 83.4% (95% confidence interval 81.9-85.0). Bivariate correlations showed 23 influencing factors that could be related to the individual professional, organization, protocol characteristics and social context. Multilevel regression analysis showed that 21% of the variation in adherence (R=0.208) was explained by protocol characteristics and social influences., Conclusion: Ambulance nurses' self-reported adherence to the NPAC seems high. To improve adherence, protocol characteristics (complexity, the degree of support for diagnosis and treatment, the relationship of the protocol with patient outcomes) and social influences (expectance of colleagues to work with the national protocol) should be addressed.

Objective: To standardize patient handover in the chain of emergency care a handover guideline was developed. The main guideline recommendation is to use the DeMIST model (Demographics, Mechanism of Injury/illness, Injury/Illness, Signs, Treatment given) to structure pre-hospital notification and handover. To benefit from the new guideline, guideline adherence is necessary. As adherence to guidelines in emergency care settings is variable, there is a need to systematically implement the new guideline. For implementation of the guideline we developed a e-learning program tailored to influencing factors. The aim of the study was to evaluate the effectiveness of this e-learning program to improve emergency care professionals' adherence to the handover guideline during pre-hospital notification and handover in the chain of emergency medical service (EMS), emergency medical dispatch (EMD), and emergency department (ED)., Methods: A prospective pre-test post-test study was conducted. The intervention was a tailored e-learning program that was offered to ambulance crew and emergency medical dispatchers (n=88). Data on adherence included pre-hospital notifications and handovers and were collected through observations and audiotapes before and after the e-learning program. Data were analyzed using X(2)-tests and t-tests., Results: In total, 78/88 (88.6%) professionals followed the e-learning program. During pre- and post-test, 146 and 169 handovers were observed respectively. After the e-learning program, no significant difference in the number of handovers with the DeMIST model (77.9% vs. 73.1%, p=.319) and the number of handovers with the correct sequence of the DeMIST model (69.9% vs. 70.5%, p=.159) existed. During the handover, the number of questions by ED staff and interruptions significantly increased from 49.0% to 68.9% and from 15.2% to 52.7% respectively (both p=.000). Most handovers were performed after patient transfer, this did not change after the intervention (p=.167). The number of handovers where information was documented during handover slightly increased from 26.9% to 29.3% (p=.632)., Conclusions: The tailored e-learning program did not improve adherence to a handover guideline in the chain of emergency care. Results show a relatively high baseline adherence rate to usage and correct sequence of the DeMIST model. Improvements in the handover process can be made on the documentation of information during handover, the number of interruptions and questions, and the handover moment.

Background: Delirium in critically ill patients has a strong adverse impact on prognosis. In spite of its recognized importance, however, delirium screening and treatment procedures are often not in accordance with current guidelines. This implementation study is designed to assess barriers and facilitators for guideline adherence and next to develop a multifaceted tailored implementation strategy. Effects of this strategy on guideline adherence as well as important clinical outcomes will be described., Methods: Current practices and guideline deviations will be assessed in a prospective baseline measurement. Barriers and facilitators will be identified from a survey among intensive care health care professionals (intensivists and nurses) and focus group interviews with selected health care professionals (n=60). Findings will serve as a foundation for a tailored guideline implementation strategy. Adherence to the guideline and effects of the implementation strategies on relevant clinical outcomes will be piloted in a before-after study in six intensive care units (ICUs) in the southwest Netherlands. The primary outcomes are adherence to screening and treatment in line with the Dutch ICU delirium guideline. Secondary outcomes are process measures (e.g. attendance to training and knowledge) and clinical outcomes (e.g. incidence of delirium, hospital-mortality changes, and length of stay). Primary and secondary outcome data will be collected at four time points including at least 924 patients. Furthermore, a process evaluation will be done, including an economical evaluation., Discussion: Little is known on effective implementation of delirium management in the critically ill. The proposed multifaceted implementation strategy is expected to improve process measures such as screening adherence in line with the guideline and may improve clinical outcomes, such as mortality and length of stay. This ICU Delirium in Clinical Practice Implementation Evaluation study (iDECePTIvE-study) will generate important knowledge for ICU health care providers on how to improve their clinical practice to establish optimum care for delirious patients., Trials Registration: Clinical Trials NCT01952899.

