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Economic evaluations for medical nutrition, such as oral nutritional supplements (ONS), are relatively uncommon compared with other health technologies, and represent an area that has not been reviewed so far. In this systematic review, economic evaluations of enteral medical nutrition in the management of disease-related malnutrition (DRM) were reviewed and qualified to estimate the economic value. Initially, 481 studies were found, of which 37 full-text articles were assessed for eligibility and were rated on their quality using the Quality of Health Economic Studies (QHES) instrument. The final review focused on the high QHES quality economic evaluation studies. As both the studied medical nutrition intervention and the form of the economic evaluation varied, a quantitative synthesis (meta-analysis) was not attempted but a critical analysis and comparison of the individual study results were performed. ONS was the most studied intervention, covering several patient populations and different health care settings. Outcomes included cost savings (n = 3), no significant extra costs per unit of clinical and/or functional improvement (n = 1), or significantly higher costs per unit of clinical and/or functional improvement but still cost-effective for the used threshold (n = 4). This review shows that the use of enteral medical nutrition in the management of DRM can be efficient from a health economic perspective., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Sarcopenia is probably an important causal factor for functional decline in acutely ill hospitalized geriatric patients. Low skeletal muscle mass, low gait speed and low grip strength are hallmarks of diagnosing sarcopenia. However there are many different diagnostic criteria to assess sarcopenia., Objectives: In this study the influence of different criteria for sarcopenia was studied on sarcopenia prevalence in geriatric patients admitted to an acute care hospital., Design: Cross sectional study design., Setting: A geriatric ward of a large Dutch hospital., Participants: Geriatric patients., Measurements: Skeletal muscle mass measured using bio impedance analysis (BIA), gait speed using the 4 meter walking test and grip strength. The sarcopenia prevalence was investigated according to criteria of: muscle mass, grip strength, the European Working Group on Sarcopenia in Elderly People, the International Working Group on Sarcopenia and the Special Interest Group of Society of Sarcopenia, Cachexia and Wasting Disorders., Results: 85 geriatric patients were included (61 women). Applying the 17 different criteria, the sarcopenia prevalence varied from 26-75% for women and from 42-100% for men. Comparing the Janssen calculation with the Maltron calculation sarcopenia prevalence ranged from respectively 26-67% and 67-70% for women and from 42-71% and 75-100% for men. Almost all patients (96%) had a low gait speed., Conclusions: Sarcopenia is highly prevalent in an acute hospitalized geriatric population, although the prevalence varies widely depending on the diagnostic criteria applied. A prospective study is needed to discover which criteria of sarcopenia can predict best adverse outcomes.

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.

Objective: To assess pressure ulcer (PrU) treatment in Swiss hospitalized pediatric patients and to determine whether there are differences in PrU treatment, according to demographic characteristics of the patients., Design: A descriptive multicenter point prevalence study was conducted in June 2009 in all German-speaking pediatric hospitals in Switzerland., Setting: All hospitalized patients from birth up to 17 years or younger in 14 Swiss pediatric hospitals, including all pediatric departments, were assessed., Patients: A total of 412 patients participated in this study., Main Outcome Measures: The instrument and method of the Dutch National Prevalence Measurement of Care Problems were used., Main Results: Thirty-five percent of the patients had a PrU. Almost all of these PrUs (94.1%) were of category 1. The most severe PrUs occurred in patients older than 8 years. Age of the patient and department were the only characteristics that significantly influenced the occurrence of PrU categories 2 to 4. Pressure ulcer categories 2 to 4 were mostly covered with hydrocolloid or polyurethane foam dressings. No pediatric-specific guideline regarding PrU treatment is used in the involved hospitals., Conclusion: Most patients had category 1 PrUs, so appropriate prevention to decrease any further trauma in these patients was necessary. Severe PrUs (categories 2-4) are mostly limited to older pediatric (aged >8 years) patients with chronic conditions or after surgery intervention. A PrU treatment guideline adapted for pediatric needs is recommended.

