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Daniela Schoberer,1 Helena Leino-Kilpi,2 Helga E Breimaier,1 Ruud JG Halfens,3 Christa Lohrmann1 1Institute of Nursing Science, Medical University of Graz, Graz, Austria; 2Turku University Hospital, University of Turku, Turku, Finland; 3Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands Purpose of the study: Health education is essential to improve health care behavior and self-management. However, educating frail, older nursing home residents about their health is challenging. Focusing on empowerment may be the key to educating nursing home residents effectively. This paper examines educational interventions that can be used to empower nursing home residents.Methods: A systematic literature search was performed of the databases PubMed, CINAHL, CENTRAL, PsycINFO, and Embase, screening for clinical trials that dealt with resident education and outcomes in terms of their ability to empower residents. An additional, manual search of the reference lists and searches with SIGLE and Google Scholar were conducted to identify gray literature. Two authors independently appraised the quality of the studies found and assigned levels to the evidence reported. The results of the studies were grouped according to their main empowering outcomes and described narratively.Results: Out of 427 identified articles, ten intervention studies that addressed the research question were identified. The main educational interventions used were group education sessions, motivational and encouragement strategies, goal setting with residents, and the development of plans to meet defined goals. Significant effects on self-efficacy and self-care behavior were reported as a result of the interventions, which included group education and individual counseling based on resident needs and preferences. In addition, self-care behavior was observed to significantly increase in response to function-focused care and reasoning exercises. Perceptions and expectations were not improved by using educational interventions with older nursing home residents.Conclusion: Individually tailored, interactive, continuously applied, and structured educational strategies, including motivational and encouraging techniques, are promising interventions that can help nursing home residents become more empowered. Empowering strategies used by nurses can support residents in their growth and facilitate their self-determination. Further research on the empowerment of residents using empowerment scales is needed. Keywords: health education, older people, empowerment, self-efficacy, self-care activities, self-determination

Friederike JS Thilo,1,2 Selina Bilger,1 Ruud JG Halfens,2 Jos MGA Schols,2,3 Sabine Hahn1 1Applied Research and Development in Nursing, Health Division, Bern University of Applied Sciences, Bern, Switzerland; 2Department of Health Services Research, 3Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, the Netherlands Purpose: To explore the needs and preferences of community-dwelling older people, by involving them in the device design and mock-up development stage of a fall detection device, consisting of a body-worn sensor linked to a smartphone application. Patients and methods: A total of 22 community-dwelling persons 75 years of age and older were involved in the development of a fall detection device. Three semistructured focus group interviews were conducted. The interview data were analyzed using qualitative descriptive analysis with deductive coding. Results: The mock-up of a waterproof, body-worn, automatic and manual alerting device, which served both as a day-time wearable sensor and a night-time wearable sensor, was welcomed. Changes should be considered regarding shape, color and size along with alternate ways of integrating the sensor with items already in use in daily life, such as jewelry and personal watches. The reliability of the sensor is key for the participants. Issues important to the alerting process were discussed, for instance, who should be contacted and why. Several participants were concerned with the mandatory use of the smartphone and assumed that it would be difficult to use. They criticized the limited distance between the sensor and the smartphone for reliable fall detection, as it might restrict activity and negatively influence their degree of independence in daily life. Conclusion: This study supports that involving end users in the design and mock-up development stage is welcomed by older people and allows their needs and preferences concerning the fall detection device to be explored. Based on these findings, the development of a “need-driven” prototype is possible. As participants are doubtful regarding smartphone usage, careful training and support of community-dwelling older people during real field testing will be crucial. Keywords: focus group interview, coding, wearable device, sensor, mock-up, smartphone

Background: Comparing inpatient fall rates can serve as a benchmark for quality improvement. To improve the comparability of performance between hospitals, adjustments for patient-related fall risk factors that are not modifiable by care are recommended. Thereafter, the remaining variability in risk-adjusted fall rates can be attributed to differences in quality of care provided by a hospital. Research on risk-adjusted fall rates and their impact on hospital comparisons is currently sparse. Therefore, the aims of this study were to develop an inpatient fall risk adjustment model based on patient-related fall risk factors, and to analyse the impact of applying this model on comparisons of inpatient fall rates in acute care hospitals in Switzerland., Methods: Data on inpatient falls in Swiss acute care hospitals were collected on one day in 2017, 2018 and 2019, as part of an annual multicentre cross-sectional survey. After excluding maternity and outpatient wards, all inpatients older than 18 years were included. Two-level logistic regression models were used to construct unadjusted and risk-adjusted caterpillar plots to compare inter-hospital variability in inpatient fall rates., Results: One hundred thirty eight hospitals and 35,998 patients were included in the analysis. Risk adjustment showed that the following factors were associated with a higher risk of falling: increasing care dependency (to a great extent care dependent, odds ratio 3.43, 95% confidence interval 2.78-4.23), a fall in the last 12 months (OR 2.14, CI 1.89-2.42), the intake of sedative and or psychotropic medications (OR 1.74, CI 1.54-1.98), mental and behavioural disorders (OR 1.55, CI 1.36-1.77) and higher age (OR 1.01, CI 1.01-1.02). With odds ratios between 1.26 and 0.67, eight further ICD-10 diagnosis groups were included. Female sex (OR 0.78, CI 0.70-0.88) and postoperative patients (OR 0.83, CI 0.73-0.95) were associated with a lower risk of falling. Unadjusted caterpillar plots identified 20 low- and 3 high-performing hospitals. After risk adjustment, 2 low-performing hospitals remained., Conclusions: Risk adjustment of inpatient fall rates could reduce misclassification of hospital performance and enables a fairer basis for decision-making and quality improvement measures. Patient-related fall risk factors such as care dependency, history of falls and cognitive impairment should be routinely assessed., (© 2022. The Author(s).)

