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Hintergrund: Um künftig trotz wachsendem Anteil an Pflegebedürftigen und Pflegefachkräftemangel eine pflegerischeVersorgung zu gewährleisten, werden vor allem im ambulanten Pflegesektor technische Assistenzsysteme (TAS) zur Unterstützung und Überwachung zu Pflegender eingesetzt. Diese Studie sollte Hinweise zu Tage fördern, warum TAS aus Sicht von Einrichtungsleitungen trotz wachsender Angebote und Akzeptanz in der Bevölkerung in bundesdeutschen Pflegeheimen selten zum Einsatz kommen. Methode: Im Rahmen der qualitativen deskriptiv‐explorativen Studie wurden, als Entscheidungsträger für Innovationsprozesse geltende, Einrichtungsleitungen um Experteninterviews gebeten, die mittels einer qualitativen Inhaltsanalyse ausgewertet wurden. Ergebnis: Aus Berlin, Brandenburg und Mecklenburg‐Vorpommern beteiligten sich 12 Einrichtungsleitungen, die in Teilen TAS bereits einsetzten. Sie explizierten überwiegend ihre eigene Zurückhaltung und ihre moralischen Bedenken sowie die Aversion insbesondere ihrer älteren Mitarbeiter gegenüber TAS. Dies und die hohen Kosten würden den Einzug von TAS in Pflegeheimen aktuell bremsen. Andererseits würden Angehörige heute schon und zukünftig auch die Pflegenden,der Wettbewerb um Pflegefachkräfte und die Pflegewissenschaft TAS zur Bewohnersicherheit und zur Arbeitserleichterung einfordern. Schlussfolgerung: Um TAS in Pflegeheimen zu etablieren, erwarteten die Interviewten eine suffiziente Beratung und Partizipation der Einrichtungsleitungen, von Seiten der Industrie, eine entsprechende Qualifizierung der künftigen Pflegenden und eine aktivere Beteiligung der Pflegewissenschaft.

Zusammenfassung Einleitung Die Ausbildung in der Gesundheits- und Krankenpflege schliest mit einer schriftlichen, mundlichen und praktischen Prufung ab. Im Land Berlin wird die schriftliche Prufung mittels einem einheitlichen zentralen Prufverfahren durchgefuhrt. Die mundlichen und praktischen Abschlussprufungen hingegen werden nicht standardisiert in den jeweiligen Ausbildungseinrichtungen entwickelt und durchgefuhrt (dezentrale Verortung). Dieses Vorgehen kann die Vergleichbarkeit der Abschlusse erheblich einschranken. Da derzeit keine systematische Statistik der erbrachten Prufungsleistungen existiert, war das Ziel dieser Studie, die Ergebnisse der dezentral gestellten mundlichen und praktischen Prufungen mit denen der zentral gestellten schriftlichen Prufungen in verschiedenen Ausbildungseinrichtungen - unter besonderer Berucksichtigung unterschiedlicher Ausbildungskonzepte - zu vergleichen. Methode Im Rahmen einer Sekundardatenanalyse wurden die Abschlussnoten der mundlichen, schriftlichen sowie praktischen Prufungen aller 4342 Auszubildenden aus den Jahren 2008-2013 von allen 16 Berliner Ausbildungseinrichtungen des Bereiches Gesundheits- und Krankenpflege miteinander verglichen. Ergebnisse Von allen absolvierten Prufungen lag der Mittelwert (die Standardabweichung) der schriftlichen Prufungen bei 2,9 (0,7), der mundlichen bei 2,6 (1,1) und der praktischen Prufungen bei 2,2 (1,0). Wahrend der Notentrend bei den einzelnen Prufungsarten uber den gesamten Zeitraum weitgehend stabil blieb, erhohte sich der Anteil an nicht bestandenen Prufungen uber die Jahre in statistisch signifikanter Weise von 2008 (7,9%) bis 2013 (12,0%). Die Differenz der Noten zwischen den zentral und dezentral verorteten Abschlussprufungen variierte in Ausbildungseinrichtungen mit traditionellem Ausbildungskonzept zwischen 0,1 und 0,9 Notenpunkten (generalistisch: -0,1 und 0,3; akademisch: -0,1 und 0) Schlussfolgerung Insbesondere bei den traditionell ausbildenden Einrichtungen zeigten sich grose Leistungsunterschiede zwischen den zentralen und dezentralen Prufungsteilen. Aus diesem Grund sollten Verfahren entwickelt werden, die in der Lage sind, die potentiell heterogenen Anforderungen und Bewertungen der praktischen und mundlichen Prufungen zu standardisieren, um eine bessere Vergleichbarkeit der Abschlusse in der Gesundheits- und Krankenpflege zu gewahrleisten.

Rationale, aims and objectives Facilitating and maintaining functional status (FS) and quality of life (QoL) and avoiding care dependency (CD) are and will increasingly become major tasks of nursing. Educational nursing home visits may have positive effects on FS and QoL in older adults. The aim of this study was to determine the effectiveness of educational home visits on FS, QoL and CD in older adults with mobility impairments. Method We performed a randomized controlled trial. The study was conducted in the living environments of 123 participants with functional impairments living in Hamburg, Germany. The intervention group received an additional nursing education intervention on mobility and QoL; the control group received care as usual. Data were collected from August 2011 to December 2012 at baseline, 6 months and 12 months of follow-up. The main outcomes were FS (Barthel Index), QoL (WHOQOL-BREF) and CD (Care Dependency Scale). Data were analyzed using descriptive statistics and generalized linear models. Results In total, 113 participants (57 in the intervention and 56 in the control group) were included in the study. The intervention had no statistical significant effect on FS, QoL and CD. Conclusions The intervention did not show the benefits that we assumed. Further studies on the effects of educational nursing interventions should be performed using different concepts and rigorous research methods.

Aims and objectives To evaluate the effects of a nurse-led, hospital-based heart failure specific education session with a three-month telephone follow-up on self-care behaviour, care dependency and quality of life for patients with chronic heart failure. Background Patient education in patients with heart failure is able to promote heart failure-specific self-care, to reduce mortality, morbidity and rehospitalisation rates and to enhance quality of life, especially if heart failure education is embedded in a multidisciplinary approach. Evidence of the effect of a nurse-led self-care education, quality of life and care dependency in addition to standard medical treatment in Germany is lacking. Design Nonblinded, prospective, single-centre, randomised controlled trial. Method Sixty-four patients were allocated either to the intervention group or to the control group. Patients in the intervention group received education about heart failure self-care with a consecutive telephone follow-up over three months in addition to standard medical treatment. Patients in the control group received standard medical treatment only. Results Data of 110 patients (58 in the intervention group and 52 in the control group) with a mean age of 62 years and mean left ventricular ejection fraction of 28·2% could be analysed. Self-care education had a significant influence on overall heart failure self-care but not on quality of life and care dependency. Conclusion A single education session with a consecutive telephone follow-up is able to improve overall self-care behaviours but not quality of life. Care dependency was not influenced by the education session. Relevance to clinical practice The easy to implement and short educational intervention has a positive effect on self-care behaviour for patients with heart failure. However, there was no effect on quality of life and care dependency. To improve quality of life and to influence care dependency, different measures have to be applied.

Objective Demographic developments have led to increased chronic diseases, such as dementia, which result in care dependency and nursing care problems like incontinence. This study aims to compare the degree of care dependency and the prevalence of nursing care problems between Austrian nursing home residents with and without dementia. Methods Since 2009 a cross-sectional study has been conducted annually in Austrian nursing homes. Data from the standardized questionnaire sampling 2155 residents with and 1422 residents without dementia between 2009 and 2012 have been analysed. Results Seventy-two percent of residents with dementia compared to 45.5% of residents without dementia are completely or to a great extent care dependent, with the highest care dependency being in hygiene, continence, (un)dressing and avoiding danger. Residents with dementia have a significantly higher prevalence of urinary incontinence (87.9% vs. 69.5%), fecal incontinence (68.2% vs. 44.5%), double incontinence (64.8% vs. 36.1%), restraints (33.5% vs. 22.4%), malnutrition (27.9% vs. 18.4%) and falls (9.9% vs. 7.0%). No significant difference was found for pressure ulcers (5.2% vs. 6.5%). Conclusion Residents with dementia have a significantly higher degree of care dependency than residents without dementia and they also have, except for pressure ulcers, a significantly higher prevalence of nursing care problems. These results should increase awareness among health care professionals of areas requiring target-oriented dementia care. Further research should explore care dependency and nursing care problems in different stages of dementia and compare the development of care dependency and nursing care problems among residents with and without dementia.