The present exploratory descriptive cross-sectional study with the participation of 814 (51.8%) caregivers in 21 Swiss nursing homes provides insight into caregivers' experiences and handling of residents' aggressive behaviour. Moreover, caregiver burden with regard to resident aggression and the consequences on the caregiver-resident-relationship were investigated. The survey was carried out by means of validated questionnaire. Approximately 38% of participants experienced aggressive incidents during the last seven days prior to data collection. In most cases aggressive behaviour was caused by residents suffering from dementia and/or depression and occurred during nursing interventions involving physical contact. As a trigger for aggressive behaviour participants predominately assumed "non-understanding and excessive demand" of residents. Reassuring conversation and keeping oneself at a distance were most often used to calm the situation. Approximately 40% of participants experienced physical attacks as especially distressing and circa 23% were frightened, particularly when aggressive behaviour occurred without warning. Approximately 4% of caregivers avoided contact with residents after an aggressive incident and 12.3% perceived a disturbed relationship. It can be assumed that caregivers do not adequately perceive emotions possibly underlying aggressive behaviour in the escalation phase and therefore may not identify early signs of beginning aggression.

Aim: This report describes the results from the last international prevalence measurement of care problems in the Netherlands, Austria and Switzerland, including the course of the prevalence rates during the past 4 years., Background: Basic care problems such as pressure ulcers, malnutrition and falls occur frequently in healthcare organizations. Measuring these care problems provides insight into their occurrence, and, while a measurement is included of the prevention, treatment and structural quality indicators, this gives institutions the possibility of improving their care regarding these care problems., Design: An annual cross-sectional multicentre study., Method: The prevalence measurement of care problems is conducted annually on one specific day in different healthcare settings, among which are hospitals and care homes. Data are collected by means of a comprehensive, standardized questionnaire that comprises three levels: institutional, ward/department and patient level., Results: Besides general characteristics of patients, results are presented for prevalence rates, prevention, treatment and quality indicators regarding each care problem for each country., (© 2013 John Wiley & Sons Ltd.)

Aim: The aim of this article was to describe the design of an international audit of the prevalence of care problems in different healthcare sectors using identical methodologies., Background: Audits, defined as a monitor of quality of health care, are increasingly applied in many countries as a strategy to improve professional practice and quality and safety of care. A prerequisite to enable a reliable comparison of quality of care audits is the use of identical instruments and methodology., Design: Annual cross-sectional multi-centre point prevalence survey., Method: This international prevalence measurement of care problems in hospitals, care homes and home care is performed in the Netherlands, Austria, Switzerland and New Zealand. This study is based on a prevalence measurement of care problems originally performed in the Netherlands. For each care problem (pressure ulcer, incontinence, malnutrition, falls and restraints) at patient level, next to patient characteristics, data are gathered about the prevalence, prevention and treatment of each care problem. In addition, at ward/department and institution level, specific quality indicators are measured related to the care problems. After the measurement, institutions enter their data into a web-based data-entry program. Institutions receive an overview of their own results and results at national level to enable a process of benchmarking., Discussion: A uniform way of measuring the prevalence of care problems internationally is a significant step forward in gaining insight into the quality of basic care in different healthcare settings in different countries and may lead to more awareness and improvement programmes., (© 2013 John Wiley & Sons Ltd.)

Objectives: To investigate whether the incidence of pressure ulcers in nursing homes in the Netherlands and Germany differs and, if so, to identify resident-related risk factors, nursing-related interventions, and structural factors associated with pressure ulcer development in nursing home residents., Design: A prospective multicenter cohort study., Setting: Ten nursing homes in the Netherlands and 11 nursing homes in Germany (around Berlin and Brandenburg)., Participants: A total of 547 newly admitted nursing home residents, of which 240 were Dutch and 307 were German. Residents had an expected length of stay of 12 weeks or longer., Measurements: Data were collected for each resident over a 12-week period and included resident characteristics (eg, demographics, medical history, Braden scale scores, nutritional factors), pressure ulcer prevention and treatment characteristics, staffing ratios and other structural nursing home characteristics, and outcome (pressure ulcer development during the study). Data were obtained by trained research assistants., Results: A significantly higher pressure ulcer incidence rate was found for the Dutch nursing homes (33.3%) compared with the German nursing homes (14.3%). Six factors that explain the difference in pressure ulcer incidence rates were identified: dementia, analgesics use, the use of transfer aids, repositioning the residents, the availability of a tissue viability nurse on the ward, and regular internal quality controls in the nursing home., Conclusion: The pressure ulcer incidence was significantly higher in Dutch nursing homes than in German nursing homes. Factors related to residents, nursing care and structure explain this difference in incidence rates. Continuous attention to pressure ulcer care is important for all health care settings and countries, but Dutch nursing homes especially should pay more attention to repositioning residents, the necessity and correct use of transfer aids, the necessity of analgesics use, the tasks of the tissue viability nurse, and the performance of regular internal quality controls., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

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.