The objectives of this study were to examine the knowledge and attitude of Indonesian community nurses regarding Pressure Injury (PI) prevention. A cross-sectional design was used and included the community nurses permanently working in the Public Health Center (Puskemas) in Bandung, West Java Indonesia. Knowledge was measured using the Pressure Ulcer Knowledge Assessment Tool (PUKAT 2.0). Attitudes were measured using a predesigned instrument which included 11 statements on a five point Likert scale. All data were collected using paper-based questionnaires. The response rate was 100%. Respondents (n = 235) consisted of 80 community nursing program coordinators (34.0%) and 155 community nurses (66.0%). Regarding knowledge, the percentage of correct answers in the total group of community nurses on the PUKAT 2.0 was 30.7%. The theme "Prevention" had the lowest percentage of correct answers (20.8%). Community nurses who had additional PI or wound care training had a higher knowledge score compared with community nurses who did not have additional PI training (33.7% vs 30.3%; Z = -1.995; P = 0.046). The median attitude score was 44 (maximum score 55; range 28-55), demonstrating a positive attitude among participants towards PI prevention. Further, the higher the education status of participants, the more positive the attitudes (H = 11.773; P = 0.003). This study shows that community nurses need to improve their basic knowledge of PI prevention. Furthermore, research should be performed to explore what community nurses need to strengthen their role in PI prevention., (© 2020 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Background: The renal diet is complex and requires alterations of the diet and careful monitoring of various nutrients. Elevated serum phosphorus is common among patients undergoing hemodialysis, and it is associated with many complications. Smartphone technology could be used to support both dietitians and patients by providing a source of accessible and reliable information., Objective: The aim of this pilot is to assess the potential efficacy of an intervention using the educational and self-monitoring mobile app KELA.AE on the phosphorous management in hemodialysis patients. Results will be used to improve both the app and a planned, rigorous large-scale trial intended to assess app efficacy., Methods: This is a prospective pilot study performed at the hemodialysis unit of Al Qassimi Hospital (Emirate of Sharjah, United Arab Emirates). All patients were assessed for eligibility and, based on inclusion criteria, considered for enrollment. Participants met with a dietitian once a week and used the mobile app regularly for 2 weeks. Outcomes (knowledge, self-reported nonadherence, dietary intake, anthropometry, and biochemical data) were measured. This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT (Consolidated Standards of Reporting Trials) 2010 checklist for reporting pilot or feasibility trials., Results: Of 26 subjects, 23 successfully completed the pilot. Patient dietary knowledge about phosphorous management improved from 51.4% (SD 13.9) to 68.1% (SD 13.3) after intervention with a large effect size (d=1.22, 95% CI 0.59 to 1.85). Dietary protein intake increased from a mean of 0.9 g/kg (SD 0.3) per day to a mean of 1.3 g/kg (SD 0.5) per day with a large effect size (d=1.07, 95% CI 0.45 to 1.69). Phosphorus to protein ratio dropped from a mean of 18.4 mg/g protein to 13.5 mg/g protein with a large effect size (d=0.83, 95% CI 0.22 to 1.43). There was no evidence of change in phosphorous intake, self-reported nonadherence, and serum phosphorus., Conclusions: The findings of this prospective pilot reveal the potential efficacy of a smartphone app as a supportive nutrition education tool for phosphorus management in patients undergoing hemodialysis. This pilot study showed that the KELA.AE app has the potential to improve knowledge and dietary choices. A rigorous randomized controlled trial should be performed to evaluate the efficacy, assessing app use of a long-term intervention., (©Cosette Fakih El Khoury, Rik Crutzen, Jos MGA Schols, Ruud JG Halfens, Mirey Karavetian. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.06.2021.)

The objectives of this study were to investigate the prevalence and the characteristics of pressure ulcers (PU) in community-dwelling older adults in Indonesia, including specific characteristics of the PU patients and their use of formal and informal care. A cross-sectional design was used for the study, with 325 participants aged 60 years or older, randomly chosen from the general community. The overall PU prevalence and the PU prevalence excluding category 1 were 10.8% (95% confidence interval [CI], 5.8-15.8) and 5.2% (95% CI 0.2-10.2), respectively. Category 1 PUs were mostly (34.3%) located on knees and toes, while category 2 and higher PUs were mostly (70.4%) located on the shoulder, sacrum, and hip. The main factors that contributed strongly to PUs among older adults in the community were the degree of physical activity, problems with sensory perception, and having a history of stroke. None of the participants with a PU received wound care or information about PUs from formal caregivers and only 11.4% received wound care from family caregivers. This study shows that pressure ulcers in community-dwelling older adults in Indonesia are a relevant and largely unaddressed problem. Developing an intervention program to manage the PU problem in the community is recommended., (© 2019 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

