Search

Aims and objectives. To investigate the effect of the implementation of a patient and family education programme for pressure ulcer prevention in an organisation for home care nursing on guideline adherence and on prevalence and severity of pressure ulcers and to examine the determining factors for the application of measures for pressure ulcer prevention. Background. Quality improvement programmes in pressure ulcer prevention are not always successful. Design. Implementation study using a pretest–post-test design. Data were collected in three probability samples. The first post-test data collection was held after six months, the second after 18 months. Method. Statistical analysis was used, comparing the pretest sample and the second post-test sample. Results. After 18 months, the proportion of subjects with adherent measures had increased from 10·4–13·9%, the proportion of subjects with non-adherent measures decreased from 45·7–36·0%, the proportion of subjects without pressure ulcer prevention increased from 43·9–50·1% ( p < 0·0001, Chi-square test). Sub-analysis revealed that a positive change in guideline adherence was observed principally in the group at risk. Better process-of-care indicators were associated by lower pressure ulcer prevalence and less severe skin lesions. The nurses’ judgement of a patient risk status was the most important factor for applying preventive measures. Furthermore, application of pressure ulcer prevention was determined by higher age (from the age category of 70–79 years), higher dependency for the activities of daily living, higher than baseline mobility score and the presence of a pressure ulcer. Conclusions. Guideline adherence in pressure ulcer prevention changed significantly after implementation of the education programme. There might have been inconsistencies in the nurses’ risk judgement. Relevance to clinical practice. Quality of pressure ulcer prevention improved, but several items for improvement remain. Adaptation of risk assessment procedures is needed. [ABSTRACT FROM AUTHOR]

Aims. The identification and description of the basic psychological process linked with the focus of family members' functioning during the acute phase of traumatic coma. Background. Earlier research learned that hope is a core category in coping with traumatic coma. Hope seems to be the drive to keep family members going and to enable them to fulfil their main task namely protecting. In two articles on the focus of family members functioning, this task is defined and the process linked with it is described. Design. A qualitative approach according to the grounded theory method with constant comparison. Method. Twenty four in-depth interviews with 22 family members of 16 patients with traumatic coma. Results. Family members describe the period after the confrontation with traumatic coma as a battle. During this battle, they feel the urge to protect their relative in coma, other family members and themselves. They go through three phases: protecting life, protecting from suffering, protecting what remains to rebuild live. In this article (Part One) we describe the initial battle and the phase of protecting life. Conclusions. All relatives go through the three phases. Family members who have already overcome previous set-backs get through the process slightly more quickly and experience less extreme emotions. Relevance to clinical practice. Understanding the process of protecting in different phases may help health care professionals to do anything in their power to avoid unnecessary suffering, to ease the pain and to support family members in their task of protecting. [ABSTRACT FROM AUTHOR]

Aims. The identification and description of the basic psychological process linked with the focus of family members' functioning during the acute phase of traumatic coma. Background. Earlier research learned that hope is a core category in coping with traumatic coma. Hope seems to be the drive to keep family members going and to enable them to fulfil their main task, namely protecting. In the two articles on the focus of family members functioning, this task is defined and the process linked with it is described. Design. A qualitative approach according to the 'grounded theory' method. Method. Twenty-four in-depth interviews with 22 family members of 16 patients with traumatic coma. Results. Family members describe the period after the confrontation with traumatic coma as a battle. During this battle, they feel the urge to protect their relative in coma, other family members and themselves. They go through three phases: protecting life, protecting from suffering, protecting what remains to rebuild life. In this article (Part Two) we describe the phase of protecting from suffering and protecting what remains to rebuild life. Conclusions. All relatives go through the three phases. Family members who have already overcome previous set-backs get through the process slightly more quickly and experience less extreme emotions. Relevance to clinical practice. Understanding the process of protecting in different phases may help health care professionals to do anything in their power to avoid unnecessary suffering, to ease the pain and to support family members in their task of protecting. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVE: The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2-4) in nursing home patients with non-blanchable erythema. BACKGROUND: No studies could be found that identify risk factors for further development of pressure ulcer in patients with non-blanchable erythema. For some patients with non-blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. DESIGN: Secondary data analyses of a previously conducted randomised controlled trial were performed. METHODS: Eighty-four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non-blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. RESULTS: The cumulative pressure ulcer incidence was 18.7% (44/235). Hypotension (relative risk = 3.42, 95% CI = 1.56-7.49), a history of a cerebral vascular accident (relative risk = 1.94, 95% CI = 1.10-3.70) and contractures (relative risk = 2.02, 95% CI 1.03-3.95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. CONCLUSIONS: In nursing home residents with non-blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. RELEVANCE TO CLINICAL PRACTICE: Patients with non-blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs. [ABSTRACT FROM AUTHOR]

AIM: This paper is a report of a review conducted to describe the current evidence about the prevention and treatment of incontinence-associated dermatitis and to formulate recommendations for clinical practice and research. BACKGROUND: Incontinence-associated dermatitis is a common problem in patients with incontinence. It is a daily challenge for healthcare professionals to maintain a healthy skin in patients with incontinence. DATA SOURCES: PubMed, Cochrane, Embase, the Cumulative Index to Nursing and Allied Health Literature, reference lists and conference proceedings were explored up to September 2008. REVIEW METHODS: Publications were included if they reported research on the prevention and treatment of incontinence-associated dermatitis. As little consensus about terminology was found, a very sensitive filter was developed. Study design was not used as a selection criterion due to the explorative character of the review and the scarce literature. RESULTS: Thirty-six publications, dealing with 25 different studies, were included. The implementation of a structured perineal skin care programme including skin cleansing and the use of a moisturizer is suggested. A skin protectant is recommended for patients considered at risk of incontinence-associated dermatitis development. Perineal skin cleansers are preferable to using water and soap. Skin care is suggested after each incontinence episode, particularly if faeces are present. The quality of methods in the included studies was low. CONCLUSIONS: Incontinence-associated dermatitis can be prevented and healed with timely and appropriate skin cleansing and skin protection. Prevention and treatment should also focus on a proper use of incontinence containment materials. Further research is required to evaluate the efficacy and effectiveness of various interventions. [ABSTRACT FROM AUTHOR]