Objective: The main objective of this study was to develop a feedback system that improves the translation of malnutrition performance data from the Dutch National Prevalence Measurement of Care Problems (LPZ) into relevant evidence- and practice-based interventions in care homes., Methods: The process consisted of two stages. The first was the development of a feedback system. Twenty-four interviews were held with health care professionals in care homes that participated in the LPZ to gain insight into needs regarding the translation of performance data into relevant improvement interventions. Subsequently, three multidisciplinary focus groups discussed how to develop a feedback system to deal with those needs. In the second stage, the feasibility of this system was evaluated via a questionnaire (N = 93) that was sent to care homes participating in LPZ., Results: It was important that performance data be more transparent regarding which information was relevant and that insight was gained into how to improve nutritional care. To address these needs, a dashboard was developed to present performance data in a transparent way. Subsequently, a decision tree was developed that links LPZ dashboard outcomes to evidence-based nutritional interventions for care homes. Forty-seven respondents (50.5%) evaluated the new feedback system (the dashboard and the decision tree) as feasible. The content and design were perceived to be very useful. Half of the participating institutions had already started working with improvement activities., Conclusion: The developed feedback system was evaluated as useful for improving nutritional patient care in the future. This system will also be developed for other health care settings., (Copyright © 2013. Published by Elsevier Inc.)

In the second in the series, Professor Ruud Halfens and Dr Judith Meijers give an overview of statistics, both descriptive and inferential. They describe the first principles of statistics, including some relevant inferential tests.

Objective: To explore the quality of pressure ulcer (PU) care in stroke patients in an Indonesian stroke-specialised hospital. The prevalence, prevention, wound treatment and hospital facilities related to PU structural quality indicators at the ward and institutional levels were assessed., Method: A multi-level cross-sectional survey was performed over three days in an Indonesian stroke-specialised hospital. All stroke patients present on the day of the measurement were included. The European Pressure Ulcer Prevalence Study Minimum Data Set and the Dutch National Prevalence Measurement of Care Problems (Landelijke Prevalentiemeting Zorgproblemen, LPZ) questionnaire were used., Results: The prevalence rates of PUs, including and excluding Category I were high in this hospital (28% and 17%, respectively). More than half of the patients/families (56%) received education about PU prevention and 74% of the patients were repositioned, although irregularly, by nurses or families. No treatment was applied to Category I PUs. Category II PUs were treated by using NaCl 0.9% solution to cleanse the wound without dressings. Category III PUs were mainly treated by using anti-microbial gauze dressing. No patient suffered a Category IV PU. Only a few structural quality indicators of PU care at ward and hospital level were met., Conclusion: PUs were quite prevalent in these stroke patients. The quality of PU care in this hospital could be improved, especially in the areas of prevention, treatment and structural quality indicators.

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.

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

Background: This study critically appraises the measurement properties of tools to measure muscle mass, strength, and physical performance in community-dwelling older people. This can support the selection of a valid and reliable set of tools that is feasible for future screening and identification of sarcopenia., Methods: The databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane were systematically searched (January 11, 2012). Studies were included if they investigated the measurement properties or feasibility, or both, of tools to measure muscle mass, strength, and physical performance in community-dwelling older people aged ≥60 years. The consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist was used for quality appraisal of the studies., Results: Sixty-two publications were deemed eligible, including tools for muscle mass (n = 16), muscle strength (n = 15), and physical performance (n = 31). Magnetic resonance imaging, computed tomography, and a 4-compartment model were used as gold standards for muscle mass assessment. Other frequently used measures of muscle mass are dual-energy x-ray and the bioelectrical impedance (BIA); however, reliability data of the BIA are lacking. Handheld dynamometry and gait speed or a short physical performance battery provide a valid and reliable measurement of muscle strength and physical performance, respectively., Conclusions: It can be concluded that several tools are available for valid and reliable measurements of muscle mass, strength, and performance in clinical settings. For a home-setting BIA, handheld dynamometry and gait speed or a short physical performance battery are the most valid, reliable, and feasible. The combination of selected instruments and its use for the screening and identification of sarcopenia in community-dwelling older people need further evaluation., (Copyright © 2013. Published by Elsevier Inc.)

