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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.

Background: Chronic wounds are an increasing problem in the aging population, patients experience a lower health-related quality of life and the care for these patients is associated with high costs. Thorough wound assessments facilitate objective monitoring of wound status and progress. A wound assessment tool can guide clinicians in these wound assessments and in recording wound progress or deterioration., Objective: Systematically identify assessment tools for chronic wounds, investigate their measurement properties, and summarize the data per assessment tool., Design: Systematic review METHODS: The databases Medline (PubMed interface), Embase, CINAHL, and CENTRAL were systematically searched until May 2020 (updated in February 2021). Studies reporting the development and/or the evaluation of measurement properties of assessment tools for chronic wounds were included. The "Consensus-based Standards for the selection of health Measurement Instruments" risk of Bias checklist was applied to evaluate the methodological quality of the included studies. Each reported measurement property was rated against criteria for good measurement properties. The evidence was summarized and the quality of the evidence was graded using a modified Grades of Recommendation, Assessment, Development, and Evaluation approach. Study selection, data extraction and quality appraisal were conducted independently by two reviewers and double-checked by a third reviewer., Results: Twenty-seven studies describing the measurement properties of fourteen assessment tools for chronic wounds were included. None of the studies reported a content validity evaluation by a relevance study or a comprehensiveness study in professionals. Six articles reported the development or revision of an existing assessment tool. The reported measurement properties included: structural validity (5 studies), reliability (18 studies), hypotheses testing for construct validity (18 studies) and responsiveness (7 studies). Internal consistency, cross-cultural validity / measurement invariance and measurement error were not reported. If criterion validity was assessed, the results were allocated to hypotheses testing for construct validity as no 'gold standard' is available., Conclusions: Fourteen assessment tools for chronic wounds were identified. Construct validity (by hypotheses testing) and responsiveness of the Pressure Ulcer Scale for Healing version 3.0 were supported by sufficient ratings based on moderate to high level quality of evidence. Reliability of the (Revised) Photographic Wound Assessment Tool had a sufficient rating based on moderate quality of evidence. The ratings of the measurement properties of the other wound assessment tools were either insufficient or indeterminate, or a sufficient result was supported by low to very low quality of evidence. Registration number in PROSPERO: CRD42020183920 Tweetable abstract: A systematic review giving a clear overview of the measurement properties of available assessment tools for chronic wounds., Competing Interests: Declaration of Competing Interest None, (Copyright © 2021. Published by Elsevier Ltd.)

Background: The trend towards more active involvement of patients in the management of their chronic condition requires professionals to interact in a way that facilitates patients' autonomy and motivation. A self-assessment tool that measures simultaneously motivating and demotivating interaction styles in counselling chronic ill patients is currently not available., Objectives: Grounded in Self-Determination Theory, this study aimed to develop and validate a self-report tool that captures healthcare professionals' motivating (i.e., autonomy-support and structure) and demotivating (i.e., control and chaos) interaction styles while supporting patients towards self-management., Methods: The Situations In Self-management support - HealthCare Professionals (SIS-HCP) was developed throughout a five-phased psychometric validation study with (1) construct definition, (2) development of the vignette-based questionnaire, (3) ecological validation and piloting, (4) psychometric evaluation (round 1) by multidimensional scaling analysis, and (5) psychometric evaluation (round 2) by internal and construct validity, and reliability testing procedures in 5 independent samples (total N = 1133), between August 2015 and March 2018., Results: Multidimensional scaling analysis provided evidence for a two-dimensional structure, with motivating, relative to demotivating counselling and high, relative to low, directive counselling representing the two axes. Four styles could be distinguished: autonomy-support (rather motivating and non-directive), structure (rather motivating & directive), control (rather demotivating & directive) and chaos (rather demotivating & non-directive) within self-management support. The SIS-HCP demonstrated good construct validity, and high internal consistency and test-retest reliability., Conclusion: The SIS-HCP is a vignette-based tool, which allows to explore, in an integrative way, which motivating (i.e., autonomy-support and structure) and demotivating (i.e., control and chaos) styles healthcare professionals use when counselling patients living with a chronic illness. The SIS-HCP might enhance professionals' awareness of their (de)motivating counselling styles and the extent to which they promote ownership among patients. The SIS-HCP represents an interesting addition to existing instruments which measure what professionals do in the field of self-management support, and how confident they feel doing so. The thorough process of development and validation led to a theoretical underpinned tool, with the identified (de)motivating dimensions yielding strong psychometric properties. The SIS-HCP can be used as a reflective tool for professionals