Aims. To determine the incidence of pressure ulcers occurring at least 48 hours after admission and risk factors for pressure ulcers grade 2-4 in a long-stay surgical Intensive Care Unit (ICU) population. Background. The incidence of pressure ulcers in intensive care units is larger than in non-intensive environments. Design. Prospective descriptive research design. Methods. Using pressure ulcers grade 2-4 as an outcome measure, a multivariate logistic regression analysis was used to identify the risk factors. Data were obtained on a daily basis in a surgical intensive care unit of the University Hospital Leuven between November 2003-March 2004. A total of 520 long-stay (>= 24 hours) intensive care patients were included. Results. Cumulative incidence of pressure ulcers grade 2-4 was 20·1%. The following variables were positively associated with pressure ulcers grade 2-4: history of vascular disease, treatment with Dopamine(R) or Dobutamine(R), intermittent haemodialysis (IHD) or continuous veno-venous haemofiltration (CVVH), mechanical ventilation. Also preventive measures were statistically positively associated with pressure ulcers grade 2-4: turning, floating heels, alternating mattresses, adequate prevention. The use of sedatives, body temperature above 38·5 °C and sitting in chair where negatively associated with pressure ulcers. Pressure ulcers are statistically associated with different risk factors and preventive measures. Conclusion. The identified risk factors are eligible to be included in a new risk assessment scale for patients admitted to intensive care units. Relevance to clinical practice. The novel insights have implications for risk assessment for patients in intensive care units. Patients admitted to intensive care units have other risk factors for pressure ulcers which are eligible to be included in a new risk assessment scale. [ABSTRACT FROM AUTHOR]

Aim. To provide an overview of what is known thus far about reasons for and determinants of non-adherent behaviour. Background. Compression, leg exercises and leg elevation are regarded as essential components in leg ulcer treatment and in the prevention of ulcer recurrence. Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherence are not fully understood. Design. Systematic review. Method. Medline, CINAHL and the Cochrane database were explored from 1995 - December 2007. Reference lists of retrieved articles were searched. Studies were eligible if they included patients with venous or mixed leg ulcers, reported reasons or determinants of non-adherence and were published in English, Dutch, French or German. Thirty-one studies were included. Results. Non-adherence is a multidimensional problem. Pain, discomfort and lack of valid lifestyle advice by healthcare professionals were primary reasons for non-adherence from patient's perspective. Conclusions. Healthcare professionals mainly focus on patient-related factors such as poor motivation, lack of knowledge and understanding and unwillingness. The beliefs that compression was unnecessary, uncomfortable, worthwhile and prevented recurrence significantly determined (non-)adherence. Relevance to nursing and nursing science. Interventions to promote adherence will require a multifaceted approach and a holistic comprehensive assessment. Therapeutic non-judgemental relationships are essential to enhance patient adherence. Effective pain management is recommended and social support by family or significant others could be encouraged. Healthcare professionals should give clear, unambiguous and tailored information. Research can best focus on the factors and processes affecting patient adherence to leg ulcer treatment. Comprehensive adherence-enhancing strategies could be developed and their effectiveness should be tested. [ABSTRACT FROM AUTHOR]

Aim: This paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses. Background: Incongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice. Method: Two focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated ( n = 789). The data were collected in 2006. Findings: Compression was applied in 58·7% of patients with venous ulcers. Pain was present in 82·9%. A third of patients with pain received analgesics, but half of these patients (52·1%) took analgesics as prescribed. Half of the nurses (50·8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68·3%), promoting physical activity (39·8%) and optimizing nutrition (16·7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3·75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult. Conclusion: Patients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management. [ABSTRACT FROM AUTHOR]

Aims and objectives. To detect problems when classifying pressure ulcers and to examine whether an e-learning program is able to increase the classification skills of qualified nurses and nursing students. Background. Both the distinction between pressure ulcer grades and the differentiation between moisture lesions is difficult. Misclassification and incorrect identification of the lesions results in inadequate preventive and therapeutic measures. Education and training are important for spreading evidence-based insights about this topic. Design. Repeated measure design, consisting of one pretest and three posttests. Methods. The experimental intervention consisted of a one-hour session during which the participants independently went over an e-learning program. The control intervention consisted of a one-hour lecture. Both interventions had the same learning contents. A convenience sample of 212 qualified nurses and 214 final-year nursing students was randomly assigned to an experimental-and a control group. Results. In the pretest, the classification skills were low. After the intervention, these skills improved significantly in both groups. The nursing students achieved better results when using the e-learning program. Among the qualified nurses, there was no difference between the learning methods. Although the classification skills decreased in the posttests, they did not drop under the level of the pretest. Conclusion. The actual classification system does not provide the necessary information about the severity of a pressure ulcer. The differential diagnosis between a moisture lesion was complicated. The classification skills of the qualified nurses and nursing students increased by both learning methods. Repetition remains, however, necessary. Relevance to clinical practice. Both instruction methods are adequate to acquire the knowledge about the differences between moisture lesions and pressure ulcers. E-learning allows studying in one's own time and place, and could therefore be very suitable for repetition of the training. How to organise this training could be a subject for further research. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: The aim of this systematic literature review was to describe the current evidence in the field of pressure ulcer treatment with hydrocolloids and to give recommendations for clinical practice and further research. BACKGROUND: Pressure ulcers are a common problem in clinical practice and generate substantial expense. A wide range of dressings is available but little is known about the effect on pressure ulcer healing. METHODS: A Cochrane-based search strategy was used in four databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Cumulative Index to Nursing and Allied Health Literature), manuals and reference lists. Randomised controlled trials on the treatment of pressure ulcers with hydrocolloids, as defined by the British National Formulary, were systematically included and analysed. RESULTS: Twenty-nine publications, dealing with 28 different studies, met the inclusion criteria and were included in the review. Hydrocolloids were most frequently used on pressure ulcers grade 2-3. Concerning the healing of the pressure ulcer, hydrocolloids are more effective than gauze dressings for the reduction of the wound dimensions. The absorption capacity, the time needed for dressing changes, the pain during dressing changes and the side-effects were significantly in favour of hydrocolloids if compared to gauze dressings. Based on the available cost-effectiveness data, hydrocolloids seemed to be less expensive compared with collagen-, saline- and povidine-soaked gauze but more expensive compared to hydrogel, polyurethane foam and collagenase. CONCLUSIONS: This review demonstrates that hydrocolloids are to be preferred to gauze dressings in the treatment of pressure ulcers. Additional research is needed to confirm these results. RELEVANCE TO CLINICAL PRACTICE: Based on the studies included in this review, hydrocolloids are frequently used in the treatment of grade 2 and 3 pressure ulcers and are more effective and less expensive than gauze dressings. Compared with alginates, polyurethane dressings, less-contact layers, topical enzymes and biosynthetic dressings, hydrocolloids are less effective. [ABSTRACT FROM AUTHOR]