Purpose: This study aimed at gaining insight into supportive care needs and cancer treatment-related symptoms, and to determine factors associated with supportive care needs. Breast cancer and its treatment cause emotional trauma and health complaints. These lead to supportive care needs in some patients, while others are more able to cope with these consequences themselves. To be able to address these needs, it is important to identify patients' needs at the time they arise., Methods: Women (n = 175) with newly-diagnosed breast cancer, under treatment in two Swiss breast cancer clinics, participated in a cross-sectional survey. Standardized instruments were used: Supportive Care Needs Survey, Cancer- and Cancer Treatment-related Symptom Scale, Hospital Anxiety and Depression Scale, Distress Thermometer, and Interpersonal Relationship Inventory., Results: The patients' most needed help with psychological issues. Many had treatment-related symptoms like fatigue (87.7%), hot flashes (71.5%), and a changed body appearance (55.8%). The majority suffered from distress (56.2%), fewer from anxiety (24.1%) and depression (12.1%). Physical and social impairment, impaired body image, distress, anxiety and depression, a lack of social support and conflicts in their personal relationships were associated with supportive care needs., Conclusions: The findings can help to identify more vulnerable patients with unmet needs and a higher demand for support. Assessment of patients enables health care professionals to provide support and counselling. In these assessments, the patients' relationship to close relatives should also be addressed., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background & Aims: Disease related malnutrition (under-nutrition caused by illness) is a worldwide problem in all health care settings with potentially serious consequences on a physical as well as a psycho-social level. In the European Union countries about 20 million patients are affected by disease related malnutrition, costing EU governments up to € 120 billion annually. The aim of this study is to calculate the total additional costs of disease related malnutrition in The Netherlands., Methods: A cost-of-illness analysis was used to calculate the additional total costs of disease related malnutrition in adults (>18 years of age) for The Netherlands in 2011 in the hospital, nursing- and residential home and home care setting, expressed as an absolute monetary value as well as a percentage of the total Dutch national health expenditure and as a percentage of the total costs of the studied health care sectors in The Netherlands., Results: The total additional costs of managing adult patients with disease related malnutrition were estimated to be € 1.9 billion in 2011 which equals 2.1% of the total Dutch national health expenditure and 4.9% of the total costs of the health care sectors analyzed in this study., Conclusions: The results of this study show that the additional costs of disease related malnutrition in adults in The Netherlands are considerable., (Copyright © 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Unlabelled: AIM.: This study focuses on the experience of healthcare staff with regard to patient and visitor violence in a general hospital. The occurrence of patient and visitor violence, staffs' interventions and the consequences of violence for different professions are investigated., Background: There is a lack of studies describing the factors influencing the occurrence of patient and visitor violence, intervention strategies and consequences. Existing studies often focus on nurses' experiences and single interactive factors between staff and patients/visitors involved., Design: A cross-sectional survey., Method: The survey was conducted in 2007 including 2495 staff working on different wards in a Swiss university general hospital. The questionnaire used was the Survey of Violence Experienced by Staff German Version-Revised., Findings: Half of the staff experienced patient and visitor violence in the past 12 months and 11% in the past week. The age of the staff and the length of experience in their present workplace influenced the exposure to patient and visitor violence. Violence occurred mainly when staff carried out tasks involving close personal contact. Only 16% of the staff was trained in aggression management. The feeling of confidence in managing patient and visitor violence depended significantly on the organizational attitude towards violence. The principal interventions used were calming and informative discussion., Conclusion: To prevent patient and visitor violence and improve management strategies, training which focuses on communication skills, which is specific to the professional context and which emphasizes patient centeredness, need to be designed and implemented. A strong organizational commitment is imperative to reduce violence., (© 2012 Blackwell Publishing Ltd.)