and for tailored training., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Skin tear classifications support the assessment and reporting of skin tears in a consistent way. The measurement properties of skin tear classifications have not been compared so far., Objectives: To critically appraise, compare and summarise the quality of the measurement properties of available skin tear classifications., Design: Systematic review., Methods: The databases MEDLINE, EMBASE, CINAHL and CENTRAL were systematically searched until January 2020. Studies reporting the development and/or the evaluation of measurement properties of skin tear classifications were included. The COSMIN Risk of Bias checklist was applied to evaluate the methodological quality of the included studies. Each reported measurement property was rated against criteria for good measurement properties. The evidence was summarised and the quality of the evidence was graded using a modified GRADE approach. Study selection, data extraction and quality appraisal were conducted independently by two reviewers and double-checked by a third reviewer., Results: Fourteen studies, describing five classifications, were included. Content validity was examined in five studies, reliability in nine studies, measurement error in two studies, and criterion validity in four studies. For three classification systems, no measurement properties were reported., Conclusions: Five skin tear classifications exist, of which only two have been psychometrically tested. The quality of evidence on their measurement properties varied between very low to moderate. To date, the ISTAP classification is the most commonly evaluated system with moderate quality evidence to support its reliability, measurement error and criterion validity. More well-designed studies using direct skin observations are needed. Protocol registration number: CRD42019138138 (PROSPERO). Tweetable abstract: A systematic review of the measurement properties of skin tear classifications., Competing Interests: Conflict of Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: In contemporary healthcare, both community and inpatient mental health and emergency services are important help-seeking avenues for persons with suicidal ideation and behaviour. Regarding nursing practice in these services, there is a strong focus on assessing and managing suicide risk. Within this clinical context, the perspectives of persons with suicidal ideation and behaviour are often overlooked., Objective: To synthesise the literature examining the perceptions and experiences of persons with suicidal ideation and behaviour regarding their interactions with nurses., Design: Review of qualitative and quantitative studies within a data-based convergent synthesis design., Data Sources: A systematic search of electronic databases (until January 2020) in PubMed, Web of Science, Embase, and PsycARTICLES. Additional articles were identified through hand searching reference lists., Review Methods: The methodological quality was assessed using the Critical Appraisal Skills Programme for qualitative studies and the QualSyst tool for quantitative studies. Thematic analysis was used to identify the key themes and subthemes., Results: In total, 26 studies were selected for analysis. Most studies were qualitative and focused on inpatient mental health services. The studies reflected a spectrum of positive and negative perceptions and experiences of persons with suicidal ideation and behaviour regarding their interactions with nurses. Three key themes were identified: being cared for and acknowledged as a unique individual, giving voice to myself in an atmosphere of connectedness, and encountering a nurturing space to address my suicidality., Conclusions: This systematic review provides insights that can be used to encourage nurses to contribute to suicide prevention and treatment as part of an approach in which they care for, connect, and collaborate with persons experiencing suicidal ideation and behaviour as unique individuals., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: As nasogastric feeding tube insertion is a frequently applied, non-risk-free nursing technique, a high level of evidence-based nursing care is required. Little evidence is available regarding the accurate determination of the insertion length of nasogastric feeding tubes. The method of using the nose-earlobe-xiphoid distance as measurement is inadequate and not supported by evidence. Findings from a recent randomized trial led to an alternative calculation: the corrected nose-earlobe-xiphoid distance formula: (nose-earlobe-xiphoid distance × 0.38696) + 30.37 + 6 cm., Objectives: To test the accuracy of the corrected nose-earlobe-xiphoid distance formula for determining the required nasogastric feeding tube insertion length in adults admitted on an intensive care unit and to investigate the probability to successfully obtain gastric aspirate for pH measurement., Design: Prospective, single-center observational study., Participants and Methods: Adult intensive care unit patients in a general hospital (N = 218) needing a small-bore nasogastric feeding tube were included between March and September 2018. Correct tip positioning was defined as a tube tip located > 3 cm under the lower esophageal sphincter. Tip positioning was verified using X-ray., Results: All nasogastric feeding tube tips were correctly positioned > 3 cm under the lower esophageal sphincter. The chance of successfully obtaining gastric aspirate within 2 h after placement of the tube was 77.9%., Conclusions: With all tips positioned > 3 cm in the stomach and zero tubes migrating back into the esophagus, the corrected nose-earlobe-xiphoid distance formula can be considered a more accurate method to determine nasogastric feeding tube insertion length., Competing Interests: Conflict of interests None declared, (Copyright © 2020. Published by Elsevier Ltd.)