Aims and objectives. To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention. Background. Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care. Methods. A cross-sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence. Results. There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6.8%. The age-, sex- and risk-standardized prevalence per regional department varied between 4.9% and 9.1%. Of the 744 subjects at risk, 33 (4.4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64.8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30.8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4.8% adherence, 76.6% no adherence and 18.6% no prevention. A proportion of 22.2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21.4% of all risk cases. Conclusions. The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. Relevance to the clinical practice. The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers. [ABSTRACT FROM AUTHOR]

Background and aims. Non-compliance with compression therapy and with leg exercises and leg elevation is a common problem, often reported in patients with venous leg ulceration. Studies on compliance-enhancing interventions and the effectiveness of these interventions in patients with venous leg ulceration were reviewed. Methods. MEDLINE, Cochrane, Embase and CINAHL were explored up to April 2005. Reference lists, wound care journals and conference proceedings were searched. Experts and manufacturers of compression systems were contacted. Studies were eligible if they included patients with venous or mixed leg ulcers and reported patient compliance outcome. Twenty studies were included. Results. Most studies describe patient compliance as the extent to which the compression system was worn and/or the extent to which treatment regimen was followed. Self-reporting was the most commonly used method of compliance assessment. There are indications that class III stockings for patients with venous ulcers enhance compliance compared with short stretch compression bandages. No real evidence is found that intermittent pneumatic compression systems improved compliance. There is no well-documented evidence that healthcare system interventions increase compliance. Educational programmes combining cognitive, behavioural and affective components were shown to have a positive effect on leg elevation, but not on compliance with compression therapy. Conclusion. The included studies have a lack of consistency in defining the standard and operationalization of compliance. Patient compliance plays an ancillary role in research. No study has been able to offer an acceptable and well-documented solution to the non-compliance problem. Relevance to clinical practice. Research might focus on the development of comprehensive compliance-enhancing strategies. A stronger commitment of healthcare providers and society is needed to make progress in this area. The scope of nursing must be expanded to also include the problems experienced by patients with leg ulcers and the improvement of patient compliance. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study of the inter-observer reliability of the European Pressure Ulcer Advisory Panel pressure ulcer classification system and of the differential diagnosis between moisture lesions and pressure ulcers. Background. Pressure ulcer classification is a valuable tool to provide a common description of ulcer severity for the purposes of clinical practice, audit and research. Despite everyday use of the European Pressure Ulcer Advisory Panel system, its reliability has been evaluated in only a limited number of studies. Methods. Asurvey was carried out between September 2005 and February 2006 with a convenience sample of 1452 nurses from five European countries. Respondents classified 20 validated photographs as normal skin, blanchable erythema, pressure ulcers (four grades), moisture lesion or combined lesion. The nurses were familiar with the use of the European Pressure Ulcer Advisory Panel classification scale. Results. Pressure ulcers were often classified erroneously (j = 0Æ33) and only a minority of nurses reached a substantial level of agreement. Grade 3 lesions were regularly classified as grade 2. Non-blanchable erythema was frequently assessed incorrectly as blanchable erythema. Furthermore, the differential diagnosis between moisture lesions and pressure ulcers appeared to be complicated. Conclusion. Inter-observer reliability of the European Pressure Ulcer Advisory Panel classification system was low. Evaluation thus needs to focus on both the clarity and complexity of the system. Definitions and unambiguous descriptions of pressure ulcer grades and the distinction between moisture lesions will probably enhance clarity. To simplify the current classification system, a reduction in the number of grades is suggested. [ABSTRACT FROM AUTHOR]

Aims and objectives. To evaluate whether postponing preventive measures until non-blanchable erythema appears will actually lead to an increase in incidence of pressure ulcers (grades 2-4) when compared with the standard risk assessment method. Background. To distinguish patients at risk for pressure ulcers from those not at risk, risk assessment scales are recommended. These scales have limited predictive validity. The prevention of further deterioration of non-blanchable erythema (grade 1 pressure ulcer) instead of the standard way of assigning prevention could be a possible new approach. Design. Randomized-controlled trial. Methods. Patients admitted to surgical, internal or geriatric wards (n = 1617) were included. They were randomly assigned to an experimental and a control group. In the experimental group (n = 826), prevention was started when non-blanchable erythema appeared, in the control group (n = 791) when the Braden score was <17 or when non-blanchable erythema appeared. In both groups, patients received identical prevention, either by using a polyethylene-urethane mattress in combination with turning every four hours or by using an alternating pressure air mattress. Pressure points were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. The Braden scale was scored every three days. Results. In the experimental group, 16% of patients received preventive measures, in the control group 32%. The pressure ulcer incidence (grades 2-4) was not significantly different between the experimental (6.8%) and control group (6.7%). Conclusion. Significantly fewer patients need preventive measures when prevention is postponed until non-blanchable erythema appears and those patients did not develop more pressure ulcers than patients who received prevention based on the standard risk assessment method. Relevance to clinical practice. Using the appearance of non-blanchable erythema to allocate preventive measures leads to a considerable reduction of patients in need of prevention without resulting in an increase in pressure ulcers. [ABSTRACT FROM AUTHOR]