Purpose: Caregivers in nursing homes often experience aggressive behavior of residents. The aim of this study was to explore the caregivers' experiences with aggressive behavior from residents and to identify environmental factors as well as caregiver and resident characteristics related to aggressive behavior in Swiss nursing homes., Design: A retrospective cross-sectional survey was conducted between November 2010 and April 2011 with a sample of caregivers working in various nursing homes in the German-speaking part of Switzerland. In total, 814 caregivers (response rate 51.8%) of 21 nursing homes participated in the study., Methods: Data were collected using the German version of the Survey of Violence Experienced by Staff (SOVES-G-R). Standard descriptive statistics were used to describe and summarize the date. To identify risk factors related to the experience of aggression by residents, multilevel logistic regression analysis was applied., Findings: The prevalence of participants reporting an aggressive incident during the 12-month period prior to data collection was 81.6%. Of these, 76.5% had experienced verbal aggression, 27.6% threats, and 54.0% physical aggression. The predictive variables in the multiple regression model for physical aggression were: staff education level (odds ratio [OR]= 1.82), gender (OR = 1.82), age (< 30 years vs. 30-45 years: OR = 1.46; < 30 years vs. > 45 years: OR = 2.13), and confidence in managing physical aggression (OR = 1.49). The predictive variables for threatening behavior were staff education level (registered nurses vs. non-registered nurses: OR = 1.70; nonstudent vs. student: OR = 1.89) and age (< 30 years vs. 30-45 years: OR = 2.00; < 30 years vs. > 45 years: OR = 2.04)., Conclusions: Caregivers in nursing homes are at high risk for experiencing aggressive behavior. The identified risk factors are in line with earlier investigations, but some contradictory results also were observed., Clinical Relevance: The high risk for registered nurses exposed to aggressive behavior and the increased risk for caregivers who feel confident in managing aggressive behavior cast a critical light on the content and aim on present programs for management of aggressive behavior. Caregivers in nursing homes should be qualified in understanding resident aggression in a comprehensive way. A critical point in this topic seems to be the interaction between caregiver and resident during basic care activities. This topic should be investigated in further research projects., (© 2012 Sigma Theta Tau International.)

Objective: The aim of this study was to describe and compare structural and process indicators of nutritional care in Austrian hospitals and nursing homes., Methods: A multicenter, cross-sectional study was performed using a standardized and tested questionnaire. Data were collected on patient and institutional levels of hospitals and nursing homes., Results: Data from 18 Austrian hospitals (n = 2326 patients) and 18 Austrian nursing homes (n = 1487 residents) were collected. The prevalence of malnutrition was 23.2% in hospitals and 26.2% in nursing homes. All hospitals and 83.3% of the nursing homes employed dietitians. Guidelines for the prevention and treatment of malnutrition were used infrequently. Nutritional screening at admission was performed in 62.6% of the hospitalized patients and 93.4% of the nursing home residents. Nutritional screening tools were used in 28.9% of the nursing home residents and 14.5% of the hospitalized patients. Oral nutritional support was preferred to enteral and parenteral nutrition in the two settings. Dietitians were consulted in 27.5% of the malnourished hospitalized patients and 74.7% of the malnourished nursing home residents., Conclusion: The study demonstrated that nursing homes fulfilled more structural indicators and performed nutritional screening at admission more often than hospitals. Nevertheless, the prevalence of malnutrition was high in the two settings and a substantial number of malnourished patients/residents received no nutritional intervention at all. These results show the necessity for improvements in the nutritional care in Austria, for instance, through the routine use of nutritional screening tools followed by tailored nutritional interventions in patients/residents in need., (Copyright © 2012 Elsevier Inc. All rights reserved.)

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.

Pressure ulcers (PUs) are a common concern for hospitalized children and adults, but knowledge about PU risk factors,prevalence, and incidence rates among children remains limited. To assess the prevalence of and risk factors for PUs in pediatric care settings, a 1-day cross-sectional study was conducted among all hospitalized children ages 0 to 18 years in all 14 pediatric hospitals in the German-speaking part of Switzerland. Data collection involved a direct systematic inspection and assessment of the skin. A standardized data collection instrument was used, and each patient was assessed by a previously instructed rater pair. The total number of participating children was 412 (75% of all hospitalized children). An overall PU prevalence of 35% (including European Pressure Ulcer Advisory Panel category 1 ulcers) was observed. Most patients with PUs (80%) had category 1 ulcers. The prevalence rate was highest among patients in the pediatric intensive care unit (PICU) (16/36, 44%), followed by the department of neonatology (47/109, 43%). The presence of a PU was significantly higher among patients with a medical device, who were young (<1 year old), had a longer length of stay, and low Braden scale score (P <0.05). Rates also varied by institution (P <0.05). Department, patient age,Braden scale score, and institution explained 25% of the variance in PU prevalence. The prevalence of PUs in pediatric patients is higher than expected, and the rate of category 1 PUs suggests that interventions to prevent PUs are needed,especially in the high-risk patients identified. Future studies are needed to further assess these risk factors, especially for patients in PICUs.