Aims and objectives The study aimed to establish the range and extent of preventive interventions undertaken by nurses for patients who are at high risk of developing or currently have a pressure ulcer. Background Since 2000, the German National Expert Standard for the prevention of pressure ulcers has provided evidence-based recommendations, but limited studies have been published on its adherence in hospitals. There are also limited observational studies that investigated whether patients who are at risk of or have pressure ulcers are provided with appropriate preventative measures. Design A nonparticipant observational descriptive design was used. Methods A sample of 32 adult patients who were at high risk of developing or currently had a pressure ulcer were observed during all shifts in medical and surgical wards in two general hospitals in Germany. Results A range of preventive interventions that were in line with the German National Expert Standard was observed. The most frequent preventive measures were ‘cleaning the patients’ skin’ and ‘minimizing exposure to moisture’ that were undertaken in more than 90% of all patients. The least frequent measures were ‘patient and relative education’, ‘assessment and recording of nutritional status’. Conclusion This study demonstrates that the pressure ulcers preventive interventions as set out in the German National Expert Standard were not fully implemented. The study highlights the need for further studies on the barriers that impede the undertaking of the interventions that may prevent the development or deterioration of pressure ulcers and the delivery of evidence-based preventative care. Relevance to clinical practice This study provides an insight into the extent of pressure ulcers preventive practices used by nurses. The results may serve as a basis for developing an effective strategy to improve nursing practice in this area and the promotion of evidence-based practice. However, our results refer to two general hospitals and for a broader population, further studies with larger data samples are needed.

Background Although enormous efforts have been made in auditing the quality of care, there are only few epidemiological studies available about the actual occurrence of immobility, malnutrition, urinary incontinence, cognitive impairment, falls and pressure ulcers in long-term care facilities. Objective The objective of this study was to provide prevalence estimates of common nursing care problems in long-term care facilities and to investigate any associations between them. Design Secondary data analysis of five consecutive annual cross-sectional multicenter studies from 2008 to 2012. Setting 262 different long-term care facilities throughout Germany. Participants 14,798 residents older than 18 years who gave informed consent. Methods Health conditions were rated based on direct resident examinations according to the current international definitions. Demographic characteristics were compared with available national population statistics. Apart from descriptive statistics, Chi 2 tests were carried out for bivariate and log-regression models were performed for multivariate associations. Results Prevalence rates were stable over the years with the highest prevalence of 73.5% (95% CI 72.8–74.2) being found for urinary incontinence, for cognitive impairment it was 54.1% (95% CI 53.3–54.9) and for immobility it was 36.5% (95% CI 35.7–37.3). The lowest prevalence rates were established for the risk of malnutrition with 13.0 (95% CI 12.4–13.5), for pressure ulcers with 4.8% (95% CI 4.5–5.1) and for falls (4.4% 95% CI 4.1–4.8). In the multivariate model, immobility was most strongly associated with all of the other conditions. No statistically significant associations were found between pressure ulcers and falls, pressure ulcers and urinary incontinence, pressure ulcers and cognitive impairment and between malnutrition and urinary incontinence. Conclusion Decision-makers and clinical practitioners may primarily focus on the maintenance and enhancement of mobility, because this seems to be the key predictor for many other health conditions in the context of care dependency in the nursing home setting.

Chronic diseases, like dementia, can lead to care dependency and nursing care problems. This study aims to compare the degree of care dependency and the prevalence of nursing care problems (pressure ulcer, incontinence, malnutrition, falls, restraints) between residents with and without dementia and between the stages of dementia. A cross-sectional design was chosen and a total of 277 residents with and 249 residents without dementia from nine Austrian nursing homes were assessed by staff using standardized instruments. Significantly more residents with than without dementia are completely or to a great extent care dependent (54.5 vs. 16.9 %). The comparison of care dependency between the stages of dementia indicates a large difference between moderate and severe dementia (completely care dependent: 9.3 vs. 44.3 %). The comparison of the assessed nursing care problems between residents with and without dementia reveals a significant difference only with regard to incontinence (urinary: 84.2 vs. 53.2 %, fecal: 50.9 vs. 17.7 %, double: 49.1 vs. 14.9 %). Urinary incontinence is high even in early dementia at 64 %, reaching 94 % in severe dementia. Fecal- and double incontinence are comparatively much lower in early dementia (both types 12 %) and rise to more than 80 % (both types) in severe dementia. These results highlight areas in which dementia care needs further improvements. The authors suggest maximizing residents’ independence to stabilize care dependency and improve incontinence care. Furthermore, longitudinal studies are recommended to deepen insight into the development of care dependency and nursing care problems in dementia residents.

Purpose The purpose of this study was to assess the long-term functional status and quality of life of older individuals with functional mobility impairment. Design A prospective longitudinal study was conducted. Methods The study sample consisted of elderly patients who had been admitted to a rehabilitation facility in Hamburg, Germany. Data were collected from February 2008 to August 2009 in the rehabilitation center and the living environment of the participants after discharge. Quality of life was assessed using the WHO Quality of Life-BREF; activities of daily living were measured using the Barthel-Index (BI). Findings Functional status and overall quality of life increased from admission (BI = 73.33) to 6 months postadmission (BI = 89.29) but decreased at 12 months postadmission (BI = 85.71). Quality of life significantly increased in the psychological domain from admission (57.85) to 6 months follow-up (67.85) (p = .010). Men showed a better functional status over time (p = .010) than women. Higher quality of life scores were associated with higher MMSE (p = .031) and self-efficacy scores (p = .019) at admission. Conclusion The findings of this study suggest a need for interventions to improve functional status and quality of life in this population, especially following 6 months after discharge. Clinical Relevance Special interventions should address physical quality of life and physical functioning. Gender differences should be considered in planning and implementing programs.

Background: Nurses' clinical judgement plays a vital role in pressure ulcer risk assessment, but evidence is lacking which patient characteristics are important for nurses' perception of patients' risk exposure.Objectives: To explore which patient characteristics nurses employ when assessing pressure ulcer risk without use of a risk assessment scale.Design: Mixed methods design triangulating observational data from the control group of a quasi-experimental trial and data from semi-structured interviews with nurses.Setting: Two traumatological wards at a university hospital.Participants: Quantitative data: A consecutive sample of 106 patients matching the eligibility criteria (age >18 years, no pressure ulcers category >2 at admission and >5 days expected length of stay). Qualitative data: A purposive sample of 16 nurses.Methods: Quantitative data: Predictor variables for pressure ulcer risk were measured by study assistants at the bedside each second day. Concurrently, nurses documented their clinical judgement on patients' pressure ulcer risk by means of a 4-step global judgement scale. Bivariate correlations between predictor variables and nurses' risk estimates were established. Qualitative data: In interviews, nurses were asked to assess fictitious patients' pressure ulcer risk and to justify their risk estimates. Patient characteristics perceived as relevant for nurses' judements were thematically clustered. Triangulation: Firstly, predictors of nurses' risk estimates identified in bivariate analysis were cross-mapped with interview findings. Secondly, three models to predict nurses' risk estimates underwent multiple linear regression analysis.Results: Nurses consider multiple patient characteristics for pressure ulcer risk assessment, but regard some conditions more important than others. Triangulation showed that these are measures reflecting patients' exposure to pressure or overall care dependency. Qualitative data furthermore indicate that nurses are likely to trade off risk-enhancing conditions against conditions perceived to be protective. Here, patients' mental capabilities like willingness to engage in one owns care seem to be particularly important. Due to missing information on these variables in the quantitative data, they could not be incorporated into triangulation.Conclusions: Nurses' clinical judgement draws on well-known aetiological factors, and tends to expand conditions covered by risk assessment scales. Patients' care dependency and self-care abilities seem to be core concepts for nurses' risk assessment. (C) 2013 Elsevier Ltd. All rights reserved.

Background: There is a need for prevention strategies in elderly individuals with mobility impairments.Purpose: The aim of this study was to determine the effects of nursing consultations on the functional abilities and quality of life of elderly individuals with mobility impairments after discharge from a rehabilitation facility.Methods: A single-site, prospective, longitudinal study with a nonequivalent control group pretest-posttest design was conducted in a geriatric rehabilitation facility and in the living environments of the patients after discharge. The intervention consisted of nurse-delivered consulting home visits and follow-up telephone calls. Patient quality of life and functional status were the primary outcomes, and self-efficacy was the secondary outcome. Data were collected at admission, at discharge, and at a 6-month follow-up visit.Results: A cohort of 124 patients participated in the study. The intervention group showed a nonsignificant improvement in functional status compared with the control group. The intervention did not affect quality of life, except for a trend toward significance in the social domain (p = .060).Conclusions: The findings of this study suggest that nursing consultations do not significantly improve functional status and have almost no effect on quality of life.