Aim. This paper reports a study investigating whether repositioning patients lying on a pressure-reducing mattress alternately for 2 hours in a lateral position and 4 hours in a supine position reduces the incidence of pressure ulcers in comparison with repositioning every 4 hours. Background. Repositioning is commonly recognized as an effective preventive measure. Almost no research has been carried out so far on the necessary turning frequencies to prevent pressure ulcer lesions. The pressure is higher in a lateral than in a supine position. Method. A two-arm randomized controlled trial was conducted in 16 Belgian elder care nursing homes. Patients with non-blanchable erythema were randomly assigned to either an experimental or a control group. In the experimental group (n = 122), patients were repositioned alternately 2 hours in a lateral position and 4 hours in a supine position. In the control group (n = 113), patients were repositioned every 4 hours. The sitting protocol was identical in both groups. Pressure areas were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. Results. In the experimental group, 16.4% patients developed a pressure ulcer lesion (grade 2-4), while 21.2% did so in the control group. The incidence was not statistically significantly different between the two groups (P = 0.40). The severity (P = 0.65) and location (P = 0.19) of pressure ulcer lesions, and the time to developing them (P = 0.29) were also similar in both groups. No patient developed a pressure ulcer at the hips. A considerable number of patients changed from a lateral to a supine position between the turning intervals. Conclusion. More frequent repositioning on a pressure-reducing mattress does not necessarily lead to fewer pressure ulcer lesions and consequently cannot be considered as a more effective preventive measure. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: This literature review aims to structure the available information on the psychological reactions of family members confronted with traumatic brain injury. The stress-coping theory and the systems theory provide the theoretical framework for this review. METHOD: Literature review. RESULTS: The level of stress experienced by the family members of patients who have traumatic brain injury is such that professional intervention is appropriate, even after 10-15 years. Not the severity of the injury but the nature of the injuries determines the level of stress. Partners experience more stress than parents. Children have specific difficulties. Young families with little social support, financial, psychiatric and/or medical problems are the most vulnerable. Coping with traumatic brain injury can be described in phases. The better family members can cope with the situation, the better the patient's recovery. There are functional and non-functional coping mechanisms and coping is influenced by such factors as gender, social and professional support and the possibility to have reciprocal communication or an affective relation with the patient. RELEVANCE TO CLINICAL PRACTICE: Support from professionals reduces the stress being experienced and encourages people to cope effectively. Conflicts with professional carers should be avoided. Every attempt should be made to develop models of long-term support and care that alleviate sources of burden on relatives. Further research is necessary to develop such models. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: Insight into the needs and experiences of family members is an initial but necessary step in providing appropriate care for both family members and the patient. This literature review aims to structure the available scientific knowledge on needs and experiences of family members of intensive care unit patients with particular extension to coma patients. Qualitative as well as quantitative studies are discussed. METHOD: Literature review. RESULTS: Needs are divided into four categories: cognitive, emotional, social and practical needs. The need for accurate and comprehensible information that leaves room for hope is universal. Family members want to speak to a doctor every day about the condition of and the prognosis for the patient, and want a nurse to explain to them about the care, the unit, the equipment and what they can do for the patient during visiting hours. Family members place great importance on being called at home if the condition of the patient changes. Emotional needs as hope, reassurance and being able to remain in the vicinity of the patient are crucial. Family members always give priority to the welfare of their relative. In their confused state, they often do not get around to paying attention to themselves. Caregivers underestimate all of the needs of family members and do not do enough to meet these needs. RELEVANCE TO CLINICAL PRACTICE: Priority needs should be central in the nurses' approach of family members. The initiative for meeting the needs must be with the caregivers. Future, focused and well-designed qualitative research over a longer period of time could clarify the process that family members go through and explain the results of quantitative studies. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: To compare the predictive value of two pressure ulcer risk assessment scales (Braden and Norton) and of clinical judgement. To evaluate the impact of effective preventive measures on the predictive validity of the two risk assessment scales. METHODS: Of the 1772 participating older patients, 314 were randomly selected and assigned to the 'turning' group; 1458 patients were assigned to the 'non-turning' group. Using the Braden and the Norton scale the pressure ulcer risk was scored twice weekly during a four-week period. Clinical assessment was monitored daily. The patients at risk in the 'turning' group (Braden score <17 or Norton score <12) were randomly assigned to a two-hour turning schedule or to a four-hour turning schedule in combination with a pressure-reducing mattress. The 'non-turning' group received preventive care based on the clinical judgement of the nurses. RESULTS: The diagnostic accuracy was similar for both scales. If nurses act according to risk assessment scales, 80% of the patients would unnecessarily receive preventive measures. The use of effective preventive measures decreased the predictive value of the risk assessment scales. Nurses predicted pressure ulcer development less well than the Braden and the Norton scale. Only activity, sensory perception, skin condition and existence of old pressure ulcers were significant predictors of pressure ulcer lesions. RELEVANCE TO CLINICAL PRACTICE: The effectiveness of the Norton and Braden scales is very low. Much needless work is done and expensive material is wrongly allocated. The use of effective preventive measures decreases the predictive value of the risk assessment scales. Although the performance of the risk assessment scales is poor, using a risk assessment tool seems to be a better alternative than relying on the clinical judgement of the nurses. [ABSTRACT FROM AUTHOR]

AIM: The aim of this paper is to present critical analysis of the validation methods of pressure ulcer risk assessment scales. BACKGROUND: The validation of pressure ulcer risk assessment scales remains a topic of considerable debate and uncertainty. The Braden scale and Norton scale are the most frequently used. Sensitivity and specificity are the recommended and most commonly used epidemiological tools to evaluate the validity of those risk assessment scales. DISCUSSION: The use of preventive measures influences both the sensitivity and specificity of the scales. Analysis of published studies on risk assessment scales reveals that, although some patients received preventive measures and others did not, this was not taken into account. Consequently, generalization of those results is not possible. Some possible alternative designs for studying the validity of risk assessment scales are discussed. CONCLUSIONS: Currently available risk assessment scales are of only limited value, and there use will result in many patients being falsely identified as at risk or not at risk. Sensitivity and specificity criteria are not the most appropriate tools to validate risk assessment scales. A risk assessment scale should be evaluated in combination with the preventive measures used. [ABSTRACT FROM AUTHOR]

BACKGROUND: Many classification systems for grading pressure ulcers are discussed in the literature. Correct identification and classification of a pressure ulcer is important for accurate reporting of the magnitude of the problem, and for timely prevention. The reliability of pressure ulcer classification systems has rarely been tested. AIMS AND OBJECTIVES: The purpose of this paper is to examine the inter-rater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using pressure ulcer photographs. DESIGN: Survey was among pressure ulcer experts. METHODS: Fifty-six photographs were presented to 44 pressure ulcer experts. The experts classified the lesions as normal skin, blanchable erythema, pressure ulcer (four grades) or incontinence lesion. Inter-rater reliability was calculated. RESULTS: The multirater-Kappa for the entire group of experts was 0.80 (P < 0.001). Various groups of experts obtained comparable results. Differences in classifications are mainly limited to 1 degree of difference. Incontinence lesions are most often confused with grade 2 (blisters) and grade 3 pressure ulcers (superficial pressure ulcers). CONCLUSIONS: The inter-rater reliability of the European Pressure Ulcer Advisory Panel classification appears to be good for the assessment of photographs by experts. The difference between an incontinence lesion and a blister or a superficial pressure ulcer does not always seem clear. RELEVANCE TO CLINICAL PRACTICE: The ability to determine correctly whether a lesion is a pressure ulcer lesion is important to assess the effectiveness of preventive measures. In addition, the ability to make a correct distinction between pressure ulcers and incontinence lesions is important as they require different preventive measures. A faulty classification leads to mistaken measures and negative results. Photographs can be used as a practice instrument to learn to discern pressure ulcers from incontinence lesions and to get to know the different grades of pressure ulcers. The Pressure Ulcer Classification software package has been developed to facilitate learning. [ABSTRACT FROM AUTHOR]