Backgrounds & Aims: Malnutrition in western health care involves a tremendous burden of illness. In this study the economic implications of malnutrition in Dutch nursing homes are investigated as part of the Health and Economic Impact of Malnutrition in Europe Study from the European Nutrition for Health Alliance., Methods: A questionnaire was developed, focussing on the additional time and resources spent to execute all relevant nutritional activities in nursing home patients with at risk of malnutrition or malnourished. Results were extrapolated on national level, based on the prevalence rates gathered within the national Prevalence Measurement of Care Problems 2009., Results: The normal nutritional costs are 319 million Euro per year. The total additional costs of managing the problem of malnutrition in Dutch nursing homes involve 279 million Euro per year and are related to extra efforts in nutritional screening, monitoring and treatment. The extra costs for managing nursing home residents at risk of malnutrition are 8000 euro per patient and 10000 euro for malnourished patients., Conclusions: The extra costs related to malnutrition are a considerable burden for the nursing home sector and urge for preventive measures., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Aims and Objectives: This study explored caregivers' perspectives regarding the conditions and situations of resident aggression and practical strategies caregivers use to deal with aggression., Background: Working in a nursing home is associated with a high risk to experience aggression from residents or patients. Despite existing recommendations for dealing with aggression there is a lack of information about caregivers' ways of dealing with it in practice., Design: A qualitative study with focus group method was conducted., Method: Five focus group interviews, with a total of 30 participants, from nursing homes in Switzerland were undertaken employing a semi-structured interview guideline. For analysing the data, qualitative content analysis was employed., Results: Analysis of the data produced three themes with additional sub-themes. One main theme concerns the explanations of the caregivers in regard to the occurrence of aggressive behaviour. This theme is subdivided into two areas, the contributory resident related factors and the caregiver related factors. The measures for handling aggressive behaviour are illustrated in the second theme 'dealing with residents'. The third theme refers to the strategies of the caregivers when confronted with aggressive behaviour -'self-protection' and 'coping with the situation'., Conclusion: Caregivers use a broad spectrum of interventions for reducing aggression, some of which are recommended by guidelines but often ignore the link between aggressive behaviour and physiological issues like pain or elimination. The caregivers only very rarely linked their practical knowledge about aggressive behaviour with theoretical knowledge., Relevance to Clinical Practice: The results give insight into the caregivers' perspectives on factors leading to aggression and their coping strategies. Caregivers are informed about relevant reasons for aggressive behaviour and its management, but do not apply a systematic approach. Furthermore, the anxiety of caregivers involved in aggression incidents is an under examined area., (© 2011 Blackwell Publishing Ltd.)

Aims: To investigate the feasibility of a survey measuring patient and visitor violence after translation and modification, namely the Survey of Violence Experienced by Staff (German version revised) and to validate the shortened Perception of Aggression Scale (POAS-S) and the Perception of Importance of Intervention Skills Scale (POIS) after adaptation for use in a general hospital setting., Background: The use of different approaches and research instruments for investigating patient and visitor violence negatively influences the comparability of studies. Typically, general hospitals use self-administered surveys. However, support for these instruments' validity is insufficient., Methods: Between November 2006-January 2007, 291 nurses working in general hospitals in the German-speaking region of Switzerland completed the SOVES-G-R, the POAS-S and the POIS (response rate=71%). Results. The participants' responses demonstrated a need for modifications to enhance the feasibility of the SOVES-G-R in two categories, namely experiences with patient and visitor violence in 'the past 12 months' and in 'the past working week'. The POAS-S revealed the same factor solution as in earlier studies, with two factors explaining 38·0% of variance. In the POIS, two factors were distinguished: (1) structured interventions and evaluation and (2) the importance of preventive measures., Conclusions: The SOVES-G-R, the POAS-S and the POIS are adequate for investigating factors influencing the occurrence of patient and visitor violence in general hospitals. Given the changes in the SOVES-G-R and the moderate size of our sample, further testing with a larger sample is recommended., Relevance to Clinical Practice: The instruments help determine which clinical settings have a greater risk of patient and visitor violence and the specific factors that influence this risk. This can facilitate the implementation of situation-specific preventive measures against patient and visitor violence in general hospitals., (© 2011 Blackwell Publishing Ltd.)