Background Nursing education is a crucial part of nursing practice; however, evidence regarding its impact on quality of life is lacking. No review has addressed the effects of overall nursing education interventions on the quality of life in a general outpatient population. Objectives The objective of this study is to evaluate the effectiveness of nurse-delivered education interventions compared with usual care with regard to the quality of life of outpatients. Methods A systematic search was performed to identify randomized controlled trials that examined the effects of nurse-delivered educational interventions on the quality of life of outpatients. The search was performed in December 2012 in the MEDLINE (via PubMed), EMBASE (via Ovid), and CINAHL (via EBSCO) databases and was limited with regard to publication time and language. The studies were appraised according to methodological quality, and p values were extracted to determine the effectiveness of the interventions. Results Twenty-nine studies were included in the review. Approximately 70% of the studies included showed no effects on quality of life. The studies that showed positive effects each used different types of interventions. A methodological appraisal revealed biases in most of the studies. Conclusions and Implications of Key Findings Because of an overall lack of effectiveness and heterogeneity between studies, no evidence for the effectiveness of nursing education interventions in outpatients was observed. Further studies should examine interventions that focus on quality of life using validated measures.

Die vorliegende deskriptiv-explorative Querschnittstudie, an der 814 Pflegende (51.8 %) aus 21 Schweizer Alters- und Pflegeheimen teilnahmen, gibt einen Einblick in die Erfahrungen und den Umgang mit aggressivem Verhalten der Bewohner(innen). Zudem wurde die Belastung aggressiven Verhaltens auf die Pflegenden und die Auswirkungen auf die Beziehung zwischen Pflegenden und Bewohner(inne)n erfasst. Die Befragung wurde mithilfe eines validierten Fragebogens durchgeführt. Rund 38 % der Pflegenden haben in den letzten sieben Arbeitstagen vor der Datenerhebung Aggressionsereignisse erlebt. In den meisten Fällen ging die Aggression von Bewohner(inne)n aus, die an Demenz und/oder Depression litten und trat während einer pflegerischen Tätigkeit mit Körperkontakt auf. Als Auslöser vermuteten die Teilnehmenden in erster Linie das «Nichtverstehen» und die «Überforderung» der Bewohner(innen). Ein «beruhigendes Gespräch» und «Distanz einnehmen» wurde am häufigsten eingesetzt, um die Situation zu beruhigen. Rund 40 % der Teilnehmenden empfinden körperliche Angriffe als belastend und etwa 23 % haben Angst, vor allem, wenn aggressives Verhalten ohne Vorwarnung auftritt. Rund 4 % der Pflegenden vermeiden anschließend häufig oder immer den Kontakt zu den betreffenden Bewohner(inne)n und 12.3 % erleben eine Störung in der Beziehung. Es ist zu vermuten, dass die Pflegenden die Emotionen der Bewohner(innen), die dem aggressiven Verhalten zugrunde liegen, in der akuten Phase der Eskalation unzureichend erfassen sowie mögliche Frühwarnzeichen beginnender Aggression spät oder nicht erkennen.

Background: Patient and visitor violence (PVV) is the most dangerous occupational hazard that health professionals must contend with. Staff training is recommended to prevent and manage PVV. There is minimal research focusing on risk factors associated with PVV in general hospital settings. Therefore, staff training is mostly based upon expert knowledge and knowledge from psychiatric and emergency settings.Objectives: This study investigates health professionals' experiences with PVV in order to describe risk factors related to PVV that occur in general hospital settings.Design: A retrospective cross-sectional survey was conducted in 2007.Setting: A university general hospital in Switzerland.Participants: 2495 out of 4845 health professionals participated (58.0% nurses & midwives, 19.2% medical doctors, 3.6% physical therapists, occupational therapists & nutritionists, 6.1% ward secretaries, medical & radiology assistants, 6.3% nursing assistants or less qualified nursing staff and 5.1% other staff). All had direct patient contact and 82% were female.Methods: Data were collected via questionnaires using the Survey of Violence Experienced by Staff German-Version-Revised, the German version of the shortened Perception of Aggression Scale and the Perception of Importance of Intervention Skills Scale. Descriptive statistics and multiple logistic regression analyses were used.Results: Risk factors associated with PVV depend upon the form of violence. Those trained in aggression management and/or those who work predominantly with patients over 65 years of age experience twice as much PVV as others. Health professionals working in emergency rooms, outpatient units, intensive care units, recovery rooms, anesthesia, intermediate care and step-down units also experience PVV more often. When health professionals are older in age, are from the medical profession, are students, or when they have an attitude rating preventive measures as being less important and aggression as emotionally letting off steam, they experience less PVV.Conclusion: Training could change the perception and the recognition of PVV, and could therefore increase the risk of experiencing PVV. The health professionals' specific occupation along with attitude and age, the patients' age, the communication and the workplace are all relevant risk factors. Further studies should investigate the impact of aggression management training and other measures that would reduce PVV. (C) 2012 Elsevier Ltd. All rights reserved.

Purpose: Caregivers in nursing homes often experience aggressive behavior of residents. The aim of this study was to explore the caregivers' experiences with aggressive behavior from residents and to identify environmental factors as well as caregiver and resident characteristics related to aggressive behavior in Swiss nursing homes. Design: A retrospective cross-sectional survey was conducted between November 2010 and April 2011 with a sample of caregivers working in various nursing homes in the German-speaking part of Switzerland. In total, 814 caregivers (response rate 51.8%) of 21 nursing homes participated in the study. Methods: Data were collected using the German version of the Survey of Violence Experienced by Staff (SOVES-G-R). Standard descriptive statistics were used to describe and summarize the date. To identify risk factors related to the experience of aggression by residents, multilevel logistic regression analysis was applied. Findings: The prevalence of participants reporting an aggressive incident during the 12-month period prior to data collection was 81.6%. Of these, 76.5% had experienced verbal aggression, 27.6% threats, and 54.0% physical aggression. The predictive variables in the multiple regression model for physical aggression were: staff education level (odds ratio [OR]= 1.82), gender (OR = 1.82), age ( 45 years: OR = 2.13), and confidence in managing physical aggression (OR = 1.49). The predictive variables for threatening behavior were staff education level (registered nurses vs. non-registered nurses: OR = 1.70; nonstudent vs. student: OR = 1.89) and age ( 45 years: OR = 2.04). Conclusions: Caregivers in nursing homes are at high risk for experiencing aggressive behavior. The identified risk factors are in line with earlier investigations, but some contradictory results also were observed. Clinical Relevance: The high risk for registered nurses exposed to aggressive behavior and the increased risk for caregivers who feel confident in managing aggressive behavior cast a critical light on the content and aim on present programs for management of aggressive behavior. Caregivers in nursing homes should be qualified in understanding resident aggression in a comprehensive way. A critical point in this topic seems to be the interaction between caregiver and resident during basic care activities. This topic should be investigated in further research projects. Language: en

Aim. This study focuses on the experience of healthcare staff with regard to patient and visitor violence in a general hospital. The occurrence of patient and visitor violence, staffs’ interventions and the consequences of violence for different professions are investigated. Background. There is a lack of studies describing the factors influencing the occurrence of patient and visitor violence, intervention strategies and consequences. Existing studies often focus on nurses’ experiences and single interactive factors between staff and patients/visitors involved. Design. A cross-sectional survey. Method. The survey was conducted in 2007 including 2495 staff working on different wards in a Swiss university general hospital. The questionnaire used was the Survey of Violence Experienced by Staff German Version-Revised. Findings. Half of the staff experienced patient and visitor violence in the past 12 months and 11% in the past week. The age of the staff and the length of experience in their present workplace influenced the exposure to patient and visitor violence. Violence occurred mainly when staff carried out tasks involving close personal contact. Only 16% of the staff was trained in aggression management. The feeling of confidence in managing patient and visitor violence depended significantly on the organizational attitude towards violence. The principal interventions used were calming and informative discussion. Conclusion. To prevent patient and visitor violence and improve management strategies, training which focuses on communication skills, which is specific to the professional context and which emphasizes patient centeredness, need to be designed and implemented. A strong organizational commitment is imperative to reduce violence.