Introduction: Adherence to ambulance and ED protocols is often suboptimal. Insight into factors influencing adherence is a requisite for improvement of adherence. This study aims to gain an in-depth understanding of factors that influence ambulance and emergency nurses' adherence to protocols., Methods: Semi-structured interviews were held with ambulance nurses, emergency nurses, and physicians (N = 20) with medical end responsibility in the Netherlands to explore influencing factors. Content analysis was used to identify influencing factors., Results: The main influencing factors for adherence were individual factors, including individual (clinical) experience, awareness, and the preference of following local protocols instead of national protocols. Organizational or external factors were involvement in protocol development, training and education, control mechanisms for adherence, and physicians' interest. Also of influence were protocol characteristics including integration of the advanced trauma life support approach, being in accordance with daily practice, and the generality of the content. Influencing factors could be a barrier as well as a facilitator for adherence., Discussion: Factors influencing ambulance and emergency nurses' protocol adherence could be assigned to individual, organizational, and external categories, as well as to protocol characteristics. To improve adherence, implementation strategies should be tailored to identified factors. Multifaceted implementation strategies will be needed to improve adherence., (Copyright © 2014 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Background: There is only limited understanding of why hand hygiene improvement strategies are successful or fail. It is therefore important to look inside the 'black box' of such strategies, to ascertain which components of a strategy work well or less well. This study examined which components of two hand hygiene improvement strategies were associated with increased nurses' hand hygiene compliance., Methods: A process evaluation of a cluster randomised controlled trial was conducted in which part of the nursing wards of three hospitals in the Netherlands received a state-of-the-art strategy, including education, reminders, feedback, and optimising materials and facilities; another part received a team and leaders-directed strategy that included all elements of the state-of-the-art strategy, supplemented with activities aimed at the social and enhancing leadership. This process evaluation used four sets of measures: effects on nurses' hand hygiene compliance, adherence to the improvement strategies, contextual factors, and nurses' experiences with strategy components. Analyses of variance and multiple regression analyses were used to explore changes in nurses' hand hygiene compliance and thereby better understand trial effects., Results: Both strategies were performed with good adherence to protocol. Two contextual factors were associated with changes in hand hygiene compliance: a hospital effect in long term (p < 0.05), and high hand hygiene baseline scores were associated with smaller effects (p < 0.01). In short term, changes in nurses' hand hygiene compliance were positively correlated with experienced feedback about their hand hygiene performance (p < 0.05). In the long run, several items of the components 'social influence' (i.e., addressing each other on undesirable hand hygiene behaviour p < 0.01), and 'leadership' (i.e., ward manager holds team members accountable for hand hygiene performance p < 0.01) correlated positively with changes in nurses' hand hygiene compliance., Conclusion: This study illustrates the use of a process evaluation to uncover mechanisms underlying change in hand hygiene improvement strategies. Our study results demonstrate the added value of specific aspects of social influence and leadership in hand hygiene improvement strategies, thus offering an interpretation of the trial effects., Trial Registration: The study is registered in ClinicalTrials.gov, dossier number: NCT00548015.