Patients undergoing surgery are prone to develop pressure ulcers during the surgical procedure. The aim of the study was to gain insight into the problem by describing the incidence, clinical features and progression of pressure ulcers and closed pressure ulcers in patients undergoing surgery lasting more than 4 hours. A prospective follow-up study was conducted in a university hospital in the Netherlands. Two-hundred and eight patients from nine surgical specialities were included in the study. The skin of patients was observed the evening before surgery and, if the patient's condition allowed it, directly postoperatively and subsequently daily for 14 days or until discharge, whichever occurred first. When patients developed a pressure ulcer they were observed daily until discharge or until the pressure ulcer had healed. The size and colour of the lesion, stage and skin condition were described every day. In addition, data were collected concerning the operation, postoperative period, and general characteristics. Forty-four patients (21.2%) developed 70 pressure ulcers in the first 2 days following surgery. Twenty-one pressure ulcers deteriorated in the days following surgery. More than half (52.9%) of the lesions developed on the heels, and 15.7% developed in the sacral area. Twenty-five patients (12%) were impaired by the lesions they developed. None of the patients in the study developed closed pressure ulcers. Pressure ulcer development during a surgical procedure is a serious problem. Therefore, preventive measures should be taken during surgery and the first few days afterwards, until the patient is able to mobilize independently. [ABSTRACT FROM AUTHOR]

Based on a review of the literature related to the prediction and prevention of pressure sores, a conceptual scheme on pressure sores is introduced. The article highlights the four elements of the scheme: pressure, shearing force, tissue tolerance for pressure and tissue tolerance for oxygen. Factors influencing pressure and shearing forces, the pressure distribution capacity of tissue, the oxygen need of tissue and oxygen supply to tissue are discussed. [ABSTRACT FROM AUTHOR]

Abstract Background The current, place-oriented nurse call systems are very static. A patient can only make calls with a button which is fixed to a wall of a room. Moreover, the system does not take into account various factors specific to a situation. In the future, there will be an evolution to a mobile button for each patient so that they can walk around freely and still make calls. The system would become person-oriented and the available context information should be taken into account to assign the correct nurse to a call. The aim of this research is (1) the design of a software platform that supports the transition to mobile and wireless nurse call buttons in hospitals and residential care and (2) the design of a sophisticated nurse call algorithm. This algorithm dynamically adapts to the situation at hand by taking the profile information of staff members and patients into account. Additionally, the priority of a call probabilistically depends on the risk factors, assigned to a patient. Methods The ontology-based Nurse Call System (oNCS) was developed as an extension of a Context-Aware Service Platform. An ontology is used to manage the profile information. Rules implement the novel nurse call algorithm that takes all this information into account. Probabilistic reasoning algorithms are designed to determine the priority of a call based on the risk factors of the patient. Results The oNCS system is evaluated through a prototype implementation and simulations, based on a detailed dataset obtained from Ghent University Hospital. The arrival times of nurses at the location of a call, the workload distribution of calls amongst nurses and the assignment of priorities to calls are compared for the oNCS system and the current, place-oriented nurse call system. Additionally, the performance of the system is discussed. Conclusions The execution time of the nurse call algorithm is on average 50.333 ms. Moreover, the oNCS system significantly improves the assignment of nurses to calls. Calls generally have a nurse present faster and the workload-distribution amongst the nurses improves.

Current nurse call systems are very static. Call buttons are fixed to the wall, and systems do not account for various factors specific to a situation. We have developed a software platform, the ontology-based Nurse Call System (oNCS), which supports the transition to mobile and wireless nurse call buttons and uses an intelligent algorithm to address nurse calls. This algorithm dynamically adapts to the situation at hand by taking the profile information of staff and patients into account by using an ontology. This article describes a probabilistic extension of the oNCS that supports a more sophisticated nurse call algorithm by dynamically assigning priorities to calls based on the risk factors of the patient and the kind of call. The probabilistic oNCS is evaluated through implementation of a prototype and simulations, based on a detailed dataset obtained from 3 nursing departments of Ghent University Hospital. The arrival times of nurses at the location of a call, the workload distribution of calls among nurses, and the assignment of priorities to calls are compared for the oNCS and the current nurse call system. Additionally, the performance of the system and the parameters of the priority assignment algorithm are explored. The execution time of the nurse call algorithm is on average 50.333 ms. Moreover, the probabilistic oNCS significantly improves the assignment of nurses to calls. Calls generally result in a nurse being present more quickly, the workload distribution among the nurses improves, and the priorities and kinds of calls are taken into account.