Die erfolgreiche Vermeidung von Dekubitus gilt als Indikator zur Beurteilung der Versorgungsqualitat im Gesundheitswesen. Wichtige Kennzahlen, um die Effektivitat praventiver Masnahmen beurteilen zu konnen, sind die Dekubituspravalenz und -inzidenz. Bisherige Aussagen zu Dekubitushaufigkeiten in deutschen Krankenhausern sind widerspruchlich. Ziel der vorliegenden Untersuchung ist es, basierend auf dem Vergleich der Ergebnisse dreier multizentrischer Studien, die tatsachliche Dekubitushaufigkeit festzustellen. Herangezogen wurden Pravalenzen aus den Erhebungen der Charite, Pravalenzen und Inzidenzraten basierend auf dem softwarebasierten Datenerhebungspaket „Kinexus ™ PS“ sowie die Ergebnisse zur Inzidenz des Generalindikators „Dekubitusprophylaxe“ der Bundesgeschaftsstelle fur Qualitatssicherung (BQS, jetzt AQUA-Institut). Bei allen Datensatzen wurden Patienten mit einem Alter uber 74 Jahren aus den Jahren 2007 und 2008 berucksichtigt. Die Berechnung des Outcomekriteriums „Dekubitus“ folgte in allen Studien gemas den Empfehlungen des European Pressure Ulcer Advisory Panel (EPUAP) und dem North American Pressure Ulcer Advisory Panel (NPUAP). Da die Identifizierung oberflachlicher Dekubitus (Kategorie I „nicht-wegdruckbare Rotung“) eine hohe Fehleranfalligkeit in sich birgt, wurden Pravalenzen und Inzidenzen jeweils mit (und ohne) Kategorie I berechnet. Das Durchschnittalter der Patienten war in allen 3 Stichproben mit 81 Jahren vergleichbar. Insgesamt betrug die Dekubituspravalenz Kategorie I–IV (II–IV) der Kinexusstudie 11,8% (6,1%) und die der Charite-Studie 11,0% (5,5%). Die Unterschiede zwischen beiden Studien waren statistisch nicht signifikant. Die Inzidenz von Dekubitus der Kategorie I–IV (II–IV) bei der BQS betrug 1,3% (0,8%), die der Kinexus-Studie 6,7% (3,9%) (p 5 quantifizierbar. Obwohl die Pravalenzen der Charite- und der Kinexus-Studien sehr gut vergleichbar waren, war die Dekubitusinzidenz in der Kinexus-Studie erheblich hoher als in der BQS-Erhebung. Die vorliegenden Ergebnisse der Kinexus-Studie liegen moglicherweise naher an vergleichbaren internationalen Studienergebnissen. Die vorliegenden Ergebnisse unterstutzen die Hypothese, dass die von der BQS (jetzt AQUA-Institut) erhobenen Inzidenzen zur Dekubitusinzidenz in hohem Mas unterschatzt werden. Insbesondere vor dem Hintergrund eines erheblichen finanziellen und personellen Aufwands ist die derzeitige verpflichtende Datenerhebungspraxis im Rahmen der Externen Qualitatssicherung von fraglichem Nutzen.

Aims and objectives. The aim of the study was to investigate factors related to the use of restraints and to explore whether the rate of nurses was an influencing factor regarding the use of restraints in German nursing homes and hospitals. Background. Restraints are frequently used measures in hospitals and nursing homes. Risks for falls and small nurse workforces are discussed in relation to the use of restraints. Design. A secondary analysis of a cross-sectional study was carried out. Methods. Data were collected by trained nurses using standardised questionnaires in 76 nursing homes (n = 5521) and 15 hospitals (n = 2827). For data analysis, a 3-level random intercept logistic model was used. Results. The prevalence of restraints (bed rails and/or belts) was 9·3% for hospital patients and 26·3% for nursing home residents. Amongst hospital patients, restraint use was more prevalent in women, older patients, patients with a high care dependency, patients who fell during the last two weeks, patients with a perceived risk of falls, polypharmacy, urinary incontinence, disorientation and confinement to bed. In the nursing homes, the restrained residents were significantly younger, more care dependent, had less falls and were more often urinary incontinent, disoriented and bedfast. The rate of nurses was not significantly related to the use of restraints in hospitals, and nursing homes according to the three-level random intercept model. Conclusions. Hospital patients with previous falls were more often restrained, but in the nursing homes, the restrained residents experienced less falls. The number of qualified nursing staff had no significant influence on the use of physical restraints. Relevance to clinical practice. Lower nurse staffing ratios were not related to higher frequencies of restraint use in this study.

Around 10% of Western Europe's population suffer from a disability which can entail a decrease of independency and quality of life. However, the lives of these people can be improved by rehabilitative treatment and care. Changing the degree of dependency from dependent to independent is essential in rehabilitation, as is the assessment of these changes. To perform such kind of measurements, assessment instruments have to be responsive. In spite of this concern, responsiveness of assessment instruments is studied to a small extent only. This also applies to the Care Dependency Scale for Rehabilitation (CDS-R), a short assessment instrument measuring the care dependency of patients regarding physical and psychosocial aspects. In this longitudinal-study, the responsiveness of the CDS-R, in general and related to different disease-groups, should be determined. Therefore, a convenience sample of 1564 patients was assessed in an Austrian rehabilitation centre with the scale after admission and before discharge. Responsiveness was determined by descriptive analysis, calculation of effect-sizes and significance tests. Differences between admission and discharge occurred on a statistically significant level for patients who changed. Kazis' effect-sizes can be considered as of small/medium effect for patients who changed (0.24/0.49), and as of large effect according to Liang (0.86/1.46). Eta squared was 0.10/0.19 which can be interpreted as of moderate/large effect for patients who changed. Responsiveness-analyses related to different disease-groups showed constantly large effect-sizes for patients with musculoskeletal-disorders. These results indicate that the CDS-R can detect patient-changes over time and discriminate between patients who change under rehabilitation or not. These aspects argue for the responsiveness of the scale, wherefore the CDS-R seems to be appropriate for the assessment of treatment/health-care effectiveness and the evaluation of individual patient-changes. Nevertheless further research is recommended to confirm the level of responsiveness of the scale in general and for different disease-groups.

BOGGATZ T and DASSEN T. Nursing Inquiry 2011; 18: 216–225 Why older persons seek nursing care: towards a conceptual model Despite similar health problems, older persons show different care seeking behaviours for a variety of reasons. The aim of this study was to identify motives underlying the attitudes of older persons to seek nursing care and to develop a theoretical rationale which allows viewing their mutual interaction. Theory development according to Walker and Avant was used as a method to derive a model from the reviewed literature. Six categories were identified that may influence seeking of nursing care: perceived threat, disposition, external options & barriers, current coping abilities, influence of significant others, and outcome value. Findings do not allow determination of factors that may predict care seeking attitude but provide a loosely structured conceptual model for culture specific investigations. Qualitative studies guided by the model should be conducted in order to develop testable theories of care seeking for different cultures and settings.

Purpose The study assessed and compared the psychosocial needs of patients with breast cancer and of their relatives, the patients’ and relatives’ burden of illness, anxiety, depression and distress and assessed the patients’ cancer treatment-related symptoms and identified relevant factors influencing patients’ and relatives’ needs. Method Seventy-two patients ( n = 72) participated with a relative in a cross-sectional mail-survey, 1–22 months after cancer treatment. Results The patients reported needing help with psychological and sexual issues. They suffered from treatment-related symptoms. More treatment-related symptoms and depression were related to the patients’ needs for supportive care. Their relatives’ needs primarily concerned access to information and communication with health care professionals. Relatives had higher levels of anxiety (25.0% vs. 22.2%), depression (12.5% vs. 8.3%) and distress (40% vs. 34%) than patients. Higher levels of depression, younger age and having a disease themselves were associated with relatives’ need for help. Conclusion Patients’ and relatives’ substantial needs and psychological problems require professional support even after completion of the patients’ treatment. Continued assessment of the patients’ and their relatives’ needs and of the patients’ symptoms provide the basis for purposeful counselling and education. Rehabilitation programs for patients and their relatives should be developed and implemented in clinical practice.