Background: The rising attention to participation and self-regulation in chronic care requires nurses to move towards an approach in which patients' perspectives and choices are central, and in which patients' competency is fostered. According to Self-Determination Theory, nurses can differ in the way they interact with patients living with a chronic illness. That is, they can interact in an autonomy-supportive, controlling, structuring or chaotic way. However, in practice, nurses often use these styles side by side depending on personal and situational demands., Objective: Rooted in Self-Determination Theory, this study sought to identify distinct profiles among nurses involving the co-occurrence of autonomy support, structure, control and chaos (aim 1), and to examine whether such profiles are meaningfully driven by nurse-related indicators (aim 2)., Design: A cross-sectional design with latent profile analysis., Methods: Data were collected using validated self-report questionnaires among nurses counselling chronically ill patients (N = 389). Latent profile analysis was performed to shed light on how nurses use different styles side by side; and subsequent MANCOVA testing was used to examine differences between the profiles in terms of nurse-related indicators., Results: Four profiles could be identified, each characterised by a unique combination of differing degrees of autonomy support, structure, control and chaos. The profiles included a motivating profile (20.31%) characterised by the dominant presence of autonomy support and structure; a demotivating chaotic profile (17.74%) characterised by the dominant presence of chaos; an active profile (24.17%) where all styles were highly present; and an undifferentiated profile (37.79%) characterised by an average presence of all styles. These four profiles were meaningfully related to a set of nurse-related indicators. Multivariate analysis (Pillai's Trace test = .38, F(15, 756) = 7.28; p < .001; η 2  = .13) indicated that job competency, job autonomy and high-quality motivation were most elevated in the motivating profile., Conclusion: Profiling has supported our understanding of the natural co-occurrence of more motivating and demotivating styles among nurses when counselling patients in self-managing their life with chronic illness. The pattern of retained profiles indicates that, for some nurses, it will be important to move away from controlling or chaotic interactions. Future intervention development should augment nurses' competence levels and high-quality motivation, with attention to reduce the pressure in nurses to act in a result-based manner. Profiling can also be valuable to better assign nurses to an employment in chronic care, and to support their personal professional growth., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Pressure ulcers are a global issue and substantial concern for healthcare systems. Various types of support surfaces that prevent pressure ulcer are available. Data about the effectiveness and cost of static air support surfaces and alternating air pressure mattresses is lacking., Objectives: To compare the effectiveness and cost of static air support surfaces versus alternating air pressure support surfaces in a nursing home population at high risk for pressure ulcers., Design: Prospective, multicentre, randomised controlled clinical, non-inferiority trial., Setting: Twenty-six nursing homes in Flanders, Belgium., Participants: A consecutive sample of 308 participants was selected based on the following eligibility criteria: high risk for pressure ulcer and/or with category 1 pressure ulcer, being bedbound and/or chair bound, aged > 65 years, and use of an alternating air pressure mattress., Methods: The participants were allocated to the intervention group (n = 154) using static air support surfaces and the control group (n = 154) using alternating air pressure support surfaces. The main outcome measures were cumulative incidence and incidence density of the participants developing a new category II-IV pressure ulcer within a 14-day observation period, time to develop a new pressure ulcer, and purchase costs of the support surfaces., Results: The intention-to-treat analysis revealed a significantly lower incidence of category II-IV pressure ulcer in the intervention group (n = 8/154, 5.2%) than in the control group (n = 18/154, 11.7%) (p = 0.04). The median time to develop a pressure ulcer was significantly longer in the intervention group (10.5 days, interquartile range [IQR]: 1-14) than in the control group (5.4 days, [IQR]: 1-12; p = 0.05). The probability to remain pressure ulcer free differed significantly between the two study groups (log-rank X² = 4.051, df = 1, p = 0.04). The overall cost of the mattress was lower in the intervention group than in the control group., Conclusions: A static air mattress was significantly more effective than an alternating air pressure mattress in preventing pressure ulcer in a high-risk nursing home population. Considering multiple lifespans and purchase costs, static air mattresses were more cost-effective than alternating air pressure mattresses., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The fundamental importance of establishing an interpersonal care relationship for quality nursing care has been highlighted. However specific elements of the interpersonal care relationship of importance to older patients in the hospital have not been identified., Objectives: The aim of this review was to explore and synthesise research findings regarding the elements of the interpersonal care relationship concept from the perspectives of older patients., Design: A systematic mixed-methods review., Data Sources: An extensive search was conducted up until October 2018 for articles without any publication date time limit in PubMed, Web of Science, Cochrane Database of Systematic Reviews and CINAHL., Review Methods: Primary studies were included if they concerned patients aged 65 years or older and their perspectives on the elements of the interpersonal care relationship with nurses. Inclusion was limited to patients without cognitive impairment who were admitted to an acute hospital setting. The methodological quality of each study was assessed using the Critical Appraisal Skills Programme for qualitative studies, the Quality Assessment Tool for Quantitative Studies and the