Objective: To identify risk factors independently predictive of pressure ulcer development in adult patient populations?, Design: A systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies., Data Sources: Fourteen electronic databases were searched, each from inception until March 2010, with hand searching of specialist journals and conference proceedings; contact with experts and a citation search. There was no language restriction., Review Methods: Abstracts were screened, reviewed against the eligibility criteria, data extracted and quality appraised by at least one reviewer and checked by a second. Where necessary, statistical review was undertaken. We developed an assessment framework and quality classification based upon guidelines for assessing quality and methodological considerations in the analysis, meta-analysis and publication of observational studies. Studies were classified as high, moderate, low and very low quality. Risk factors were categorised into risk factor domains and sub-domains. Evidence tables were generated and a summary narrative synthesis by sub-domain and domain was undertaken., Results: Of 5462 abstracts retrieved, 365 were identified as potentially eligible and 54 fulfilled the eligibility criteria. The 54 studies included 34,449 patients and acute and community patient populations. Seventeen studies were classified as high or moderate quality, whilst 37 studies (68.5%) had inadequate numbers of pressure ulcers and other methodological limitations. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status. Skin moisture, age, haematological measures, nutrition and general health status are also important, but did not emerge as frequently as the three main domains. Body temperature and immunity may be important but require further confirmatory research. There is limited evidence that either race or gender is important., Conclusions: Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. The review highlights the limitations of over-interpretation of results from individual studies and the benefits of reviewing results from a number of studies to develop a more reliable overall assessment of factors which are important in affecting patient susceptibility., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Aims: To gain insight into the knowledge and attitudes of nurses and nursing assistants and to study the correlation between knowledge, attitudes and the compliance with the pressure ulcer prevention guidelines provided to residents at risk of pressure ulcers in nursing homes., Background: There is a lack of evidence on knowledge and attitudes of nurses and nursing assistants towards pressure ulcer prevention in nursing homes., Design: A cross-sectional multi-centre study., Methods: A convenience sample of nine Belgian nursing homes, representing 18 wards was chosen in the study. In total, 145 nurses and nursing assistants were included. The compliance with the guidelines was evaluated in 615 residents, and data were collected using validated instruments., Results: Fully compliant prevention was found in only 6·9% of the residents at risk. The mean knowledge score of the nurses was 29·3 vs. 28·7% for the nursing assistants. The overall attitude score was 74·5%, and attitude scores were significantly different between nurses and nursing assistants. Nurses showed to have a more positive attitude towards pressure ulcer prevention than nursing assistants, respectively 78·3 and 72·3%. A more positive attitude was a significant predictor of pressure ulcer prevention compliance with the guidelines provided to residents at risk of pressure ulcers in nursing homes., Conclusions: Knowledge about pressure ulcer prevention of both nurses and nursing assistants in nursing homes was low. Attitudes were a significant predictor of the application of fully compliant prevention in residents at risk., Relevance to Clinical Practice: Pressure ulcer prevention is an important aspect in daily care for residents at risk in nursing homes. These insights will contribute to evidence-based practice in this area of care and will form the basis for the development of an education strategy for pressure ulcer prevention and management in nursing homes., (© 2011 Blackwell Publishing Ltd.)

Background: While there has been great interest in the effect of nurse staffing levels have on the quality of care in hospitals, less attention has been given to determining the factors that affect the nursing workload. There are no existing studies that help define measurable factors that have a clear relation to nursing workload., Objectives: The aim of this study was to determine the most important and measurable factors, other than patient acuity, that influence nursing workload., Design: A cross-sectional design., Settings: Hospitals within the acute hospital care setting., Participants: Persons with a nursing educational background, working in Belgian acute care hospitals., Methods: A self-administered questionnaire was developed based on the results of an integrative review, the use of focus groups and a survey on measurability and relevance of the included factors. The questionnaire listed relevant and measurable factors related to nursing workload. Weight and frequency of each factor was assessed., Results: The initial list consisted of 94 factors. These factors were regrouped and organised into a questionnaire of 28 measurable and sufficiently relevant factors affecting the nursing workload. More than half of the initial factors seemed to be relevant, but hard to measure on a daily basis. Based on the impact of each factor, the number of work interruptions was the most important factor related to nursing workload., Conclusions: It is unlikely that a workload instrument will ever be able to take into account all possible factors affecting the nursing workload. Nevertheless, the number of work interruptions, the patient turnover rate and the number of mandatory registrations should be included in the development or revision of a workload measurement tool., (© 2011 Elsevier Ltd. All rights reserved.)

Aim: Development and psychometric testing of an instrument to assess venous leg ulcer lifestyle knowledge., Background: Nurses often lack knowledge to provide adequate leg ulcer advice. No valid and reliable instruments are available to assess knowledge on venous leg ulcer advice among nurses., Methods: The instrument was developed based on a literature review and patient cases. Content validity was evaluated in a Delphi procedure by nine leg ulcer experts. Item-analysis, construct validity and stability were assessed. A sample of 350 nurses and student nurses participated. Data collection took place between February and April 2009., Results: The instrument included four topics: (1) Compression therapy, (2) Physical activity/leg exercises, (3) Leg elevation and (4) Pain management. Multiple-choice questions were developed to assess factual knowledge. Patient cases were developed to assess more complex cognitive skills. Content validity was established. The quality of the response alternatives varied between 0.01 and 0.68. The difficulty index for questions evaluating factual knowledge ranged from 0.12 to 0.78. Patient cases' questions had a difficulty index between 0.07 and 0.60. The score of participants with (theoretically expected) more expertise was significantly higher than the score of participants with (theoretically expected) less expertise. The intraclass correlation coefficients ranged between 0.71 and 0.77. Eleven questions had moderate kappa-values (0.41-0.60), and in eight questions, there was fair agreement (0.30-0.40)., Conclusion: An instrument with an acceptable content validity and construct validity was developed. The instrument can be applied in nursing education, nursing practice and nursing research to evaluate venous leg ulcer advice knowledge., (© 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.)

Purpose: We compared the effectiveness of a 3-in-1 perineal care washcloth versus standard of care (water and pH neutral soap) to prevent and treat incontinence-associated dermatitis (IAD). The product under study was a soft, premoistened washcloth, including a 3% dimethicone formula, with cleansing, moisturizing, and barrier protection properties., Design: Randomized, controlled clinical trial., Subjects and Setting: The study sample comprised a random sample of 11 nursing home wards (6 experimental and 5 control) in a convenience sample of 4 nursing homes in Belgium. The sample included nursing home residents at risk for and/or affected by IAD defined as incontinent of urine, feces, urine/feces, and/or having erythema of the perineal skin (not caused by pressure/shear), and/or having an edematous skin in the genital area., Methods: Participants in the experimental group were treated according to a standardized protocol, including the use of a 3-in-1 perineal care washcloth impregnated with a 3% dimethicone skin protectant. Participants in the control group received perineal skin care with water and pH neutral soap, the standard of care in Belgian nursing homes. The study period was 120 days. Data were collected between February and May 2010. Incontinence-associated dermatitis prevalence and severity were assessed using the IAD Skin Condition Assessment Tool. The surface (cm), redness, and depth of the perineal lesion were assessed daily by the nurses. This tool generates a cumulative severity score (maximum score = 10) based on area of skin affected, degree of redness, and depth of erosion., Results: Four hundred sixty-four nursing home residents were assessed and 32.9% (n = 141) met the criteria for inclusion, including 73 subjects in the experimental group and 68 in the control group. Baseline IAD prevalence was comparable in both groups (experimental: 22.3% vs control: 22.8%, P = .76). Baseline IAD severity was 6.9/10 in the experimental group and 7.3/10 in the control group. A significant intervention effect on IAD prevalence was found (experimental: 8.1% vs control: 27.1%, F = 3.1, P = .003). A nonsignificant effect on IAD severity could be determined (experimental: 3.8/10 vs control: 6.9/10, F = 0.8, P = .06)., Conclusion: The use of a 3-in-1 washcloth, impregnated with a 3% dimethicone formula, resulted in a significantly reduced prevalence of IAD and a trend toward less severe lesions. These findings provide indicative evidence for the use of 3-in-1 perineal care washcloth as an effective intervention against the use of water and a pH neutral soap to prevent and/or treat IAD.