Aims and objectives. This study explored caregivers’ perspectives regarding the conditions and situations of resident aggression and practical strategies caregivers use to deal with aggression. Background. Working in a nursing home is associated with a high risk to experience aggression from residents or patients. Despite existing recommendations for dealing with aggression there is a lack of information about caregivers’ ways of dealing with it in practice. Design. A qualitative study with focus group method was conducted. Method. Five focus group interviews, with a total of 30 participants, from nursing homes in Switzerland were undertaken employing a semi-structured interview guideline. For analysing the data, qualitative content analysis was employed. Results. Analysis of the data produced three themes with additional sub-themes. One main theme concerns the explanations of the caregivers in regard to the occurrence of aggressive behaviour. This theme is subdivided into two areas, the contributory resident related factors and the caregiver related factors. The measures for handling aggressive behaviour are illustrated in the second theme ‘dealing with residents’. The third theme refers to the strategies of the caregivers when confronted with aggressive behaviour – ‘self-protection’ and ‘coping with the situation’. Conclusion. Caregivers use a broad spectrum of interventions for reducing aggression, some of which are recommended by guidelines but often ignore the link between aggressive behaviour and physiological issues like pain or elimination. The caregivers only very rarely linked their practical knowledge about aggressive behaviour with theoretical knowledge. Relevance to clinical practice. The results give insight into the caregivers’ perspectives on factors leading to aggression and their coping strategies. Caregivers are informed about relevant reasons for aggressive behaviour and its management, but do not apply a systematic approach. Furthermore, the anxiety of caregivers involved in aggression incidents is an under examined area.

Background The occurrence of pressure ulcers in long-term care facilities is regarded as a nursing-sensitive indicator of care. The aim of this study was to measure the frequency, categories, and points of origin of pressure ulcers in German nursing homes. Methods and sample In spring 2010, a nationwide prevalence study was conducted in 52 nursing homes (n=3610 residents). According to a standardized study protocol, trained nurses collected data about pressure ulcer risk and pressure ulcers. Results The prevalence of pressure ulcers was 3.9% (95% CI 3.3-4.6). Excluding skin redness, the proportion of pressure ulcers of nursing home origin was 1.2% (95% CI 0.9-1.6). Risk-adjusted (adjusted for immobility) results showed no statistically significant differences between institutions. Conclusion Compared to international figures, the prevalence of pressure ulcers in German nursing homes is very low.

Objective. The objective of the study was to evaluate the effect of being treated in intensive care units in comparison with general hospital wards regarding pressure ulcer occurrence when controlled for various risk factors. Background. Pressure ulcer occurrence is commonly used as an indicator for the quality of care. Large-scale incidence studies are costly and difficult to perform. Design. Secondary analysis of patient data (n = 32,400) collected during 2002–2009 as part of eight multicentre pressure ulcer surveys in 256 German hospitals. Methods. Ward-acquired pressure ulcer rate was used for the calculation of effect sizes as a surrogate parameter for pressure ulcer incidence. The SRISAG (surface, repositioning, immobility, shear forces, age, gender) logistic regression model was used to control for differences in case mix. Results. Pressure ulcer prevention and intrinsic and extrinsic risk factors differ for patients from hospital wards compared with those from intensive care wards. The ward-acquired pressure ulcer rate in general hospital wards was 3·9% (1·5% excluding grade 1). In intensive care, the rate was 14·9% (8·5% excluding grade 1), which corresponds with an unadjusted odds ratio of 4·3 (95%CI 3·8–4·9). After the SRISAG model was applied, the odds ratio was reduced to 1·5 (CI 1·2–1·7). Conclusion. When surface, repositioning, immobility, shear forces, age and gender are controlled for the institutional factor intensive care unit vs. general hospital wards is no longer a high-risk factor for the development of pressure ulcer. The SRISAG model is simple and can be used to compare the occurrence of pressure ulcer between different medical specialties. Relevance to clinical practice. Application of this model allows more valuable comparison of the occurrence of pressure ulcer in different specialities and enables clinical practitioners and health care planners to use this outcome as an indicator for the quality of care to avoid confounding.

Aims and objectives. The objective of this study was to compare fall rates in older hospital inpatients with and without cognitive impairment. Relationships between age, gender, mobility, cognitive impairment, care dependency, urinary incontinence and medical disciplines were investigated. Background. Falls are common in older people with cognitive impairment, but studies in the hospital setting are rare. Design. A secondary analysis of three nationwide prevalence studies in German hospitals from the years 2005, 2006 and 2007 was conducted. Method. Trained staff nurses used a standardised instrument to collect data about accidental falls within the last two weeks in their institutions and about other patient characteristics. Data from 9246 patients aged 65 years or older from 37 hospitals were analysed. Results. The fall rate for cognitively impaired patients was 12·9%, while only 4·2% of older persons without cognitive impairment experienced a fall. Comparison between medical disciplines showed great differences concerning fall risk for confused and non-confused inpatients. In multivariate logistic regression analysis, the odds-ratio association of cognitive impairment and falls was 2·1 (CI 1·7-2·7). Higher age (OR 1·5, CI 1·2-1·9), greater care dependency (OR 1·6, CI 1·1-2·1), reduced mobility (OR 2·6, CI 1·9-3·7) and being a patient on a geriatric ward (OR 1·8, CI 1·1-2·9) were also statistically significant predictors in this model. Conclusions. Cognitively impaired older people constitute a high-risk group for accidental falls in hospitals. Relevance to clinical practice. Fall prevention strategies in the hospital setting should address cognitively impaired inpatients as an important high-risk group. Language: en

Aims. (1) To gain insight into the psychosocial needs and distress of close relatives of women under treatment for breast cancerand identify how they perceive the interpersonal relationship with the patient and (2) to determine factors associated with therelatives’ psychosocial needs.Background. Breast cancer affects patients but also close relatives. Relatives need support themselves but there is still a lack ofknowledge about their specific needs.Design. Relatives of women newly diagnosed with breast cancer participated in a cross-sectional survey.Method. Relatives were approached by patients, who were contacted by nurses in two Swiss breast cancer clinics. The patientsreceived the questionnaire for their closest relative, who decided independently of the patient about participation. Standardisedquestionnaires were completed by 107 relatives.Results. The relatives needed help with access to information and health care professionals. They needed information about thepatients’ treatment (50AE9%), honest information (41AE6%) and had difficulties with confidence in health care professionals(39AE2%). The majority (61AE0%) suffered from distress, less (26AE1%) from anxiety and depression (10AE9%). Distress, anxiety andconflict in their interpersonal relationship were associated with the relatives’ unmet psychosocial needs.Conclusions. The findings increase the knowledge of the psychosocial needs of relatives of patients with breast cancer andprovide the basis for purposeful support. Distress, anxiety and conflicts in the relationship are important factors that mayidentify more vulnerable relatives with unmet needs or a higher demand for support.Relevance to clinical practice. Assessment of the relatives’ specific needs, distress and anxiety is important, and the relatives’perception of their relationship should be addressed. Health care professionals are key persons in contact with relatives andshould motivate the patients to involve their relatives in the illness and treatment process. Support programmes for relatives ofpatients with breast cancer should be developed in Swiss cancer clinics.Key words: breast cancer, needs, nurses, nursing, psychosocial, relatives

Aims and objectives. The objective of this study was to describe the relationship between the German National Expert Standard Pressure Ulcer Prevention and the pressure ulcer prevalence in German nursing homes and hospitals. Background. The patient outcome pressure ulcer does not only depend on individual characteristics of patients, but also on institutional factors. In Germany, National Expert Standards are evidence-based instruments that build the basis of continuing improvement in health care quality. It is expected that after having implemented the National Expert Standard Pressure Ulcer Prevention, the number of pressure ulcers should decrease in health care institutions. Design. The analysed data were obtained from two cross-sectional studies from 2004–2005. Methods. A multilevel analysis was performed to show the impact of the National Expert Standard Pressure Ulcer Prevention on pressure ulcer prevalence. Results. A total of 41·5% of hospitals and 38·8% of the nursing homes claimed to use the National Expert Standard in the process of developing their local protocols. The overall pressure ulcer prevalence grade 2–4 was 4·7%. Adjusted for hospital departments, survey year and individual characteristics, there was no significant difference in the prevalence of pressure ulcers between institutions that refer to the National Expert Standard or those referring to other sources in developing their local protocols (OR = 1·14, 95% CI = 0·90–1·44). Conclusions. There was no empirical evidence demonstrating that local protocols of pressure ulcer prevention based on the National Expert Standard were superior to local protocols which refer other sources of knowledge with regard to the pressure ulcer prevalence. Relevance to clinical practice. The use of the National Expert Standard Pressure Ulcer Prevention can neither be recommended nor be refused. The recent definition of implementation of Expert Standards should be mandatory for all health care institutions which introduce Expert Standards.