The objective of this article was to study characteristics of pressure ulcer patients and their ulcers, pressure ulcer preventive and treatment measures in four Indonesian general hospitals. A multicentre cross-sectional design was applied to assess pressure ulcers and pressure ulcer care in adult patients in medical, surgical, specialised and intensive care units. Ninety-one of the 1132 patients had a total of 142 ulcers. Half (44·0%) already had pressure ulcers before admission. The overall prevalence of category I-IV pressure ulcers was 8·0% (95% CI 6·4-9·6), and the overall nosocomial pressure ulcer prevalence was 4·5% (95% CI 3·3-5·7). Most pressure ulcer patients had friction and shear problems, were bedfast, had diabetes and had more bedridden days. Most ulcers (42·3%) were category III and IV. One third of the patients had both pressure ulcers and moisture lesions (36·3%) and suffered from pain (45·1%). The most frequently used prevention measures were repositioning (61·5%), skin moisturising (47·3%), patient education (36·3%) and massage (35·2%). Most pressure ulcer dressings involved saline-impregnated or antimicrobial gauzes. This study shows the complexities of pressure ulcers in Indonesian general hospitals and reveals that the quality of pressure ulcer care (prevention and treatment) could be improved by implementing the recent evidence-based international guideline., (© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Recent evidence suggests that an increase in baccalaureate-educated registered nurses (BRNs) leads to better quality of care in hospitals. For geriatric long-term care facilities such as nursing homes, this relationship is less clear. Most studies assessing the relationship between nurse staffing and quality of care in long-term care facilities are US-based, and only a few have focused on the unique contribution of registered nurses. In this study, we focus on BRNs, as they are expected to serve as role models and change agents, while little is known about their unique contribution to quality of care in long-term care facilities., Methods: We conducted a cross-sectional study among 282 wards and 6,145 residents from 95 Dutch long-term care facilities. The relationship between the presence of BRNs in wards and quality of care was assessed, controlling for background characteristics, i.e. ward size, and residents' age, gender, length of stay, comorbidities, and care dependency status. Multilevel logistic regression analyses, using a generalized estimating equation approach, were performed., Results: 57% of the wards employed BRNs. In these wards, the BRNs delivered on average 4.8 min of care per resident per day. Among residents living in somatic wards that employed BRNs, the probability of experiencing a fall (odds ratio 1.44; 95% CI 1.06-1.96) and receiving antipsychotic drugs (odds ratio 2.15; 95% CI 1.66-2.78) was higher, whereas the probability of having an indwelling urinary catheter was lower (odds ratio 0.70; 95% CI 0.53-0.91). Among residents living in psychogeriatric wards that employed BRNs, the probability of experiencing a medication incident was lower (odds ratio 0.68; 95% CI 0.49-0.95). For residents from both ward types, the probability of suffering from nosocomial pressure ulcers did not significantly differ for residents in wards employing BRNs., Conclusions: In wards that employed BRNs, their mean amount of time spent per resident was low, while quality of care on most wards was acceptable. No consistent evidence was found for a relationship between the presence of BRNs in wards and quality of care outcomes, controlling for background characteristics. Future studies should consider the mediating and moderating role of staffing-related work processes and ward environment characteristics on quality of care.

Background: the prevalence of sarcopenia increases with age. Physical activity might slow the rate of muscle loss and therewith the incidence of sarcopenia., Objective: to examine the association of physical activity with incident sarcopenia over a 5-year period., Design: data from the population-based Age, Gene/Environment, Susceptibility-Reykjavik Study were used., Setting: people residing in the Reykjavik area at the start of the study., Subjects: the study included people aged 66-93 years (n = 2309)., Methods: the amount of moderate-vigorous physical activity (MVPA) was assessed by a self-reported questionnaire. Sarcopenia was identified using the European Working Group on Sarcopenia in Older People algorithm, including muscle mass (computed tomography imaging), grip strength (computerised dynamometer) and gait speed (6 m)., Results: mean age of the participants was 74.9 ± 4.7 years. The prevalence of sarcopenia was 7.3% at baseline and 16.8% at follow-up. The incidence proportion of sarcopenia over 5 years was 14.8% in the least-active individuals and 9.0% in the most-active individuals. Compared with the least-active participants, those reporting a moderate-high amount of MVPA had a significantly lower likelihood of incident sarcopenia (OR = 0.64, 95% CI 0.45-0.91). Participants with a high amount of MVPA had higher baseline levels of muscle mass, strength and walking speed, but baseline MVPA was not associated with the rate of muscle loss., Conclusion: a higher amount of MVPA seems to contribute to counteracting the development of sarcopenia. To delay the onset of sarcopenia and its potential adverse outcomes, attention should be paid to increasing physical activity levels in older adults., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The involvement of users is recommended in the development of health related technologies, in order to address their needs and preferences and to improve the daily usage of these technologies. The objective of this literature review was to identify the nature and extent of research involving older people in the development of fall detection systems., Methods: A scoping review according to the framework of Arksey and O'Malley was carried out. A key term search was employed in eight relevant databases. Included articles were summarized using a predetermined charting form and subsequently thematically analysed., Results: A total of 53 articles was included. In 49 of the 53 articles, older people were involved in the design and/or testing stages, and in 4 of 53 articles, they were involved in the conceptual or market deployment stages. In 38 of the 53 articles, the main focus of the involvement of older people was technical aspects. In 15 of the 53 articles, the perspectives of the elderly related to the fall detection system under development were determined using focus groups, single interviews or questionnaires., Conclusions: Until presently, involvement of older people in the development of fall detection systems has focused mainly on technical aspects. Little attention has been given to the specific needs and views of older people in the context of fall detection system development and usage.