Mixed-Methods Appraisal Tool. Thematic analysis was used to structure the results of the included studies., Results: Of the 7596 studies found, 24 were included in this review. Twenty articles had a qualitative, three a quantitative and one a mixed methods design. Older patients consider dignity and respect as core values that need to be met in the interpersonal care relationship. Five core elements of the interpersonal care relationship were identified to meet these core values: elements related to caring behaviour and attitude, person-centred care, patient participation, communication and situational aspects. These core elements were structured according to three categories, identified in the literature, that determine the quality of the interpersonal care relationship: nurse-, older-patient-related elements and situational aspects., Conclusions: The elements identified in this review can guide efforts to define the interpersonal care relationship between older patients and nurses. Nurses should be supported and motivated by education and practice to adapt their behaviour, attitudes and communication to meet older patients' expectations. Hospital management can also encourage nurses to communicate well. Investment in the current organisation of care is needed to improve nurses' work overload and presence. Further research is needed to clarify the underlying processes influencing the experience of the interpersonal care relationship from the perspectives of older patients, nurses, informal caregivers and hospital management., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Healthcare providers play an important role in providing preconception care to women and men of childbearing age. Yet, the provision of preconception care by healthcare providers remains low., Objectives: To provide an overview of barriers and facilitators at multiple levels that influence the provision of preconception care by healthcare providers., Design: A mixed-methods systematic review., Data Sources: PubMed, Web of Science, CINAHL, The Cochrane Library, and EMBASE were systematically searched up to April 27, 2017. The search strategy contained MeSH terms and key words related to preconception care and healthcare providers. Reference lists of included studies and systematic reviews on preconception care were screened., Review Methods: Publications were eligible if they reported on barriers and facilitators influencing the provision of preconception care by healthcare providers. Data were extracted by two independent reviewers using a data extraction form. Barriers and facilitators were organized based on the social ecological model. The methodological quality of included studies was evaluated using the Critical Appraisal Skills Programme Qualitative checklist for qualitative studies, the Quality Assessment Tool for quantitative studies, and the Mixed Methods Appraisal Tool for mixed methods studies., Results: Thirty-one articles were included. Barriers were more reported than facilitators. These were situated at provider level (unfavourable attitude and lack of knowledge of preconception care, not working in the field of obstetrics and gynaecology, lack of clarity on the responsibility for providing preconception care) and client level (not contacting a healthcare provider in the preconception stage, negative attitude, and lack of knowledge of preconception care). Limited resources (lack of time, tools, guidelines, and reimbursement) were frequently reported at the organizational and societal level., Conclusions: Healthcare providers reported more barriers than facilitators to provide preconception care, which might explain why the provision of preconception care is low. To overcome the different client, provider, organizational, and societal barriers, it is necessary to develop and implement multilevel interventions., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Critically ill patients suffering from fecal incontinence have a major risk of developing incontinence-associated dermatitis (IAD). The presence of moisture and digestive enzymes (lipase, protease) negatively influences skin barrier function. Additional risk factors will make some patients even more vulnerable than others. In order to provide (cost) effective prevention, this specific patient population should be identified timely., Objectives: To identify independent risk factors for the development of IAD category 2 (skin loss) in critically ill patients with fecal incontinence., Design: A cross-sectional observational study., Setting and Participants: The study was performed in 48 ICU wards from 27 Belgian hospitals. Patients of 18 years or older, with fecal incontinence at the moment of data collection, were eligible to participate. Patients with persistent skin redness due to incontinence (IAD category 1) were excluded., Methods: Potential risk factors were carefully determined based on literature and expert consultations. Data were collected over a period of eight months by trained researchers using patient records and observation of skin care practices. At the time a patient was included in the study, all relevant data from the past six days, or since admission at the ICU, were recorded. Simultaneously, direct skin observations were performed and high definition photographs were ratified by an expert IAD researcher. A multiple binary logistic regression model was composed to identify independent risk factors. Variables with P < .25 in single binary logistic regression analyses were added to the multiple model using a forward procedure. A cut-off value of P < .1 was established to retain variables in the final model. Nagelkerke's R 2 and Hosmer-Lemeshow statistic were calculated as measures of model fit., Results: The sample comprised of 206 patients, of which 95 presented with IAD category 2, and 111 were free of IAD. Seven independent risk factors were identified: liquid stool [odds ratio (OR) 4.69; 95% confidence interval (CI) 2.28-9.62], diabetes (OR 2.89; 95% CI 1.34-6.27), age (OR 1.05; 95% CI 1.02-1.08), smoking (OR 2.67; 95% CI 1.21-5.91), non-use of diapers (OR 2.97; 95% CI 1.39-6.33), fever (OR 2.60; 95% CI 1.23-5.53), and low oxygen saturation (OR 2.15; 95% CI 1.03-4.48). Nagelkerke's R 2 was 0.377. The Hosmer-Lemeshow statistic indicated no significant difference between the observed and expected values (p = .301)., Conclusions: Liquid