Background: Improving hand hygiene compliance is still a major challenge for most hospitals. Innovative approaches are needed., Objective: We tested whether an innovative, theory based, team and leaders-directed strategy would be more effective in increasing hand hygiene compliance rates in nurses than a literature based state-of-the-art strategy., Design and Setting: A cluster randomised controlled trial called HELPING HANDS was conducted in 67 nursing wards of three hospitals in the Netherlands., Participants: All affiliated nurses of the nursing wards. Wards were randomly assigned to either the team and leaders-directed strategy (30 wards) or the state-of-the-art strategy (37 wards)., Methods: The control arm received a state-of-the-art strategy including education, reminders, feedback and targeting adequate products and facilities. The experimental group received all elements of the state-of-the-art strategy supplemented with interventions based on social influence and leadership, comprising specific team and leaders-directed activities. Strategies were delivered during a period of six months. We monitored nurses' HH compliance during routine patient care before and directly after strategy delivery, as well as six months later. Secondary outcomes were compliance with each type of hand hygiene opportunity, the presence of jewellery and whether the nurses wore long-sleeved clothes. The effects were evaluated on an intention-to-treat basis by comparing the post-strategy hand hygiene compliance rates with the baseline rates. Multilevel analysis was applied to compensate for the clustered nature of the data using mixed linear modelling techniques., Results: During the study, we observed 10,785 opportunities for appropriate hand hygiene in 2733 nurses. The compliance in the state-of-the-art group increased from 23% to 42% in the short term and to 46% in the long run. The hand hygiene compliance in the team and leaders-directed group improved from 20% to 53% in the short term and remained 53% in the long run. The difference between both strategies showed an Odds Ratio of 1.64 (95% CI 1.33-2.02) in favour of the team and leaders-directed strategy., Conclusions: Our results support the added value of social influence and enhanced leadership in hand hygiene improvement strategies. The methodology of the latter also seems promising for improving team performance with other patient safety issues., Trial Registration: ClinicalTrials.gov [NCT00548015]., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: The aim of this study was to compare conventional medical follow-up with follow-up containing additional nursing consultations regarding the psychosocial adjustment and health-related quality of life (HRQOL) of head and neck cancer patients., Methods: Using a quasi-experimental design, patients were enrolled consecutively into two groups. Experimental care covered six 30-min bimonthly nursing follow-up consultations during the first year posttreatment. Data were collected at posttreatment months 1 (baseline), 6, and 12 for both groups., Results: The intervention group was significantly worse at baseline, based on two of the seven adjustment scales and on the majority of HRQOL scales. However, their outcome at 6 and 12 months was consistent with that of the group which received conventional follow-up. Thus, the intervention group had a larger improvement in scores, and this was significant for one of the seven adjustment scales and 19 of the 33 HRQOL scales at 6 and 12 months, respectively. Most of the differences in HRQOL scales were clinically relevant at 6 months., Conclusion: These results suggest that nurse-led consultations for patients with head and neck cancer have a positive effect, primarily with respect to HRQOL. Nurse-led follow-up leads to a similar psychosocial adjustment as conventional follow-up, even among patients who showed worse performance at the start of follow-up. Thus, nurse-led follow-up may be a cost-effective way to improve follow-up care for this patient group.

Background: With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly., Methods/design: The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver 'care as usual'. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models/multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients' and professionals' approval of the program, and the barriers and facilitators to implementation., Discussion: The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care., Trial Registration: The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797.

Background: Although hand hygiene (HH) compliance has been an important issue for years, the compliance rate is still a problem in health care today., Methods: This was an observational, prospective, before-and-after study. We measured HH knowledge and HH compliance before (baseline), directly after (poststrategy), and 6 months after the performance of HH team strategies (follow-up). The study was composed of employed nurses and physicians working in the department of internal medicine of a university hospital. We performed a multifaceted improvement program including HH education, feedback, reminders, social influence activities including the use of role models, and improvement of HH facilities., Results: Ninety-two nurses and physicians were included. Compared with baseline, there was a significant improvement in the overall mean HH knowledge score at poststrategy (from 7.4 to 8.4) and follow-up (from 7.4 to 8.3). The overall HH compliance was 27% at baseline, 83% at poststrategy, and 75% at follow-up. At baseline, the compliance rate was 17% in nurses and 43% in physicians and significantly improved to 63% in nurses and 91% in physicians at follow-up., Conclusion: Our multifaceted HH improvement program resulted in a sustained improvement of HH knowledge and compliance in nurses as well as physicians., (Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Due to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved., Methods: Mixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12)., Results: 290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people's exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP., Conclusions: This study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising.

The objective of this study was to identify factors that influence emergency nurses' adherence to an emergency department national protocol (EDNP). A survey of emergency nurses (n=200) and physicians with medical end responsibility on an emergency department (n=103) was carried out. Emergency nurses' self-reported adherence to the EDNP was 38%, 55% of the nurses and 44% of the physicians were aware of the protocol. Interference with professional autonomy, insufficient organizational support and the EDNP's applicability were indicated as barriers for adherence. The main influencing factor seems awareness. Other factors related to the individual, the organization and to protocol characteristics. Solely disseminating the EDNP is not enough to get the protocol used in clinical practice.