The aim of this study was to measure the prevalence of (infected) chronic wounds in Dutch nursing homes and to explore which signs and symptoms are used to diagnose infected chronic wounds. Moreover, it was to determine which structural quality indicators related to chronic wound care at ward and institutional levels were fulfilled. In April 2012, as part of the annual National Prevalence Measurement of Care Problems of Maastricht University [Landelijke Prevalentiemeting Zorgproblemen (LPZ)], a multi-center cross-sectional point-prevalence measurement was carried out together with an assessment of relevant care quality indicators. The prevalence was 4·2%; 16 of 72 (22%) chronic wounds were considered to be infected. Increase of exudate (81·3%; n = 13), erythema (68·8%; n = 11), pain (56·3%; n = 9) and wound recalcitrance (56·3%; n = 9) were considered to be diagnostic signs and symptoms of a chronic wound infection. Although at institutional level most quality indicators were fulfilled, at ward level this was not the case. Despite the relatively low number of residents, we consider our population as representative for the nursing home population. It may be an advantage to appoint specific ward nurses and to provide them specifically with knowledge and skills concerning chronic wounds., (© 2013 The Authors. International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Implementing clinical practice guidelines (CPGs) in healthcare settings is a complex intervention involving both independent and interdependent components. Although the Consolidated Framework for Implementation Research (CFIR) has never been evaluated in a practical context, it appeared to be a suitable theoretical framework to guide an implementation process. The aim of this study was to evaluate the comprehensiveness, applicability and usefulness of the CFIR in the implementation of a fall-prevention CPG in nursing practice to improve patient care in an Austrian university teaching hospital setting., Methods: The evaluation of the CFIR was based on (1) team-meeting minutes, (2) the main investigator's research diary, containing a record of a before-and-after, mixed-methods study design embedded in a participatory action research (PAR) approach for guideline implementation, and (3) an analysis of qualitative and quantitative data collected from graduate and assistant nurses in two Austrian university teaching hospital departments. The CFIR was used to organise data per and across time point(s) and assess their influence on the implementation process, resulting in implementation and service outcomes., Results: Overall, the CFIR could be demonstrated to be a comprehensive framework for the implementation of a guideline into a hospital-based nursing practice. However, the CFIR did not account for some crucial factors during the planning phase of an implementation process, such as consideration of stakeholder aims and wishes/needs when implementing an innovation, pre-established measures related to the intended innovation and pre-established strategies for implementing an innovation. For the CFIR constructs reflecting & evaluating and engaging, a more specific definition is recommended. The framework and its supplements could easily be used by researchers, and their scope was appropriate for the complexity of a prospective CPG-implementation project. The CFIR facilitated qualitative data analysis and provided a structure that allowed project results to be organised and viewed in a broader context to explain the main findings., Conclusions: The CFIR was a valuable and helpful framework for (1) the assessment of the baseline, process and final state of the implementation process and influential factors, (2) the content analysis of qualitative data collected throughout the implementation process, and (3) explaining the main findings.

Background: The international literature shows that there are considerable deficits in nutritional care provision in nursing homes. Limited knowledge and negative attitudes can contribute to these deficits but international studies on knowledge and attitudes among nursing staff are rare., Objective: The study aimed to assess the knowledge and attitudes of registered nurses and nurse aides towards malnutrition care in nursing homes., Design: This study followed a multicentre, cross sectional design., Setting and Participants: The study was performed in 66 Austrian nursing homes with 1152 participants., Measurements: The validated Knowledge of Malnutrition-Geriatric (KoM-G) questionnaire and the Staff Attitudes to Nutritional Nursing Care Geriatric (SANN-G) scale were used for data collection., Results: On average, 60.6% of the respondents answered the questions correctly, whereas registered nurses knew significantly more (65.6%) than nurse aides (57.3%). The question that was answered correctly by most dealt with the factors that positively affect oral nutritional intake (87.2%) while the question which was incorrectly answered by most was on the professions involved in malnutrition treatment (26.1%). 39.2% of respondents had positive attitudes towards nutritional care. Registered nurses displayed more positive attitudes (48.1%) than nurse aides (33.6%). The most positive attitudes were shown in the 'Intervention' subscale while the least positive attitudes were indicated in the 'Norms' subscale. A medium positive correlation between knowledge and attitudes was found (r=.423, p<0.000)., Conclusion: This study identified specific knowledge deficits and areas of negative attitudes in registered nurses and nurse aides, which will enable tailored training programmes to be developed.

Background: Research- and/or evidence-based knowledge are not routinely adopted in healthcare and nursing practice. It is also unclear which implementation strategies are effective in nursing practice and what expenditures of time and money are required for the successful implementation of clinical practice guidelines (CPGs). The aim in this study was to assess the effectiveness and required time investment of multifaceted and tailored strategies for implementing an evidence-based fall-prevention guideline (Falls CPG) into nursing practice in an acute care hospital setting., Methods: A before-and-after, mixed-method design was used within a participatory action research approach (PAR). The study was carried out in two departments of an Austrian university teaching hospital and included all graduate and assistant nurses. Data were collected through a questionnaire, group discussions and semi-structured interviews. Qualitative data were content-analysed using a template based on the Consolidated Framework for Implementation Research (CFIR), which also served as a theoretical framework for the study. Quantitative data were descriptively analysed using appropriate tests for independent groups., Results: By applying multifaceted and tailored implementation strategies, the graduate and assistant nurses' knowledge on fall prevention, how to access the Falls CPG and the guideline itself increased significantly between baseline and final assessment (p ≤ .001). Qualitative data also revealed an increase in participant awareness of fall prevention. A baseline positive attitude towards guidelines improved significantly towards the end of the project (p = .001). Required fall prevention equipment like baby monitors or one-way glide sheets were available for use and any required environmental adaptations, e.g. a handrail in the corridor, were made. Hospital nursing personnel (approximately 150) invested a total of 1192 hours of working time over the course of the project., Conclusions: Multifaceted strategies tailored to the specific setting within a PAR approach and guided by the CFIR enabled the effective implementation of a CPG into acute care nursing practice. Nursing managers now have sound knowledge of the time resources required for CPG implementation.