stool, diabetes, age, smoking, non-use of diapers, fever, and low oxygen saturation were independently associated with IAD category 2 in critically ill patients with fecal incontinence., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Chronic conditions put a heavy burden on healthcare in every country. Supporting persons with a chronic illness to take an active role in the management of their condition is a core component in the Chronic Care Model. It implies confidence and good skills from professionals. To date, there is no evidence on final year nursing students' performance in supporting patients' self-management, nor on factors associated with this performance., Objectives: To explore self-reported performance of supporting patients' self-management by final year nursing students, and person-related factors associated with this performance., Design: A correlational multi-centre study of final year nursing students (N=256) from eight nursing schools., Methods: Students were recruited from a convenience sample of eight nursing schools. All final year students were invited to participate. Data were collected between January 2015 and May 2016 using self-administered validated questionnaires. Theoretical behavioural frameworks were used to select hypothesized associated factors for self-management support: self-efficacy to perform self-management support and socio-structural factors (Social Cognitive Theory); needs for autonomy, competence and relatedness, and patient-invested contingent self-esteem (Self-Determination Theory); and attitudes towards supporting patients' self-management (Theory of Planned Behaviour)., Results: Final year nursing students (N=256) reported an overall low level of performance in delivering self-management support during internship. Students lacked mainly competencies in collaborative goal setting and shared decision making. Students reported a significant gap between their confidence and their actual performance in self-management support (p<0.001). About 33% of the variance in students' performance is predicted by four person-related factors, i.e. self-efficacy to perform self-management support, general feeling of competency on internship, belief on patients' knowledge about condition management, and contingency of a student's professional self-esteem upon patients' achievements., Conclusion: Final year nursing students are actually not ready to support patients' self-management even though they will soon be in practice as qualified nurses. Nursing curricula should be further attuned to the complex competencies of self-management support. Special attention is needed to broaden the perspective on self-management support. Learning opportunities can be introduced in classroom activities and on internship., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Accurate detection of symptoms is essential in palliative care. Identification of clustering of symptom is valuable to develop target interventions. This area is largely understudied in older palliative cancer patients., Objectives: To identify symptom clustering in older palliative cancer patients, and patient groups based on the clustering of symptoms, and to evaluate the difference in functional dependence and experiencing life as not meaningful between the identified patient groups., Design: A cross-sectional study., Setting: Geriatric and non-geriatric wards of seven acute care hospitals., Participants: 400 palliative cancer patients aged 65 years and older., Methods: Symptoms were collected using a validated instrument which assesses physical, psychological, functional, social, and existential symptoms by means of a structured interview with a researcher. An agglomerative hierarchical clustering analysis was used to analyse the data., Results: The cluster analysis revealed five groups of symptoms: (1) urological and gastrointestinal symptoms, and their treatment complications, (2) psychological and existential symptoms, (3) pain, constipation, sleeplessness and airway problems, (4) functionality problems, and (5) fatigue-related symptoms. Three patient groups were identified: (1) symptom-free group, (2) physical discomfort group, and (3) physical and psychological discomfort group. In the last group, significant more patients had a geriatric risk profile and less of them received chemotherapy. Patients in this group were more often functionally dependent and experienced their life as not meaningful., Conclusion: Five groups of symptoms were identified. Three patient groups were identified which reported different levels of functionality and experiencing life as meaningful. Healthcare professionals should be triggered to detect symptom clusters and be alert to the presence of the other symptoms in the cluster when identifying one symptom. They should also be alert to patients with a geriatric risk profile because of their higher risk of experiencing physical and psychological symptoms and the influence these symptoms have on being functionally dependent and experiencing life as not meaningful., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: To identify peer workers' perceptions and experiences of barriers to implementation of peer worker roles in mental health services., Design: Review of qualitative and quantitative studies., Data Sources: A comprehensive electronic database search was conducted between October 2014 and December 2015 in PubMed, CINAHL, Web of Science, The Cochrane Library, and PsycARTICLES. Additional articles were identified through handsearch., Review Methods: All articles were assessed on quality. A thematic analysis informed by a multi-level approach was adopted to identify and discuss the main themes in the individual studies. Reporting was in line with the 'Enhancing transparency in reporting the synthesis of qualitative research' statement., Results: Eighteen articles met the inclusion criteria. All studies adopted qualitative research methods, of which three studies used additional quantitative methods. Peer workers' perceptions and experiences cover a range of themes including the lack of credibility of peer worker roles, professionals' negative attitudes, tensions with service users, struggles with identity construction, cultural impediments, poor organizational arrangements, and inadequate overarching social and mental health policies., Conclusions: This review can inform policy, practice