CDS sum scores were 0.94 (95% CI: 0.92–0.95) and 0.93 (95% CI: 0.92–0.95), and corresponding standard errors of measurement were 3.2 and 3.3. The items mobility, day/ night pattern and learning ability contained the largest amounts of measurement error and the lowest interrater reliability. Results indicate that CDS sum scores are reproducible estimates characterizing the care dependency in the home care setting. Interrater agreement is too low to make clinical decisions on individual level.

Aims. To explore nurses' experiences with patient and visitor violence, as well as other related factors, in Swiss general hospital settings. Background. Patient and visitor violence is a complex occupational hazard among health care professions, with nursing in general, experiencing the highest rate of patient and visitor violence. International research has found that staff and patient attributes, interaction between staff and patients, as well as environmental characteristics are important factors associated with the occurrence of patient and visitor violence. Previous studies, however, have only partially described these factors in the general hospital setting. Mainland European general hospital settings are even less well researched. Design. A retrospective cross-sectional survey was conducted in 2007. Methods. A total of 291 nurses working in different clinical departments in general hospitals provided data. The questionnaire used was a modified German version of the Survey of Violence Experienced by Staff. Results. The findings revealed that 72% of nurses had experienced verbal patient and visitor violence and 42% physical patient and visitor violence in the past 12 months. Also, 23% were physically injured and 1·4% took one or more days of sick leave. Patient and visitor violence was distressing for the nursing staff. A higher risk for patient and visitor violence was observed with registered nurses nursing anxious or cognitively impaired patients, for rehabilitation units with longer-term nurse-patient/nurse-relative interactions and for workplaces with an absence of formal procedures for patient and visitor violence. Conclusions. The results indicate that the clinical setting has little impact on the occurrence of patient and visitor violence. Patient and visitor violence appears to be influenced more by the additional factors specific to the type of interaction and situation. Research should follow up on these specific findings to further improve policies, procedures and intervention strategies. Relevance to clinical practice. To prevent patient and visitor violence, Swiss general hospitals should take into consideration the risk factors associated with patient and visitor violence. Existing policies, procedures and staff education should be improved on. Language: en

Pressure ulcers and falls are frequent adverse events with negative impacts for hospital patients. Guidelines recommend risk assessment as the first step in prevention. Care dependency correlates with falls and pressure ulcers and the Care Dependency Scale showed a diagnostic validity comparable to that of specific risk assessment tools. The aim of this study was to establish a simple and valid screening index for the risk of falls and pressure ulcers in hospitals by using the Care Dependency Scale and to evaluate this index within two validation samples from different countries. Quantitative, cross-sectional data from two German surveys and one Dutch survey were analysed. A total of 305 Dutch and German hospitals with 21,880 patients took part. The diagnostic validity of the Care Dependency Scale was evaluated by computing receiver operator characteristics curves, the areas under the curves, sensitivity, specificity and positive and negative predictive values.The Scale demonstrated a good diagnostic validity for pressure ulcer risk screening in Dutch and German hospitals. The diagnostic validity regarding the risk for falls was satisfying in Germany and moderate in the Netherlands. Using the Care Dependency Scale for risk screening could reduce the necessity of further assessment by more than a half.

Aims Among various risk assessment scales for the development of pressure ulcers in long-term care residents that have been published in the last three decades, the Braden scale is among the most tested and applied tools. The sum score of the scale implies that all items are equally important. The aim of this study is to show whether specific items are of greater significance than others and therefore have a higher clinical relevance. Design Data analysis of six pressure ulcer prevalence studies (2004–2009). Methods A total of 17 666 residents (response rate 79.6%) in 234 long-term care facilities participated in 6 annual point prevalence studies that were conducted from 2004 to 2009 throughout Germany. For the classification of the sample regarding pressure ulcers as a dependent variable and the Braden items as predictor variables, Chi-square Automatic Interaction Detector (CHAID) for modelling classification trees has been used. Results Pressure ulcer prevalence was 5.4% including pressure ulcer grade 1 and 3.4% for pressure ulcer grades 2–4. CHAID analysis for the classification tree provided the item ‘friction and shear’ as the most important predictor for pressure ulcer prevalence. On the second level, the strongest predictors were ‘nutrition’ and ‘activity’ and on the third level they were ‘moisture’ and ‘mobility’. Residents with problems regarding ‘friction and shear’ and poor nutritional status present with an 18.0 (14.8) pressure ulcer prevalence which is 3–4 times higher than average. Conclusion CHAID analyses have shown that all items of the Braden scale are not equally important. For residents in long-term care facilities in Germany, the existence of ‘friction and shear’ as a potential and especially as a manifest problem has had the strongest association with pressure ulcer prevalence.

AIM OF THE STUDY: The aim of this study was to display the values of the quality indicators “falls in the institution” and “institutionally acquired pressure ulcers” of 76 German nursing homes in bar graphs and funnel plots and to discuss the advantages and disadvantages of both methods. METHODS: In 2009 a nationwide prevalence study has been conducted in 76 nursing homes (n=5 521). Among others two trained data collectors assessed the fall and pressure ulcer risks, the presence of pressure ulcers and whether nursing home residents fell. Risk adjusted fall and pressure ulcer prevalence rates were calculated per institution and displayed in bar graphs and funnel plots. RESULTS: The proportions of residents with pressure ulcers grade 2, 3 or 4 varied between 0 and 11%. The average pressure ulcer prevalence was 2.5%. On average, 6% of residents at risk for falling fell during the last 2 weeks. The proportions of fallen residents varied between 0% and 100%. In bar graphs differences between institutions and rankings can be displayed. However, the precision of the point estimates is not taken into account. Furthermore, criteria for determining conspicuous institutions are arbitrary. In funnel plots values are plotted against their precision. Although there were differences between the investigated nursing homes, most of them could be explained by chance. CONCLUSION: Funnel plots should be used when comparing medical or nursing performance between health care institutions. They take the precision of estimates into account that is usually the size of the institution. Despite differences, there was no nursing home with a prevalence of institutionally acquired pressure ulcers that was significantly higher than those in all the other institutions. In 2 out of 75 nursing homes the proportions of fallers were higher than expected by chance. In terms of performance improvement the reasons for this should be further investigated. However, in spite of the advantages of funnel plots they do not provide guidance as to whether the measured results can be tolerated and are acceptable.

Background The application of standardized pressure ulcer risk assessment scales is recommended in clinical practice. Objectives The aims of this study were to compare the interrater reliabilities of the Braden and Waterlow scores and subjective pressure ulcer risk assessment and to determine the construct validity of these three assessment approaches. Design Observational. Settings Two intensive care units of a large University Hospital in Germany. Participants 21 and 24 patients were assessed by 53 nurses. Patients' mean age was 69.7 (SD 8.3) and 67.2 (SD 11.3). Methods Two interrater reliability studies were conducted. Samples of patients were assessed independently by a sample of three nurses. A 10-cm visual analogue scale was applied to measure subjective pressure ulcer risk rating. Intraclass correlation coefficients (ICC) and standard errors of measurement (SEM) were used to determine interrater reliability and agreement of the item and sum scores. Pearson product moment correlation coefficients ( r ) were used to indicate the degree and direction of the relationships between the measures. Results The interrater reliability for the subjective pressure ulcer risk assessment was ICC(1,1)=0.51 (95% CI 0.26–0.74) and 0.71 (95% CI 0.53–0.85). Interrater reliability of Braden scale sum scores was ICC(1,1)=0.72 (95% CI 0.52–0.87) and 0.84 (95% CI 0.72–0.92) and for Waterlow scale sum scores ICC(1,1)=0.36 (95% CI 0.09–0.63) and 0.51 (95% CI 0.27–0.72). The absolute degree of correlation between the measures ranged from 0.51 to 0.77. Conclusions Interrater reliability coefficients indicate a high degree of measurement error inherent in the scores. Compared to subjective risk assessment and the Waterlow scale scores the Braden scale performed best. However, measurement error is too high to draw valid inferences for individuals. Less than 26–59% of variances in scores of one scale were determined by scores of another scale indicating that all three instruments only partly measured the same construct. The use of the Braden-, Waterlow- and Visual Analogue scales for measuring pressure ulcer risk of intensive care unit patients is not recommended.