Aim: To determine whether bacteriological analysis of a wound swab is supportive in the clinical assessment of infection of a chronic wound., Methods: Patients attending an outpatient wound clinic who had endured a chronic wound for more than 3 weeks were clinically assessed for infection. In addition, standardized wound swabs were taken according to the Levine technique and the microbiological findings of the swabs compared with the clinical assessment of the wounds., Results: There was no significant relationship between the clinical assessments of the chronic wounds and the qualitative or quantitative bacteriological results of the swabs., Conclusion: Microbiological analysis of wound swabs taken from chronic wounds to support clinical assessment of the wounds is waste of time and money. It may be preferable to assess chronic wounds clinically, however, validation studies of these signs and symptoms are needed.

Objective: Pressure ulcers (PUs) still form an important and distressing problem in Dutch nursing homes. Pressure ulcer prevention protocols are generally based on current guidelines. The authors developed an alternative 3-step protocol to help prevent pressure ulcers. The effects of this new 3-step protocol on the prevalence of pressure ulcers in patients at risk of developing PUs in the Avoord nursing homes in Etten-Leur/Zundert (Netherlands) were calculated. In addition, the protocol's general cost effects were explored., Method: Data on the prevalence of PUs and the use of preventive measures were derived from the annual independent International Prevalence Measurement of Care Problems of Maastricht University (Landelijke prevalentiemeting Zorgproblemen [LPZ]). This annual measurement was implemented in 1998 and measures care problems such as the prevalence of PUs and related preventive measures. Data on patients at risk of developing PUs at the Avoord nursing homes in Etten- Leur/Zundert (Netherlands) were analyzed and compared with national data between 2002 and 2011., Results: The introduction of the 3-step protocol resulted in a significant reduction of the nosocomial prevalence of category 2-4 PUs. The prevalence was reduced from 8.7% to 0.5% during the first year and remained stable at about 2% throughout the rest of the study period. The prevalence at the national level also decreased during this period, but not as much, and was still significantly higher in 2011. The use of alternated systems decreased to almost 1%. Use of static air mattresses showed an almost linear rise in the Avoord nursing homes from the start of the implementation of the protocol, while the trend for both types of mattresses remained stable on a national level. Introducing the static air mattress instead of the more expensive alternating mattresses helped to reduce the mean daily costs of mattresses at the Avoord nursing homes by more than 70% compared to national figures. The workload of the nursing staff decreased as well due to the reduction of repositioning., Conclusion: The introduction of the 3-step protocol showed to be effective. The prevalence of PUs and the mean daily costs were reduced to, and have been sustained at, a significantly lower level. .

Objectives: To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship., Design: This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement., Setting: Care homes., Participants: 75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time., Measurements: A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency., Results: The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p <0.001). The prevalence of malnutrition in the demented group showed no significant reduction over the years. GEE analysis showed that malnutrition and dementia are related and that care dependency and age are important influencing factors in this relation., Conclusion: The results show that compared to the non-demented residents, the prevalence of malnutrition does not decline in demented care home residents over the years. Moreover, the findings of this study stress that malnutrition and dementia are related, while care dependency and age are confounding factors in this relationship.

Since 1998, the National Prevalence Measurement of Care Problems (LPZ) has annually measured the prevalence, prevention and treatment of a number of care problems in many health care organisations. These problems include pressure ulcers, incontinence, intertrigo, malnutrition, falls and the use of restraints. This article describes trends in the prevalence of these problems during the past few years and the preventive and treatment measures taken for clients residing in psychogeriatric and/or somatic wards of nursing homes. The results show that the prevalence of these care problems has declined in general. Nevertheless, the individual interventions (preventive measures and treatment) have not really changed in recent years. It is concluded that the extra attention paid to these care problems might already have had a positive effect on their prevalence. This must be further investigated. In any case, extra follow-up steps need to be taken to bring about a further decline. The article describes which steps the project group has already taken in this respect.

Translating guidelines into nursing practice remains a considerable challenge. Until now, little attention has been paid to which interventions are used in practice to implement guidelines on changing clinical nursing practice. This cross-sectional study determined the current ranges and rates of implementation-related interventions in Austria, Germany, and The Netherlands and explored possible differences between these countries. An online questionnaire based on the conceptual framework of implementation interventions (professional, organizational, financial, and regulatory) from the Cochrane Effective Practice and Organization of Care (EPOC) data collection checklist was used to gather data from nursing homes and hospitals. Provision of written materials is the most frequently used professional implementation intervention (85%), whereas changes in the patient record system rank foremost among organisational interventions (78%). Financial incentives for nurses are rarely used. More interventions were used in Austria and Germany than in The Netherlands (20.3/20.2/17.3). Professional interventions are used more frequently in Germany and financial interventions more frequently in The Netherlands. Implementation efforts focus mainly on professional and organisational interventions. Nurse managers and other responsible personnel should direct their focus to a broader array of implementation interventions using the four different categories of EPOC's conceptual framework.