Background: Hand hygiene prescriptions are the most important measure in the prevention of hospital-acquired infections. Yet, compliance rates are generally below 50% of all opportunities for hand hygiene. This study aims at evaluating the short- and long-term effects of two different strategies for promoting hand hygiene in hospital nurses., Methods/design: This study is a cluster randomised controlled trial with inpatient wards as the unit of randomisation. Guidelines for hand hygiene will be implemented in this study. Two strategies will be used to improve the adherence to guidelines for hand hygiene. The state-of-the-art strategy is derived from the literature and includes education, reminders, feedback, and targeting adequate products and facilities. The extended strategy also contains activities aimed at influencing social influence in groups and enhancing leadership. The unique contribution of the extended strategy is built upon relevant behavioural science theories. The extended strategy includes all elements of the state-of-the-art strategy supplemented with gaining active commitment and initiative of ward management, modelling by informal leaders at the ward, and setting norms and targets within the team. Data will be collected at four points in time, with six-month intervals. An average of 3,000 opportunities for hand hygiene in approximately 900 nurses will be observed at each time point., Discussion: Performing and evaluating an implementation strategy that also targets the social context of teams may considerably add to the general body of knowledge in this field. Results from our study will allow us to draw conclusions on the effects of different strategies for the implementation of hand hygiene guidelines, and based on these results we will be able to define a preferred implementation strategy for hospital based nursing., Trial Registration: The study is registered as a Clinical Trial in ClinicalTrials.gov, dossier number: NCT00548015.

Background: Complications related to venous access devices (VADs) remain the major drawback of home parenteral nutrition (HPN) support. In addition to technical issues, patients also experience psychosocial problems. The aim of this study is to present an overview of VAD-related complications in patients on long-term HPN and to assess whether these adversities are related to experienced psychosocial problems and quality of life (QOL)., Methods: Information on VAD-related complications was collected from the medical charts of 110 adult HPN patients who were followed by the 2 major referral centers in the Netherlands. In addition, a survey was conducted in this group to characterize psychosocial problems and assess their association with technique-related complications; 75 patients (68%) responded., Results: At the time of survey, the majority of patients (76%) had developed 1 or more episodes of catheter-related sepsis at some point during their HPN treatment. The overall incidence of VAD-related blood stream infections (BSIs) was 3 per 1,000 venous access days. The incidence of VAD occlusions was 0.8 per 1,000 venous access days. During the observation period, there was a highly significant association between the incidence of VAD-related complications and the occurrence of psychosocial complaints (eg, depression, fatigue, social impairment, and decreased QOL)., Conclusions: Psychosocial complaints are associated with previously experienced VAD-related complications in patients on HPN therapy. Although only an association, and not a causal relationship is demonstrated by these findings, our results underscore the need for preventive and therapeutic measures regarding both types of problems in these patients.

Background: Cancer patients are presented with advice and instructions during treatment and at discharge. Most recommendations aim at relief of physical problems, psychosocial well-being, and patients' health care behaviors. Patients often struggle to incorporate advice into daily life, and this influences symptom relief, quality of life, and even longevity., Objective: The aim of this study was to gain insight into the content and form of discharge advice to cancer patients and to determine the factors that hinder or promote the actual adoption of advice by patients., Methods: Using a descriptive, exploratory research design, data were collected using structured interviews in a convenience sample of 21 head and neck cancer patients who had completed treatment with curative intent 2 to 6 months earlier. Descriptive statistics and a thematic content analysis procedure were used to analyze the data., Results: Findings showed that advice or instructions received by individual patients had a range from 1 to 13, and that 17 out of 21 patients received 4 advices or more. Relevant influencing factors included patient characteristics (cognition, emotion, behavior, and social aspects) and characteristics of health professionals (content and efficacy of advice, professional attitude, behavior, and communication)., Conclusions: Cancer patients try but often struggle to fit the multitude and complexity of advice from health professionals into everyday life., Implications for Practice: There seems to be an excellent opportunity for health professionals to support cancer patients by further tailoring of follow-up care. Knowledge and insight into the challenges patients face posttreatment will benefit both professionals and patients.