and research from the unique perspective of peer workers. Mental health professionals and peer workers should enter into an alliance to address barriers in the integration of peer workers and to enhance quality of service delivery. Longitudinal research is needed to determine how to address barriers in the implementation of peer worker roles., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: To investigate what published research reveals about the views and experiences of oncology health workers when caring for ethnic minority patients., Design: Systematic review of qualitative and quantitative studies., Data Sources: The following databases were systematically screened: PubMed, CINAHL, Web of Science, and AnthroSource. Reference lists were checked for additional articles., Review Methods: Empirical studies or systematic reviews (1/2000 to 12/2013) were included if they concerned the oncology setting and the views or experiences of healthcare workers and care users belonging to an ethnic or cultural minority group. The methodological quality of each individual study was assessed using the Critical Appraisal Skills Programme for Qualitative Studies and the Quality Assessment Tool for Quantitative Studies., Results: Eighteen publications met the inclusion criteria. Thirteen articles had a qualitative, four a quantitative, and one a mixed methods design. The results in the individual studies were heterogeneous. Most studies reported challenges or barriers when caring for ethnic minority patients, whereas fewer than half of the articles discussed facilitating factors and opportunities. Oncology health workers participating in the included studies sought to provide professional standards of care and tried to adapt care to the needs of ethnic minority patients. However, they experienced formidable communication barriers and they feared doing things that might be considered culturally insensitive. The organizational aspects of care for the oncology patient appeared to have a significant influence on how healthcare providers view and experience oncology care for ethnic minority patients., Conclusions: Views and experiences of participating oncology health workers were characterized by a willingness to provide proper care for ethnic minority patients, but this was hampered by a tangle of interrelated issues such as linguistic barriers, fear and uncertainty, and assumptions about cultural matters. Organizational aspects were shown to be a strong influence on healthcare workers caring for ethnic minority patients. Due to methodological limitations of the included studies, conclusions should be viewed with caution., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Pressure ulcers impose a substantial financial burden. The need for high-quality health care while expenditures are constrained entails the interest to calculate the cost of preventing and treating pressure ulcers and their impact on patients, healthcare, and society., Objectives: The aim of this paper is to provide insight into the cost of pressure ulcer prevention and treatment in an adult population., Methods: A systematic literature review was performed to conform the Cochrane Collaboration guidelines for systematic reviews. The search strategy contained index terms and key words related to pressure ulcers and cost. The search was performed in Medline, CINAHL, Web of Science, The Cochrane Library, Embase, and EconLit covering articles up to September 2013. Reference lists and conference abstracts were screened. Articles were eligible if they reported on direct medical cost of pressure ulcer prevention or treatment, and provided national cost estimates, cost per patient, or cost per patient per day. The Consensus on Health Economic Criteria checklist was used to assess methodological quality of the included studies., Results: In total, 2542 records were retrieved. After assessing eligibility, 17 articles were included. Five articles reported on both the cost of prevention and treatment, three articles reported on cost of prevention, and nine articles reported on the cost of pressure ulcer treatment. All articles were published between 2001 and 2013. Cost of pressure ulcer prevention per patient per day varied between 2.65 € to 87.57 € across all settings. Cost of pressure ulcer treatment per patient per day ranged from 1.71 € to 470.49 € across different settings. The methodological heterogeneity among studies was considerable, and encompassed differences regarding type of health economic design, perspective, cost components, and health outcomes., Conclusions: Cost of pressure ulcer prevention and treatment differed considerable between studies. Although the cost to provide pressure ulcer prevention to patients at risk can importantly impact health care services' budgets, the costs to treat a severe pressure ulcer were found to be substantially higher. Methodological heterogeneity among studies identified the need to use available, and study design-specific methodological guidelines to conduct health economic studies, and the need for additional pressure ulcer specific recommendations., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: The economic impact of pressure ulcer prevention and treatment is high. The results of cost-of-illness studies can assist the planning, allocation, and priority setting of healthcare expenditures to improve the implementation of preventive measures. Data on the cost of current practice of pressure ulcer prevention or treatment in Flanders, a region of Belgium, is lacking., Aim: To examine the cost of pressure ulcer prevention and treatment in an adult population in hospitals and nursing homes from the healthcare payer perspective., Design: A cost-of-illness study was performed using a bottom-up approach., Settings: Hospitals and nursing homes in Flanders, a region of Belgium., Methods: Data were collected in a series of prospective multicentre cross-sectional studies between 2008 and 2013. Data collection included data on risk assessment, pressure ulcer prevalence, preventive measures, unit cost of materials for prevention and treatment, nursing time measurements for activities related to pressure ulcer prevention and treatment, and nursing wages. The cost of pressure ulcer prevention and treatment in hospitals and nursing homes was calculated as annual cost for Flanders, per patient, and per patient per