Background: Persons with dementia are two to three times more likely to fall compared to persons without dementia. In long-term care settings, the dementia prevalence is highest. Therefore, older long-term care residents with dementia can be considered a high-risk group for falls. Nevertheless, no systematic evaluation of fall determinants in this population was found. The purpose of this study was to identify fall determinants among older long-term care residents with dementia or cognitively impaired persons in long-term care, by conducting a systematic literature review., Methods: We searched English, French, Dutch, and German articles listed in: CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, and Web of Science. Additionally, references of included articles were screened. Studies were included if determinants or circumstances of falls in older persons with dementia living in long-term care were assessed., Results: Eight studies met the inclusion criteria. Three studies were excluded from detailed analysis because of insufficient quality. Use of psychotropic drugs, a "fair or poor" general health, gait impairments, and age were associated with an increased fall risk. Also trunk restraints were associated with an increased number of falls while full bedrails and wandering behavior were protective against falls., Conclusions: Fall risk factors known from other populations, e.g. use of psychotropic drugs, physical restraints, and health conditions, are found in long-term care residents with dementia as well. Due to the limited evidence available, future studies with adequate sample sizes and prospective designs are required to determine specific fall risk factors and verify existing results in this population.

Unlabelled: To investigate the role of malnutrition, impaired mobility and care dependency in predicting fallers in older Dutch home care clients., Design: This study is a secondary analysis of data of the annual independent national prevalence measurement of care problems of Maastricht University. The design involves a cross-sectional, multicentre point prevalence measurement (malnutrition, mobility), and a 30 days incidence measurement (falls)., Setting: Dutch home care organisations., Participants: 2971 clients (older than 65 years) from 22 home care organizations participated., Measurements: A standardized questionnaire was used to register amongst others data of weight, height, number and type of diseases (like for example neurologic diseases, dementia, CVA, COPD, eye/ear disorders, musculoskeletal disorders), nutritional intake, use of psychopharmaca, undesired weight loss, fall history, mobility, and care dependency., Results: The study was able to show that fallers are more often malnourished than non-fallers in the univariate analysis. Most importantly the study indicated by multivariate analysis that fallers could be predicted by the risk factors immobility ((OR 2.516 95% CI 1.144-5.532), high care dependency (OR 1.684 95% CI 1.121-2.532) and malnutrition (OR 1.978 95% CI 1.340-2.920)., Conclusion: The findings of this study stress that malnutrition, impaired mobility and care dependency are potential reversible factors related to falls. Therefore early identification and management of nutritional status, impaired mobility and care dependency are important aspects for a possible fall prevention strategy.

Background: Pressure ulcers are a common and serious health care problem in all health care settings. Results from annual national pressure ulcer prevalence surveys in the Netherlands and Germany reveal large differences in prevalence rates between both countries over the past ten years, especially in nursing homes. When examining differences in prevalence and incidence rates, it is important to take into account all factors associated with the development of pressure ulcers. Numerous studies have identified patient related factors, as well as nursing related interventions as risk factors for the development of pressure ulcers. Next to these more process oriented factors, also structural factors such as staffing levels and staff quality play a role in the development of pressure ulcers. This study has been designed to investigate the incidence of pressure ulcers in nursing homes in the Netherlands and Germany and to identify patient related factors, nursing related factors and structural factors associated with pressure ulcer development. The present article describes the protocol for this study., Methods/design: A prospective multicenter study is designed in which a cohort of newly admitted nursing home residents in 10 Dutch and 11 German nursing homes will be followed for a period of 12 weeks. Data will be collected by research assistants using questionnaires on four different levels: resident, staff, ward, and nursing home., Discussion: The results of the study will provide information on the incidence of pressure ulcers in Dutch and German nursing homes. Furthermore, information will be gathered on the influence of patient related factors, nursing related factors and structural factors on the incidence of pressure ulcers. The present article describes the study design and addresses the study's strengths and weaknesses.

Background: Nursing work environments (NWEs) in Canada and other Western countries have increasingly received attention following years of restructuring and reported high workloads, high absenteeism, and shortages of nursing staff. Despite numerous efforts to improve NWEs, little is known about the effectiveness of interventions to improve NWEs. The aim of this study was to review systematically the scientific literature on implemented interventions aimed at improving the NWE and their effectiveness., Methods: An online search of the databases CINAHL, Medline, Scopus, ABI, Academic Search Complete, HEALTHstar, ERIC, Psychinfo, and Embase, and a manual search of Emerald and Longwoods was conducted. (Quasi-) experimental studies with pre/post measures of interventions aimed at improving the NWE, study populations of nurses, and quantitative outcome measures of the nursing work environment were required for inclusion. Each study was assessed for methodological strength using a quality assessment and validity tool for intervention studies. A taxonomy of NWE characteristics was developed that would allow us to identify on which part of the NWE an intervention targeted for improvement, after which the effects of the interventions were examined., Results: Over 9,000 titles and abstracts were screened. Eleven controlled intervention studies met the inclusion criteria, of which eight used a quasi-experimental design and three an experimental design. In total, nine different interventions were reported in the included studies. The most effective interventions at improving the NWE were: primary nursing (two studies), the educational toolbox (one study), the individualized care and clinical supervision (one study), and the violence prevention intervention (one study)., Conclusions: Little is known about the effectiveness of interventions aimed at improving the NWE, and published studies on this topic show weaknesses in their design. To advance the field, we recommend that investigators use controlled studies with pre/post measures to evaluate interventions that are aimed at improving the NWE. Thereby, more evidence-based knowledge about the implementation of interventions will become available for healthcare leaders to use in rebuilding nursing work environments.