Objectives: To construct a set of quality indicators (QIs) for dementia diagnosis and management in a primary care setting., Design: RAND modified Delphi method, including a postal survey, a stakeholders consensus meeting, a scientific expert consensus meeting, and a demonstration project., Setting: Primary care., Participants: General practitioners (GPs), primary care nurses (PCNs), and informal caregivers (ICs) in postal survey and stakeholders consensus meeting. Eight national dementia experts in scientific consensus meeting. Thirteen GPs in the demonstration project., Measurements: Mean face validity and feasibility scores. Compliance rates using GPs' electronic medical record data., Results: The initial set consisted of 31 QIs. Most indicators showed moderate or good face validity and feasibility scores. Consensus panels reduced the preliminary set used in the demonstration project to 24 QIs. The overall compliance to the QIs was 45.3%. Discriminative validity of the set was good; significant differences in adherence were found between GPs with high and low levels of patients aged 65 and older in their practice, with and without PCNs, and with positive and negative attitudes toward dementia (all P<.05). Based on the demonstration project, one QI was excluded. The final set consisted of 23 QIs; 15 QIs contained innovative quality criteria on collaboration between GPs and PCNs, referral criteria, and assessment of caregivers' needs., Conclusion: This new set of dementia QIs is feasible, reliable, and valid and can be used to improve primary dementia care. Because of the innovative quality criteria, the set is complementary to the existing dementia QIs.

Purpose: This article describes the content of and adherence with a nurse-led home visiting programme (Dutch Geriatric Intervention Programme; DGIP) for vulnerable older people. The randomised Dutch EASYcare Study showed positive patient endpoints for DGIP. Describing content and adherence is rarely performed, but highly important for understanding the results of trials., Method: DGIP is a complex multicomponent intervention tailored to the patients' needs. This process evaluation describes these components and patient characteristics and creates meaningful clusters of these specific components using hierarchical cluster analysis. Both patient/caregiver and physician adherence rates and possible predictors were investigated., Results: In line with the heterogeneity among the subjects, the individual treatment plans turned out to be highly tailored. Cluster analysis identified five clusters of intervention components. DGIP turned out to be largely unsuitable for one group of very vulnerable older participants in urgent need of more care. Overall, physician adherence was 75% and was better than patient adherence (51% complete/partial adherence). Adherence levels increased when both patients, caregivers and physicians received recommendations., Conclusions: The content of a multicomponent tailored home-visiting programme was very diverse, matching the heterogeneity among frail elderly subjects. Detailed process and cluster analysis helped to understand the content of the intervention, sharpen target criteria and identify possibilities to improve adherence.

Objective: caregiver effects of geriatric care models focusing primarily at the patient have not been consistently studied. We studied caregiver effects of a nurse-led comprehensive geriatric evaluation and management (GEM) programme for community-dwelling frail older people that showed-in a randomised comparison with usual care--health-related quality of life benefits for the care receivers., Methods: this randomised trial included 110 caregiver/patient dyads who were followed up for 6 months. Primary analyses were intention-to-treat analyses of caregiver burden assessed with Zarit Burden Interview (ZBI; 0-88; higher means more burden). Preplanned subgroup analyses were conducted for cognition, living arrangement and patient/caregiver co-residence., Results: overall, perceived caregiver burden showed no significant differences between study groups in changes over time. However, perceived burden was at baseline more than eight points higher in caregivers sharing a household with patients (n = 23) compared to caregivers living separately (n = 87). The intervention performed better in caregivers living together with the patient than in caregivers living separately (P for interaction = 0.04). Co-resident caregivers experienced six-Zarit point improvement compared with four-point deterioration in the non-co-resident caregivers., Conclusions: GEM at home benefited patients, but maybe not caregivers. Caregiver effects are related to whether caregivers live with the patient or not.

Background: Daily observation by nurses of the cognitive function of patients is of high ecological validity because cognitive functioning is observed in a natural setting around the clock., Aim: To evaluate why and how geriatric nurses observe the cognitive functioning of their patients., Design: Survey., Methods: A self-developed questionnaire was administered to a purposeful sample of nurses working on geriatric wards of seven acute care hospitals. The questions were open-ended. Data were analysed through content analysis., Results: The questionnaire was completed by 97 nurses (response rate 77%). Categorisation of the many objectives reported by the nurses revealed four themes: to tailor nursing interventions (51%), to determine discharge arrangements (46%), to support medical diagnosis and therapy (43%) and to map specific elements of functional capacity (34%). Nurses reported also many different domains to observe (mode 2; range 0-7), only 73% of which were actual cognitive domains. The most commonly mentioned cognitive domain was psychomotor behaviour (63%), followed by executive functions (48%), language (37%), attention (33%), thinking (25%) and consciousness (20%)., Conclusions: Geriatric nurses not only made daily observations of their patients' cognitive functioning to support medical diagnoses, but also to guide nursing interventions and determine discharge arrangements. The assessment domains varied fairly widely, because the participants' understanding of the concept cognitive functioning was vague, incomplete and often incorrect., Relevance to Clinical Practice: This is the first study that investigated why geriatric nurses make daily observations of their patients' cognitive functioning. In addition, we explored their understanding of the concept of cognitive functioning. Based on the fact that the content of an assessment is determined by its aim, the objectives to perform daily observations have to be clear and stated explicitly. To observe patients in an unambiguous way, it will be necessarily to develop a validated observation scale.