day., Results: The mean (SD) cost for pressure ulcer prevention was €7.88 (8.21) per hospitalised patient at risk per day and €2.15 (3.10) per nursing home resident at risk per day. The mean (SD) cost of pressure ulcer prevention for patients and residents identified as not at risk for pressure ulcer development was €1.44 (4.26) per day in hospitals and €0.50 (1.61) per day in nursing homes. The main cost driver was the cost of labour, responsible for 79-85% of the cost of prevention. The mean (SD) cost of local treatment per patient per day varied between €2.34 (1.14) and €77.36 (35.95) in hospitals, and between €2.42 (1.15) and €16.18 (4.93) in nursing homes., Conclusions: Related to methodological differences between studies, the cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders was found to be low compared to other international studies. Recommendations specific to pressure ulcer prevention are needed as part of methodological guidelines to conduct cost-of-illness studies., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objectives: Cancer treatment can impair fertility. The aim of this review was to investigate (1) fertility information needs, receipt and provision, (2) fertility information preferences, and (3) factors associated with receiving/providing fertility information. Cancer patients' and professional caregivers' perspectives were considered., Design: Mixed-methods systematic review., Data Sources: Six electronic databases (PubMed, Web of Science, CINAHL, CRD, Embase) were systematically screened to retrieve articles published between January 2001 and March 2012. Reference lists and conference abstracts were checked for additional publications., Review Methods: The principles outlined in the Cochrane Handbook for Systematic Reviews of Intervention were applied. Publications were included if they explored fertility-related information/communication in cancer patients/survivors of reproductive age or professional caregivers. The Critical Appraisal Skills Programme for Qualitative Studies and the Quality Assessment Tool for Quantitative Studies were used to assess the methodological quality. A standardised form based on the Cochrane guidelines for systematic reviews was used to extract the data. Two independent reviewers performed all methodological steps., Results: Of the 1872 papers found, 27 were included in this review. The majority (66-100%) of the cancer patients wanted information about the impact of cancer therapy on fertility. The need and importance were higher in younger and childless patients, and in patients having childbearing plans. The number of patients receiving this information ranged from 0% to 85%. Several factors were associated with the lack of information receipt, including female gender and age 35 years or older. Patients preferred information via an individual consultation. In the diagnostic phase patients needed information about the impact of the treatment on fertility and preservation options. At the end or after the treatment, information needs shifted towards long term effects. Professional caregivers experienced several barriers in providing fertility information, including caregiver-, patient- and institutional-related factors. Nurses in particular, perceived difficulty in providing fertility-related information due to additional barriers associated with limited responsibility and opportunity in fertility information provision., Conclusion: Professional caregivers experienced multiple barriers that hinder information provision. Further exploration of the role of Advanced Nurse Practitioners/Midwifes and the development of an evidence based intervention to overcome caregiver-related barriers are recommended to improve information provision., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Frail older people admitted to nursing homes are at risk of a range of adverse outcomes, including pressure ulcers. Clinical decision support systems are believed to have the potential to improve care and to change the behaviour of healthcare professionals., Objectives: To determine whether a multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention improves adherence to recommendations for pressure ulcer prevention in nursing homes., Design: Two-armed randomized controlled trial in a nursing home setting in Belgium. The trial consisted of a 16-week implementation intervention between February and June 2010, including one baseline, four intermediate, and one post-testing measurement. Primary outcome was the adherence to guideline-based care recommendations (in terms of allocating adequate pressure ulcer prevention in residents at risk). Secondary outcomes were the change in resident outcomes (pressure ulcer prevalence) and intermediate outcomes (knowledge and attitudes of healthcare professionals)., Setting: Random sample of 11 wards (6 experimental; 5 control) in a convenience sample of 4 nursing homes in Belgium., Participants: In total, 464 nursing home residents and 118 healthcare professionals participated., Methods: The experimental arm was involved in a multi-faceted tailored implementation intervention of a clinical decision support system, including interactive education, reminders, monitoring, feedback and leadership. The control arm received a hard-copy of the pressure ulcer prevention protocol, supported by standardized 30 min group lecture., Results: Patients in the intervention arm were significantly more likely to receive fully adequate pressure ulcer prevention when seated in a chair (F=16.4, P=0.003). No significant improvement was observed on pressure ulcer prevalence and knowledge of the professionals. While baseline attitude scores were comparable between both groups [exp. 74.3% vs. contr. 