To our knowledge, no studies have analyzed the influence of annual audit and feedback on the prevalence rates of malnutrition. This study analyzes the trend of malnutrition prevalence rates between 2004 and 2007 and the effects of previous audits and feedback from the annual Dutch National Prevalence Measurement of Care Problems (LPZ) and the effect of the participation in Dutch national improvement programs. From 2004 to 2007, an annual multicenter study was performed in Dutch hospitals, nursing homes, and home care organizations using a standardized questionnaire involving measurements at institutional, ward, and patient levels. The data were analyzed by logistic multilevel analysis. Nutritional status was assessed by BMI, undesired weight loss, and nutritional intake. In total, 80 hospitals, 141 nursing homes, and 48 home care organizations participated. The prevalence of malnutrition tended to decrease in hospitals and home care over the years. In nursing homes, prevalence rates were stable. Furthermore, the more often hospitals and home care organizations participated in the annual LPZ audits, the lower the prevalence rate of malnutrition (P < 0.001). Participation in national improvement programs also resulted in lower prevalence rates (P = 0.027). In conclusion, malnutrition prevalence rates have decreased over the last 4 y in hospitals and home care in The Netherlands. Participation in the LPZ and involvement in national improvement programs positively influenced these malnutrition prevalence rates, possibly indicating that increasing awareness and actively working toward improvement could be important in lowering these rates.

The objective of this study was to provide data on malnutrition prevalence in hospitals, nursing homes and home-care organisations in The Netherlands in a nationally representative sample, and to assess the factors such as age, sex, time since admission, ward type and disease for identifying patients at high risk of malnutrition. A cross-sectional, multi-centre design with a standardised questionnaire was used to measure the prevalence of malnutrition. Nutritional status was assessed by BMI, undesired weight loss and nutritional intake. In this study, 12 883 patients were included. The prevalence of malnutrition was the highest in hospitals (23.8 %), followed by home-care organisations (21.7 %) and nursing homes (19.2 %). Logistic regression analysis revealed no association with age, time since admission and ward type. Being female was associated with malnutrition only in nursing homes. Blood diseases, gastrointestinal tract diseases, infection, chronic obstructive pulmonary disease, dementia and cancer were the factors associated with malnutrition in hospitals. Dementia was associated with malnutrition in nursing homes, while gastrointestinal tract diseases, diabetes mellitus and cancer were the associated factors in home care. This study shows that malnutrition is still a substantial problem in hospitals, nursing homes and home care in The Netherlands. Malnutrition is a problem for more than one in five patients. Despite growing attention to the problem, more continued alertness is required.

Principles: The aim of this study was to obtain an overview of stroke-specialised rehabilitation facilities in German-speaking Switzerland, as well as the numbers of stroke patients treated. It also focused on the mode of goal-setting and evaluation, and the use of instruments to assess the patient's state and progress., Method: Out of 28 stroke rehabilitation facilities, 21 participated in a structured telephone interview. Of these, 18 institutions provided full data., Results: The results show that the facilities (n = 18) vary considerably in numbers of patients treated per year (Ø 124, range 7-500) and length of stay (Ø 40 +/- 17.23). Goal-setting and evaluation, including the setting of short term and long term goals, is a common feature. They differ, however, in terms of patient involvement, processes and professions participating in goal-setting and evaluation. A variety of instruments are used for patient assessment at admission and during rehabilitation. Admission to rehabilitation does not rely on standardised patient health status assessment., Conclusions: Stroke rehabilitation in German-speaking Switzerland embraces a heterogeneous landscape with respect to use of instruments, goal-setting and evaluation process and patient involvement. To facilitate comparison, the same core instruments for assessment and evaluation should be selected and consistently applied. Also, the admission criterion "potential for rehabilitation" should be transformed into a universally and scientifically valid term. The effect of patient involvement in goal-setting on rehabilitation outcome has not yet been investigated. Thus no recommendations can be made for the moment.

Background: Pressure ulcers are a common, painful and costly condition. Results of a 1991 study into the knowledge among Dutch hospital nurses on the usefulness of measures to prevent pressure ulcers showed moderate knowledge. Results were confirmed by subsequent studies. In recent years, Dutch guidelines have been updated and the attention given to pressure ulcer care has been increased. This was expected to improve pressure ulcer care and to increase nurses' knowledge. The aims of the current study were to investigate (1) how much nurses employed in Dutch hospitals know about the usefulness of 28 preventive measures considered in the most recent national pressure ulcer guideline; (2) whether differences in knowledge exist between nurses working in hospitals that audit pressure ulcers and those employed in hospitals that do not; and (3) to study whether knowledge among Dutch hospital nurses regarding the usefulness of preventive measures had changed between 1991 and 2003., Methods: A cross-sectional study design among nurses employed in Dutch hospitals in 2003 was used to investigate their knowledge and differences in knowledge between nurses employed in different types of institution. A comparative design was used to assess whether knowledge differed between this population and that of Dutch hospital nurses in 1991. The nurses' knowledge was assessed by a written questionnaire. Data of 522 respondents meeting the inclusion criteria were analyzed and compared with the results of the 351 nurses included in the 1991 study., Results: Knowledge in 2003 was slightly better than that in 1991. The nurses were moderately aware of the usefulness of preventive measures. Nurses employed in organizations that monitored pressure ulcers did not display greater knowledge than those employed in organizations that did not do so., Conclusion: Knowledge among Dutch hospital nurses about the usefulness of measures to prevent pressure ulcers seems to be moderate. Being employed in an institution that monitors pressure ulcer care hardly affects the knowledge level. Knowledge about prevention has improved little since 1991.