Objectives: This paper reports on a pilot study examining the incidence of nurses' errors in preparation and administration of intravenous drugs. Furthermore, the study aimed to evaluate the short-term effects of implementation of a new protocol for preparation and administration of intravenous drugs., Setting: Two nursing departments of internal medicine at a 953 beds University Medical Centre in The Netherlands., Methods: By means of a prospective, quasi-experimental design, nurses were observed during the process of preparation and administration of intravenous drugs. Observation was performed before and after the implementation of a new protocol. Seventy-two nurses at two nursing departments were observed during the study., Main Outcome Measure: A mean pre-test and post-test quality score at two departments of internal medicine., Results: At baseline, average quality scores for nurses at the two departments were 64 (intervention ward) and 67 (control ward) on a 0-100 quality scale. The pre-test quality scores were not statistically significant for the two nursing wards (T = 1.36, df = 55, P = 0.18). After the implementation of the new protocol, nurses at the intervention ward scored better (72) than nurses at the control ward (69). The mean score at the intervention ward was significantly higher than the score in nurses of the control ward (T = -2.20, df = 53, P = 0.04)., Conclusions: The number of errors in the preparation and administration of intravenous drugs is high. This study shows that implementing a protocol for the preparation and administration of these drugs can reduce the number of errors.

To describe rheumatologists' knowledge, attitude and current management of fatigue in patients with rheumatoid arthritis (RA), a postal questionnaire was sent to all rheumatologists (N = 204) and trainees (N = 49), members of the Dutch Society of Rheumatology. The overall response rate was 44% (N = 110). In general, rheumatologists' knowledge about RA-related fatigue was in accordance with the literature but they perceive a lack of their own knowledge about aetiology and evidence-based interventions to prevent and treat fatigue. The majority of the rheumatologists believe that fatigue is a multi-disciplinary diagnosis and is preferably managed by the nurse specialist (34%). Assuming that the patient will raise the issue, most of the rheumatologists pay attention to fatigue during the first consultation and less often during follow-up consultations. There is a need for knowledge about causes and treatments for RA-related fatigue to ensure that patient outcomes are improved.

Patients with a bipolar disorder need to cope with the problems they encounter, the consequences of their disease, and unpleasant events to stay well. This study was undertaken to gain greater insight into the coping styles of outpatients with a bipolar disorder when confronted with problems and unpleasant events. The participants (N = 157) completed the Utrecht Coping List and a questionnaire addressing various demographic and clinical characteristics. The results showed outpatients with a bipolar disorder to have a less active reaction pattern and a more avoidant coping style compared with people from the general population.

In communicating with patients, especially patients receiving palliative care, empathy plays an important role. Little research has as yet been conducted into the development of the empathetic capacity of nursing students at various educational levels. An instrument that may be suitable for such research is the Staff-Patient Interaction Response Scale for Palliative Care Nursing (SPIRS-PCN). The purpose of the article is to determine the validity and reliability of the SPIRS-PCN, an instrument measuring empathy in palliative care. The criterion-related validity, homogeneity, and interrater reliability of the SPIRS-PCN were determined in nursing students (n = 357) who varied in gender, age, religious orientation, educational level, and experience in patient care. The validity of the SPIRS-PCN was underlined by identification of differences for religious orientation and the amount of experience. The variables gender, age, and educational level were not significant in relation to SPIRS-PCN scores. The homogeneity (Cronbach's alpha = .80) and interrater reliability (.74) of the instrument were adequate. We conclude that validity of the SPIRS-PCN was partially supported, whereas reliability was demonstrated. The instrument is feasible in educational situations; we recommend further research into the instrument's validity, especially in the progression of students' scores during the study program.