74.5% (P=0.92)], the mean score after the intervention was 83.5% in the experimental group vs. 72.1% in the control group (F=15.12, P<0.001)., Conclusion: The intervention was only partially successful to improve the primary outcome. Attitudes improved significantly while the knowledge of the healthcare workers remained unsatisfactorily low. Further research should focus on the underlying reasons for these findings., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: Malnutrition is a common problem in the elderly. It is not clear if oral health is associated to malnutrition in this population. The aim of this systematic review is to determine whether an association exists between oral health and malnutrition in the elderly in a long-term care facility., Design: Systematic review., Data Source: Medline, Cochrane and Cinahl were systematically searched for to identify articles published between January 1985 and May 2011. Reference lists were checked for additional publications., Review Methods: Publications were included if they explored the association between oral health status and malnutrition. As no consensus about terminology was found, a sensitive filter was developed. The methodological quality of the studies was assessed. Two independent reviewers performed all methodological steps., Results: Sixteen studies met the criteria for inclusion. Eleven studies used a multivariate approach; nine of these found an association between oral health status and malnutrition. Four studies found a relationship between masticatory problems and malnutrition. Five studies found an association between malnutrition and dental condition, number of oral problems, tongue alteration, problems with saliva flow, and candidiasis. Overall, the methodological quality of the studies was medium., Conclusions: Tentative evidence indicates an independent association between oral health status and malnutrition in the elderly residing in a long-term care facility. Caution is needed for the interpretation of these results because of the absence of a gold standard to define and assess malnutrition and oral health status and the presence of methodological limitations throughout the studies., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: The duration and the amount of pressure and shear must be reduced in order to minimize the risk of pressure ulcer development. Alternating low pressure air mattresses with multi-stage inflation and deflation cycle of the air cells have been developed to relieve pressure by sequentially inflating and deflating the air cells. Evidence about the effectiveness of this type of mattress in clinical practice is lacking., Aim: This study aimed to compare the effectiveness of an alternating low pressure air mattress that has a standard single-stage inflation and deflation cycle of the air cells with an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells., Methods and Materials: A randomised controlled trial was performed in a convenience sample of 25 wards in five hospitals in Belgium. In total, 610 patients were included and randomly assigned to the experimental group (n=298) or the control group (n=312). In the experimental group, patients were allocated to an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells. In the control group, patients were allocated to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. The outcome was defined as cumulative pressure ulcer incidence (Grade II-IV). An intention-to-treat analysis was performed., Results: There was no significant difference in cumulative pressure ulcer incidence (Grade II-IV) between both groups (Exp.=5.7%, Contr.=5.8%, p=0.97). When patients developed a pressure ulcer, the median time was 5.0 days in the experimental group (IQR=3.0-8.5) and 8.0 days in the control group (IQR=3.0-8.5) (Mann-Whitney U-test=113, p=0.182). The probability to remain pressure ulcer free during the observation period in this trial did not differ significantly between the experimental group and the control group (log-rank χ(2)=0.013, df=1, p=0.911)., Conclusion: An alternating low pressure air mattress with multi-stage inflation and deflation of the air cells does not result in a significantly lower pressure ulcer incidence compared to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. Both alternating mattress types are equally effective to prevent pressure ulcer development., (© 2011 Elsevier Ltd. All rights reserved.)

Background: Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking., Aims and Objectives: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP)., Design: Prospective psychometric instrument validation study., Methods: A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008., Results: A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC=0.88 (95% CI=0.84-0.91, P<0.001)]. For the total instrument, the internal consistency (Cronbachs alpha) was 0.79., Conclusion: The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: Profound knowledge of pressure ulcers is important to enable good prevention. Validity and reliability of instruments assessing pressure ulcer knowledge are limited evaluated in previous research., Aims and Objectives: To develop a valid and reliable instrument to assess knowledge of pressure ulcer prevention., Design: Prospective psychometric instrument validation study., Methods: An extensive literature review was performed to develop an instrument to assess knowledge of pressure ulcer prevention. Face and content validity were evaluated in a double Delphi procedure by an expert panel of nine trustees of the European Pressure Ulcer Advisory Panel (EPUAP) who each have extensive experience in pressure ulcer care and research (PhD level). A convenience sample of 608 nurses and nursing students from Belgium and The Netherlands participated to evaluate validity of the multiple-choice test items (item difficulty, discriminating index, quality of the response alternatives), construct validity, internal consistency, and stability of the instrument. The data were collected between February and May 2008., Results: A 26-item instrument was developed, reflecting 6 themes expressing the most relevant aspects of pressure ulcer prevention. The content validity was excellent (CVI=0.78-1.00). Group scores of nurses with a (theoretically expected) high level of expertise were found to be statistically significantly higher than those of participants with (theoretically expected) less expertise (P<0.001). The item difficulty index of the questions ranged from 0.27 to 0.87, while values for item discrimination ranged from 0.29 to 0.65. The quality of the response alternatives was found to be good. The overall internal consistency reliability (Cronbach's alpha) was 0.77. The 1-week test-retest intraclass correlation coefficient (stability) was 0.88., Conclusion: The instrument demonstrated acceptable psychometric properties and can be applied in both research and practice for evaluating knowledge about pressure ulcer prevention., (Copyright 2009 Elsevier Ltd. All rights reserved.)