Aims: The aim of this paper was to detect which non-direct patient care factors are related to nursing workload in acute hospital nursing care and to develop a conceptual model to describe the relationship between the non-direct patient care factors and nursing workload., Background: Since the 1930s, efforts to measure nursing workload have been undertaken. Still, it remains unclear which of the non-direct patient care elements are essential to the nursing workload., Data Sources: PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, Engineering Village 2, Elin and the British Nursing Index were searched from 1970 up to July 2009., Review Methods: Studies were included in this integrative review if they described factors that are related to nursing workload or if they presented models that explored the association between potential factors, excluding the factors related to direct patient care., Results: Thirty publications were included. The influencing variables were classified in five categories based on their level of impact: the hospital and ward, nursing team, individual nurse, patient and family and meta-characteristics. The variables were also classified, based on their cause-effect relationship. Some factors have a direct impact on the patient-nurse relationship, while others have an effect on the work fluency or on the subjective perception of the nursing workload. A conceptual model was built, based on the interaction between both classifications and derived from the systems theory., Conclusions: Nursing workload has a multi-causal aetiology. The influencing factors from this review can be integrated in a workload measurement tool., (© 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.)

Background: Patient care guidelines are usually implemented one at a time, yet patients are at risk for multiple, often preventable, adverse events simultaneously., Objective: This study aimed to test the effect of the SAFE or SORRY? programme on the incidence of three adverse events (pressure ulcers, urinary tract infections and falls). This paper describes Part I of the study: the effect on the incidence of adverse events., Design: A cluster randomised trial was conducted between September 2006 and November 2008. After a three-month baseline period the intervention was implemented followed by a nine-month follow-up period., Settings: Ten wards from four hospitals and ten wards from six nursing homes were stratified for institute and ward type and then randomised to intervention or usual care group., Participants: During baseline and follow-up, patients (≥18 years) with an expected length of stay of at least five days, were asked to participate., Methods: The SAFE or SORRY? programme consisted of the essential recommendations of guidelines for the three adverse events. A multifaceted implementation strategy was used for the implementation: education, patient involvement and feedback on process and outcome indicators. The usual care group continued care as usual. Data were collected on the incidence of adverse events and a Poisson regression model was used to estimate the rate ratio of the adverse events between the intervention and the usual care group at follow-up., Results: At follow-up, 2201 hospital patients with 3358 patient weeks and 392 nursing home patients with 5799 patient weeks were observed. Poisson regression analyses showed a rate ratio for the development of an adverse event in favour of the intervention group of 0.57 (95% CI: 0.34-0.95) and 0.67 (95% CI: 0.48-0.99) for hospital patients and nursing home patients respectively., Conclusion: This study showed that implementing multiple guidelines simultaneously is possible, which is promising. Patients in the intervention groups developed 43% and 33% fewer adverse events compared to the usual care groups in hospitals and nursing homes respectively. Even so, more research is necessary to underline these results., Trial Registration: clinicaltrials.gov, number NCT00365430., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Evidence-based guidelines for pressure ulcer prevention have been developed and promoted by authoritative organizations. However, nonadherence to these guidelines is frequently reported. Negative attitudes and lack of knowledge may act as barriers to using guidelines in clinical practice., Aims: To study the knowledge and attitudes of nurses about pressure ulcer prevention in Belgian hospitals and to explore the correlation between knowledge, attitudes, and the application of adequate prevention., Methods: A cross-sectional multicenter study was performed in a random sample of 14 Belgian hospitals, representing 207 wards. Out of that group, 94 wards were randomly selected (2105 patients). Clinical observations were performed to assess the adequacy of pressure ulcer prevention and pressure ulcer prevalence. From each participating ward, a random selection of at least five nurses completed an extensively validated knowledge and attitude instrument. In total, 553 nurses participated. A logistic regression analysis was performed to evaluate the correlation between knowledge, attitudes, and the application of adequate prevention., Results: Pressure ulcer prevalence (Category I-IV) was 13.5% (284/2105). Approximately 30% (625/2105) of the patients were at risk (Bradenscore <17 and/or presence of pressure ulcer). Only 13.9% (87/625) of these patients received fully adequate prevention whilst in bed and when seated. The mean knowledge and attitude scores were 49.7% and 71.3%, respectively. The application of adequate prevention on a nursing ward was significantly correlated with the attitudes of the nurses (OR = 3.07, p = .05). No independent correlation was found between knowledge and the application of adequate prevention (OR = 0.75, p = .71)., Conclusions: Knowledge of nurses in Belgian hospitals about the prevention of pressure ulcers is inadequate. The attitudes of nurses toward pressure ulcers are significantly correlated with the application of adequate prevention. No correlation was found between knowledge and the application of adequate prevention., (Copyright ©2011 Sigma Theta Tau International.)

Aims: This paper is a report of a study conducted to gain a better insight into the current nutritional care practices in Belgian hospital wards for older people, and to study the association between these practices and the prevalence of malnutrition., Background: In 1999, the Council of Europe assessed nutritional care practices and support in 12 European countries and showed them to be sparse and inconsistent. At the time of research, no studies had described the association between nutritional care practices and malnutrition prevalence in Belgium., Methods: In 2007, a cross-sectional survey was carried out in a representative sample of Belgian hospital wards for older people. In total, 2094 patients from 140 wards for older people were included., Results: The overall prevalence rate of malnutrition in wards for older people was 31.9%. Nutritional care practices such as nutritional screening and assessment, use of a standardized screening instrument and a nutritional protocol were suboptimal. Multilevel analysis revealed that ward characteristics explained for 9.1% whether a patient was malnourished or not. None of the registered nutritional care practices could explain a patient's individual risk., Conclusion: Malnutrition is a frequently occurring problem on hospital wards for older people. Increased consciousness among healthcare professionals and hospital policy makers of the importance of nutritional care will contribute to further improvement in care quality., (© 2010 The Authors. Journal of Advanced Nursing © 2010 Blackwell Publishing Ltd.)