Question: What are potential risk factors for urinary incontinence in nursing home residents older than 65 years at the time of admission and over time?, Method: Secondary analysis of data from the Minimum Data Set of the Resident Assessment Instrument in a cross-section as well as a longitudinal section. The sample contained data of 2722 residents from 42 different geriatric and nursing homes in north-west Switzerland., Results: The cross-sectional analysis showed the variable "moving in bed" as the most important personal variable for incontinence at admission. LONGITUDINAL ANALYSES: The most important risk factor was 'moving in bed' as it continued its action even at 12 months. In a further analysis (incontinence one year after admission with the risk factors at admission) the items "long-term memory, state season and walking in room" were important factors., Conclusion: The data suggest that mental and physical exercises could be a way to reduce urinary incontinence. However, physical exercises would be the most important, because "moving in bed" continued its action even at 12 months. Despite some limitations attributable to the data collection, this is the first study in Switzerland to examine risk factors for urinary incontinence among nursing home residents.

Objective: To examine whether participating in a pressure ulcer prevalence survey and receiving feedback results in an improvement in quality of care., Design: Cross-sectional studies from 1998 to 2002 were compared over time., Setting: Sixty-two acute care hospitals in the Netherlands., Study Participants: Patients hospitalized at the moment of the surveys., Interventions: Each hospital was given hospital-specific performance data and national aggregate data, and peer comparisons to improve the quality of care., Main Outcome Measures: The case-mix-adjusted prevalence of pressure ulcers of grade >or=2, the percentage of high-risk patients receiving adequate prevention, and the total number of enabling conditions present were compared between successive surveys using multi-level analysis, in order to estimate a linear trend model and trend differences for each hospital., Results: The case-mix-adjusted prevalence of pressure ulcers decreased over the 5-year period, while the percentage of patients receiving adequate prevention and the total number of enabling conditions present increased. The total number of enabling conditions had a significant effect on the decrease in case-mix-adjusted prevalence: more enabling conditions led to a lower case-mix-adjusted prevalence (chi(2) = 125; degrees of freedom = 1; P < 0.00). The percentage of patients receiving adequate prevention also had an effect on the change in case-mix-adjusted prevalence, with a higher percentage leading to a lower case-mix-adjusted prevalence. This effect, however, was not significant., Conclusions: Monitoring prevalence and giving feedback results in an improvement in quality of care in terms of pressure ulcer prevention. It is very important to continue conducting surveys to avoid attention moving away from this topic, which may in turn lead to a deterioration in the quality of pressure ulcer care. Further research to find the most effective feedback approach is needed.

Background: Acute care hospitals participating in the Dutch national pressure ulcer prevalence survey use the results of this survey to compare their outcomes and assess their quality of care regarding pressure ulcer prevention. The development of a model for case-mix adjustment is essential for the use of these prevalence rates as an outcome measure., Objective: The development of a valid model for case-mix adjustment to compare the prevalence rates in the acute care hospitals that participated in the 1998 Dutch pressure ulcer prevalence survey, for the purpose of performance comparisons among the hospitals., Design: Cross-sectional design., Subjects: Subjects were patients residing in the 43 acute care hospitals that participated in the national pressure ulcer prevalence survey on May 26, 1998., Measures: The study examined the validity of a model for case-mix adjustment of pressure ulcer prevalence rates and compared hospitals to evaluate the impact of adjusted prevalence rates on their performance., Results: A logistic model was developed for case-mix adjustment, using age, malnutrition, incontinence, activity, mobility, sensory perception, friction and shear, and ward specialty. This model was found to have content, construct, and internal validity. Case-mix adjustment influenced the hospitals' performance., Conclusion: The data of the national pressure ulcer prevalence survey can be used to develop a valid model for case-mix adjustment. Conclusions about the quality of care were influenced by the use of case-mix adjusted outcomes as a measure of this quality.

Background: The consequences of chronic obstructive pulmonary disease (COPD) on daily life, encapsulated by the term "health-related quality of life" (HRQL), are important in determining appropriate home care. There is a need to understand the relative contribution of respiratory impairment, physical disability, coping, age, and socioeconomic variables on HRQL., Methods: Patients with COPD were recruited on admission to a pulmonary rehabilitation centre. Respiratory impairment was assessed by lung function tests and physical disability was evaluated by a 12 minute walking test. HRQL was assessed by means of the St George's Respiratory Questionnaire (SGRQ) measuring "symptoms", "activity", and "impact". Because the SGRQ does not include a measure of "well being", this was taken from the medical psychological questionnaire for lung diseases. The COPD coping questionnaire and a questionnaire covering basic socioeconomic variables were also used., Results: One hundred and twenty six patients of mean (SD) age 65 (9) years and mean (SD) forced expiratory volume in one second (FEV1) 39 (9)% predicted were included. The scores on the SGRQ indicated severe impairment. Correlations were found between lung function parameters, 12 minute walking test, and the HRQL "activity" and "impact" components. Coping strategies were correlated with the "activity", "impact", and "well being" components. No correlations were found between age, socioeconomic variables, and HRQL. FEV1, 12 minute walking test, and the coping strategies "avoidance" and "emotional reaction" were the best predictors of HRQL., Conclusion: In patients with COPD methods of improving physical performance and teaching adequate coping strategies should be considered in order to improve HRQL.