Aim. Comparison of the diagnostic accuracy of two pressure ulcer risk assessment scales and one generic nursing assessment tool. Background. Guidelines for pressure ulcer prevention recommend an initial risk screening of all patients, followed by appropriate nursing interventions. Additionally, personal and financial resources have to be allocated carefully to avoid excessive or too little treatment. Risk assessments should be accurate and applicable, and some studies showed that generic nursing tools also provide specific information for nursing diagnoses, like risk for pressure ulcer. Design. Cross sectional observational study. Methods. A total of 1053 adult patients of a university hospital in Germany were investigated. For each patient, the Braden Scale, the Waterlow Scale and the Care Dependency Scale were completed. A skin inspection was conducted by trained nurses. Correlations between the three scales and the mean values of each pressure ulcer risk assessment scales for each Care Dependency Scale value were calculated. To determine the association between susceptibility to pressure ulcer and observed pressure ulcer, the area under the curve was calculated. Results. There was a higher correlation between the Braden Scale and the Care Dependency Scale (r = 0·82) than between the two pressure ulcer risk assessment scales (−0·65). The highest area under the curve was reached by the Braden Scale (0·86), followed by the Care Dependency Scale (0·83) and the Waterlow Scale (0·81). Only the Braden Scale (cut-off 18) and the Care Dependency Scale (cut-off 65) reached the psychometric requirements of at least 70% sensitivity and 70% specificity. Conclusions. The Care Dependency Scale could be used for both a general nursing assessment and as a screening tool for risk for pressure ulcers. The Braden Scale showed the highest association with the occurrence of pressure ulcer. Relevance to clinical practice. The Care Dependency Scale is a useful screening tool to identify patients at risk for pressure ulcers. Nursing assessment activities might be reduced by using a generic nursing assessment tool also for specific risk screening.

Increasing costs within health care require an efficient use of time and staff in order to appropriately satisfy patients’ needs. The application of valid and reliable instruments enables nurses to determine patients’ care needs. However, to ensure acceptance in nursing practice, assessment instruments must not only be reliable and valid, but also practical and useful. One such instrument for rehabilitation is the Care Dependency Scale for rehabilitation. The scale has been used in rehabilitation, but so far it has not been evaluated from the nurses’ perspective. Therefore, this study aims to determine how nurses evaluate the clinical utility of the Care Dependency Scale for rehabilitation. In this context the application and testing of a staff view assessment instrument was deemed necessary, and this constitutes the second aim of the study. Nurses from several Austrian rehabilitation units were asked to complete the staff view assessment instrument to evaluate the Care Dependency Scale for rehabilitation. Ethical approval was obtained. Results indicate that the staff view assessment instrument enables evaluation of the clinical utility of the Care Dependency Scale for rehabilitation. Most nurses agree that the Care Dependency Scale for rehabilitation is a clinically useful instrument, improves communication and cooperation within the nursing team and is easy and quick to use/analyse/ interpret. It may therefore be recommended for application in daily nursing practice.

Aim.The aim of this study was to determine the validity and reliability of the modified Arabic Care Dependency Scale for self-assessment of older persons in Egypt and to compare these self-assessments to proxy assessments by care givers and family members.Background.The Care Dependency Scale is an internationally used instrument to measure care dependency. The Arabic version may improve data collection on this phenomenon in the Middle East where the population is ageing.Design.A cross-sectional study with a sample of 611 older persons living in Greater Cairo. Participants belonged to three groups: nursing home residents, home care recipients and non-care recipients; 459 participants were also rated by proxies and 171 repeated their self-assessment after two weeks.Methods.The correlation between sum scores of the Care Dependency Scale and the Activities of Daily Living scale was calculated to establish criterion validity. Construct validity was determined by comparing care recipients and non-care recipients with regard to their Care Dependency Scale sum scores and by exploratory factor analysis. Intraclass coefficients were used to assess test-retest reliability of self-ratings for each item. Mean differences between self and proxy assessment were calculated.Results.The Care Dependency Scale had a strong correlation to the Activities of Daily Living scale and is able to distinguish between care recipients and non-care recipients. Factor analysis revealed one factor for basic needs and one factor for psychosocial needs. ICC values were > 0 center dot 7 for most items related to the factor for basic needs among care recipients. Proxy assessment yielded higher care dependency than self assessment.Conclusion.Care Dependency Scale items for basic needs are suitable to assess care dependency among Egyptian care recipients.Relevance to clinical practice.Assessment of care dependency is useful to obtain data for appropriate resource allocation among care recipients.

Aim. The aim of this study was to identify the attitudes of Egyptian nursing home residents towards staying in a nursing home and to differentiate between various types of these attitudes. Background. The number of older persons in Egypt who require nursing care is increasing. In response, nursing homes in bigger cities like Cairo were founded, although family care seems to be the prevalent norm. Methods. Semi-structured guideline interviews were performed with 21 residents from four different nursing homes in Cairo. Interviews were analyzed using qualitative content analysis. Findings. One category of resident was those who were sent to the nursing home by persons closely related to them. Another category made their own decision to move to a nursing home. Relationships with social networks and self-help abilities are factors of importance in influencing decision-making. Conclusion. Nursing homes in Egypt fulfil different functions for different types of older persons. Charitable institutions are a last resort for those with no income and a disrupted social network. For better-off older persons, nursing homes may provide the benefits of socialising with peers and receiving medical treatment.

Aim of the study The aim of this study was to investigate the relationship between the use of the National Nursing Expert Standard Pressure Ulcer Prevention and the pressure ulcer prevalence in German nursing homes and hospitals. Methods Data were collected within two nationwide surveys conducted by the Department of Nursing Science of the Charite, Berlin, Germany. The surveys, designed as cross-sectional prevalence studies, serve as an investigation of the amount of clinically relevant nursing phenomena, i. e., pressure ulcers. Prevalence per facility in the at-risk group was explored by a ranking procedure of the 95 nursing homes and hospitals. The facilities were divided into two groups according to whether they used the German Expert Standard to develop the local protocol or not. Results The pressure ulcer prevalence of the at-risk group ranged from 0% to 24.6% in nursing homes and from 7% to 40% in hospitals. In about 40% of the hospitals and nursing homes the local protocol of pressure ulcer prevention was based on the German Expert Standard. The ranking figure indicates that there is no statistically significant relation between Expert Standard-based local protocols and the pressure ulcer prevalence in the at-risk group. Conclusion A clear advantage to use the German Expert Standard compared with other sources cannot be shown with these data. However, a uniform pressure ulcer prevention is an essential quality feature of nursing care. The degree of implementation and the consequent transfer of the recommendations to daily practice should be evaluated regularly.

Pressure ulcer prevalence rates provide useful information about the magnitude of this health problem. Only limited information on pressure ulcers in Germany was available before 2001. The purpose of this study was to compare results of seven pressure ulcer prevalence surveys which were conducted annually between 2001 and 2007 and to explore whether pressure ulcer prevalence rates decreased. The second aim was to evaluate if the measured prevalence rates of our sample could be generalised for all German hospitals. Results of seven point pressure ulcer prevalence studies conducted in 225 German hospitals were analysed. Chi-square tests, chi-square trend tests and one-way ANOVA to assess differences and trends across the years were applied. The sample was stratified according to pressure ulcer risk and speciality. Finally, study samples were compared with the potential population. In total data of 40,247 hospital patients were analysed. The overall pressure ulcer prevalence rate in German hospitals was 10.2%. Patient samples of each year were comparable regarding gender, age and pressure ulcer risk. Pressure ulcer prevalence rates decreased from 13.9% (year 2001) to 7.3% (year 2007) (p

Background Pressure ulcers are common in acute and long-term care. However, critically ill patients usually have multiple risk factors for pressure ulcers. Objectives The study was conducted to assess pressure ulcer incidence in intensive care patients, the factors related to pressure ulcer incidence and the course of pressure ulcers after the admission to an intensive care unit. Design A longitudinal design. Setting This study was carried out in cardiological and surgical intensive care of a general hospital and in a nephrological intensive care of a university hospital. Participants All patients admitted to intensive care wards during the period from April until October 2006 were invited to take a part in the study. One hundred and twenty-one patients were involved in the study. The inclusion criteria were adult intensive care patients, males and females, all diagnosis were included. The exclusion criterion was patients whose age less than 18 years. Method Each patient was assessed twice; first, upon admission and second upon discharge or death, or after 2 weeks if the patient was still in intensive care. The assessed data included pressure ulcer preventive measures, risk factors using Braden score, pressure ulcer characteristics and treatment. Additionally, incontinence supplies (urine/bowel) if used and the severity of illness using Acute Physiology and Chronic Health Evaluation (APACHE II score) were assessd. Results This study revealed a total incidence of 3.3% (4.5% in nephrological patients and 2.9% in surgical patients). Sixteen patients with a total of 21 pressure ulcers were admitted to the intensive care units. During the patients' stay at the intensive care units six pressure ulcers developed newly and five pressure ulcers healed. The mean of the APACHE II score of patients with new pressure ulcers (16.6) were higher than in patients without new pressure ulcers (11.5). Conclusion Pressure ulcer incidence is low in this study compared to other studies. Pressure ulcers can be healed in intensive care patients. Using some preventive measures such as foam and alternating air pressure mattresses may help to decrease pressure ulcer development. Hydrocolloid dressing may help to increase the healing rate of pressure ulcers.