Aims: To describe and discuss of the added value of systematic development and validation of nursing interventions in nursing care., Background: An adherence-promoting intervention for leg ulcer patients was developed in 2008, based on the model of van Meijel. This model requires a systematic development using an analysis of patients' (lived) experiences and professionals' views on (good) care. It employs a cyclical process of trying out, evaluating, revising and reassessing the adapted intervention in patients. The intervention consists of information and counselling sessions carried out by tissue viability nurses and focuses on wearing compression hosiery, practising leg elevation, physical activity and performing leg exercises., Discussion: Exploring patients' and nurses' perspectives during the development of intervention increases the likelihood that the resultant intervention is both feasible and attuned to patients' needs. Various implementation issues were identified during the developmental process. Validation of the intervention through its use in nursing care aids in refining the intervention and in linking the techniques most successful in effecting behavioural change to theoretical constructs. It contributes to the refinement of concepts of behavioural theories by clarifying the processes underlying the intervention's effectiveness. Direct involvement of the researcher in the validation phase has great added value., Implications for Nursing: Patient involvement in intervention development is essential, as is the researcher's direct involvement in practical situations in which the intervention is tested. Qualitative (evaluation) approaches are recommended., Conclusion: Although the systematic development of nursing interventions is time-consuming, the contribution to the development of nursing practice and nursing science makes it worthwhile., (© 2010 The Authors Journal of Advanced Nursing © 2010 Blackwell Publishing Ltd.)

Aim and Objectives: Examining the (experienced) changes associated with a nursing intervention to enhance adherence to leg ulcer lifestyle advice., Background: Few interventions to enhance adherence to leg ulcer treatment are developed and tested., Design: Qualitative evaluation approach and pre-post-test design were used., Method: Twenty-six patients with venous ulcers in a community care setting participated. Data were collected by means of interviews and participant observation. Frequency and duration of wearing compression, leg exercising and leg elevation, activity level, pain and ulcer size were registered at baseline, after the end of the intervention and three months later. Inductive content analysis and Wilcoxon signed-rank test were used., Results: Knowledge about leg ulcer advice increased. The education contributed to more consciously following of the advice. The rationale of the advice and its association with healing or recurrence remained often unclear. More patients performed exercises after the intervention and at follow-up. Patients often looked out onto a 'new' perspective where enhancement of quality of life and even healing might be attainable. Some patients regained independence after learning how to apply and remove compression garments themselves. The frequency of exercising and the duration of exercises increased significantly. Step counts had not altered significantly. Patients not elevating the legs at baseline elevated the legs more and for a longer period of time after the intervention. This effect on leg elevation decreased after three months. No significant changes were reported on hours wearing compression., Conclusions: The perceived changes suggest that the intervention holds a promise for current home care. Combining qualitative and quantitative research assisted to determine the possible effects of the intervention, increasing the potential for a meaningful randomised trial in the future., Relevance to Clinical Practice: Education about leg ulcer advice should be incorporated in nursing practice. Further testing of the intervention is recommended., (© 2011 Blackwell Publishing Ltd.)

Even though the central position of the client has been recognized in psychiatric nursing education, the client is seldom formally involved in the feedback provided to students during practical training. This research paper focuses on three questions: (1) What conditions support the gathering of meaningful client feedback to enhance the student's learning process and client's wellbeing? (2) Does the use of the practical model for client feedback lead to positive experiences, and if so, under what conditions? (3) To what extent is a client's feedback on the student's work performance, consistent with feedback from the mentor (nurse from the ward), the teacher and the student? Based on a literature review, participatory observation and contacts with experts, a practical model was developed to elicit client feedback. Using this model in two psychiatric inpatient services, clients were actively and formally involved in providing feedback to four, final year psychiatric nursing students. Clients, nurses, teachers and students were interviewed and data were analysed using a qualitative explorative research approach. Analyses revealed that client feedback becomes meaningful in a safe environment created by the psychiatric nurse. Client feedback generates a learning effect for the student and supports the student's recognition of the value and vulnerability of the psychiatric client., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherent behaviour are not fully understood. Literature about processes underlying adherence in leg ulcer patients is scarce., Objectives: To explore the processes underlying adherent behaviour in patients with leg ulcers who received an intervention to enhance adherence to leg ulcer lifestyle advice., Design: A qualitative field study was conducted among patients receiving an adherence-promoting intervention., Settings: The study was carried out in a home care setting in Belgium., Participants: Twenty-six patients with venous leg ulcers were included and received the intervention from five tissue viability nurses in a community healthcare organisation., Methods: Semi-structured interviews with open-ended questions were held with patients and nurses after the end of the intervention. Data were also collected by means of participant observation. Data collection and data analysis took place iteratively and analysis was validated by means of researcher triangulation., Results: Trust in the nurse was central to leg ulcer treatment adherence. Patients who had a trusting relationship with their nurse showed better adherence to the recommended lifestyle modifications. Trust was facilitated by nurses spending meaningful time with the patient, which means they took time to talk with the patient. Trust was also established because nurses provided care beyond patients' expectations, taking time for wound care and being attentive to pain and other problems. A trusting relationship promoted 'compliance' even if patients were not convinced of the benefits of the leg ulcer lifestyle advice. Perceived physical improvement and diminished discomfort after following the lifestyle advice convinced patients of the importance and positive effect of the regimen, which they doubted at first. Self-efficacy for performing leg exercises was often much higher than self-efficacy for being physically active and elevating the legs. Physical impediments, co-morbidities and socio-structural impediments influenced the patient's ability to adhere to leg ulcer advice., Conclusions: A conceptual framework to understand adherence to leg ulcer treatment was developed. Nurses should be aware of how nurse-related factors can affect adherence. Aspects that foster trust could be incorporated into leg ulcer care., (Copyright © 2010 Elsevier Ltd. All rights reserved.)