Aims: To determine not only prevalence rates of urinary incontinence (UI) in nursing home residents but also factors influencing these prevalence rates, and to provide an overview of risk factors associated with UI in this group. Methods: A systematic review was performed using multiple databases including MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Library from January 1997 to April 2008. In addition, the bibliographies of all relevant articles were searched. Two authors independently assessed the eligibility of all studies and extracted data on study design, population characteristics, definition of incontinence, measurement instrument, risk factors and prevalence rates. Results: Twelve articles containing 16 studies met the eligibility criteria. Prevalence rates of UI in nursing home residents ranged from 43% to 77% (median 58%). When comparing studies, the influencing factors on UI prevalence of age and sex were identified. In total 45 risk factors were described. Within individual study populations, sex, age, cognitive function, dementia, bedfast and locomotion were associated with UI. Conclusions: UI prevalence rates in nursing homes are high and the influencing factors poorly understood. Although important risk factors similar to those in the general population have been identified, risk factors related to the care process should be further investigated. Neurourol. Urodynam. 28:288–294, 2009. 2009 Wiley-Liss, Inc.

Background Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention. Design The design of this study was a cross-sectional study (point prevalence). Setting The study setting was intensive care units. The sample consisted of 169 patients – 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards. Results The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients. Conclusions The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.

Title. Care dependency of hospitalized children: testing the Care Dependency Scale for Paediatrics in a cross-cultural comparison. Aim. This paper is a report of a study to examine the psychometric properties of the Care Dependency Scale for Paediatrics in Germany and Egypt and to compare the care dependency of school-age children in both countries. Background. Cross-cultural differences in care dependency of older adults have been documented in the literature, but little is known about the differences and similarities with regard to children’s care dependency in different cultures. Method. A convenience sample of 258 school-aged children from Germany and Egypt participated in the study in 2005. The reliability of the Care Dependency Scale for Paediatrics was assessed in terms of internal consistency and interrater reliability. Factor analysis (principal component analysis) was employed to verify the construct validity. A Visual Analogue Scale was used to investigate the criterion-related validity. Findings. Good internal consistency was detected both for the Arabic and German versions. Factor analysis revealed one factor for both versions. A Pearson’s correlation between the Care Dependency Scale for Paediatrics and Visual Analogue Scale was statistically significant for both versions indicating criterion-related validity. Statistically significant differences between the participants were detected regarding the mean sum score on the Care Dependency Scale for Paediatrics. Conclusion. The Care Dependency Scale for Paediatrics is a reliable and valid tool for assessing the care dependency of children and is recommended for assessing the care dependency of children from different ethnic origins. Differences in care dependency between German and Egyptian children were detected, which might be due to cultural differences.

Background Pressure ulcers have a known impact on quality of life as well as on morbidity and mortality of the persons affected. Remarkable differences in pressure ulcer prevalence between the Netherlands and Germany have been found during the last 6 years. This study explores to what extent the individual risk of the population and quality indicators of the institutions can explain the variation in national prevalence. Methods Data of a binational multi-centred cross-sectional study in 103 hospitals (n = 21 378 patients) and 129 nursing homes (n = 15 579 residents) were analysed using random effects regression models to calculate the differences in national prevalences within the nursing homes and hospitals, adjusted for personal risk for pressure ulcer and quality indicators. Results The prevalence of pressure ulcers among the at-risk group (Bradenscore ≤20) in nursing homes was 30.8% in the Netherlands and 8.3% in Germany [OR: 4.9 (CI 95%: 4.2–5.7)]. In hospitals, the prevalence among the at-risk group was 26.1% in the Netherlands and 21.2% in Germany [OR: 1.3 (CI 95%: 1.2–1.5)]. After adjusting for individual risk factors (age, gender, Bradenscore) as well as for quality structures (use of prevention and treatment protocols, experts groups, information leaflets, nurses training, central pressure ulcer statistics and regular updating of protocols), the chance of developing a pressure ulcer was 6.05 times higher (CI 95%: 4.0–9.2) in a Dutch nursing home than in a German nursing home. Within the hospitals, the OR for Dutch patients was 2.03 (CI 95%: 1.4–3.0). Conclusion A remarkable national variation exists in pressure ulcer prevalence and nursing practice. Neither the populations vulnerability for pressure ulcers nor pressure ulcer management as measured in this study could explain this national variation. Therefore, other risk factors should be taken into consideration. Additionally, it is possible that quality indicators are implemented in differing ways with varying levels of effectiveness. Therefore, further research is needed to examine prospectively and in more detail the reality of care within facilities in both countries.

Aims. To review systematically the interrater reliability of pressure ulcer classification systems to find out which classification should be used in daily practice. Background. Pressure ulcer classification systems are important tools in research and practice. They aim at providing accurate and precise communication, documentation and treatment decisions. Pressure ulcer classifications are criticised for their low degree of interrater reliability. Design. Systematic review. Methods. The data bases MEDLINE, EMBASE, CINAHL and the World Wide Web were searched. Original research studies estimating interrater reliability of pressure ulcer classification systems were included. Study selection, data extraction and quality assessment was conducted independently by two reviewers. Results. Twenty-four out of 339 potentially relevant studies were included in the final data synthesis. Due to the heterogeneity of the studies a meaningful comparison was impossible. Conclusions. There is at present not enough evidence to recommend a specific pressure ulcer classification system for use in daily practice. Interrater reliability studies are required, in which comparable raters apply different pressure ulcer classification systems to comparable samples. Relevance to clinical practice. It is necessary to determine the interrater reliability of pressure ulcer classifications among all users in clinical practice. If interrater reliability is low the use of those systems is questionable. On the basis of this review there are no recommendations as to which system is to be given preference.

Rationale In view of an increasing necessity for systematic assessments, nursing practice would benefit from a simplification of assessment procedures. These assessments should be scientifically based. Aims To evaluate the possibility of assessing pressure ulcer risk as well as care dependency simultaneously with a standardized instrument for nursing homes and hospitals. Methods Care dependency was measured with the Care Dependency Scale (CDS). The quantitative analyses were accomplished with data from a cross-sectional study that was performed in 2005 in 39 German nursing homes and 37 hospitals with a total of more than 10 000 participants. The scale's construct validity was calculated with Pearson's r, and predictive validity was evaluated by computing sensitivity and specificity values and the area under the curve (AUC). Item-level analyses included calculations of odds ratios, relative risks and logistic regression analyses. Results Construct validity of the CDS was r = 0.79 (P

Summary Background An important barrier in the implementation of effective incontinence treatments is the level of knowledge of the nurses concerning assessment and treatment of urinary incontinence. Therefore, it is important to assess current nurses’ knowledge and practice in urinary incontinence care so that nurses can receive adequate training and education. Aims and objectives This article reports on the development and testing of the Urinary Incontinence Practice and Knowledge Scale as well as the results of nurses’ practice and knowledge about urinary incontinence. Methods A cross-sectional design with a convenience sample of nurses and nurse assistants was used. Results Nurses answer two-thirds of the questions correctly. The level of knowledge of the nurse assistants is lower than that of nurses. Education and experience in the field are associated with the level of knowledge. Nurses and nurse assistants perform continence-related actions only ‘sometimes’ or ‘often’ at best. Both groups have best results in the subscale ‘Support’ and they have most deficits in ‘Documentation’. Conclusion Nurses and nurse assistants need more education and training in urinary incontinence care. Special focus should lie on documentation. The results give information towards adequate education and training for nurses as well as nurse assistants.