Aims and Objectives: This study investigates possible differences in malnutrition prevalence rates in Dutch and German nursing homes. It seeks to provide insight into the screening, prevention and treatment of malnutrition and the indicators for nutritional care policy., Background: For decades, malnutrition has been an important problem in health care settings worldwide. A considerable percentage of frail older people suffer from malnutrition. In European nursing homes, the reported prevalence rates range widely (2% to 85%)., Method: This is a multicentre, cross-sectional prevalence study of malnutrition in Dutch and German nursing homes using standardised methodology, with the participation of respectively 5848 and 4923 residents (65+ years)., Results: Patient characteristics differed significantly between the two countries. Dutch residents were more often male, younger, more care-dependent and significantly more at risk of malnutrition (31·7%). However, overall malnutrition prevalence rates did not differ significantly (Netherlands 26·8% and Germany 26·5%). All German residents were screened at admission, whereas only 73·1% of the Dutch residents were. As part of screening, nutritional screening tools were used in 38·0% of Dutch and 42·1% of the German residents. A dietician was consulted for 36·7% Dutch and 9·3% German malnourished residents. The proportion of malnourished receiving nutritional intervention was larger in Germany than in the Netherlands. Structural indicators for nutritional policy were fulfilled more often in the Netherlands care at institutional level whereas in Germany they were fulfilled more often at ward level., Conclusion: In this study, German residents had a somewhat better nutritional status than Dutch residents and more is done to enhance nutritional status in German nursing homes. The differences would be somewhat larger if both populations were more comparable., Relevance to Clinical Practice: Comparing malnutrition prevalence rates, prevention and interventions in health care institutions and countries gives insight into international differences in quality of care., (© 2011 Blackwell Publishing Ltd.)

Rationale, Aims and Objectives: Annual national prevalence surveys have been conducted in the Netherlands over the past 10 years and have revealed high prevalence rates in Dutch nursing homes. Pressure ulcer guideline implementation is one of the factors that can influence prevalence rates. Previous research has shown that these guidelines are often only partly implemented in Dutch nursing homes. Reasons for this lack of pressure ulcer guideline implementation are not known. Therefore, the aim of this study is to investigate the current situation regarding pressure ulcer guideline dissemination and implementation in Dutch nursing homes., Methods: Semi-structured interviews were conducted in eight nursing homes in the Netherlands from January till December 2008. In each nursing home, interviews were held with eight persons., Results: The implementation of pressure ulcer guidelines was lacking in some of the nursing homes. Risk assessment scales were often not used in practice, repositioning schemes were not always available and, when they were, they were often not used in practice. Knowledge about guideline recommendations was also lacking and pressure ulcer education was inadequate. Barriers to applying guideline recommendations in practice were mostly related to personnel and communication., Conclusions: The implementation of pressure ulcer guidelines does not seem to be successful in all nursing homes and needs more attention. Barriers mentioned by the interviewees in applying guideline recommendations need to be addressed. Providing adequate education for nursing home staff and increasing attention for pressure ulcer care can be the first steps in improving the implementation of pressure ulcer guidelines., (© 2010 Blackwell Publishing Ltd.)

Purpose: The study assessed and compared the psychosocial needs of patients with breast cancer and of their relatives, the patients' and relatives' burden of illness, anxiety, depression and distress and assessed the patients' cancer treatment-related symptoms and identified relevant factors influencing patients' and relatives' needs., Method: Seventy-two patients (n=72) participated with a relative in a cross-sectional mail-survey, 1-22 months after cancer treatment., Results: The patients reported needing help with psychological and sexual issues. They suffered from treatment-related symptoms. More treatment-related symptoms and depression were related to the patients' needs for supportive care. Their relatives' needs primarily concerned access to information and communication with health care professionals. Relatives had higher levels of anxiety (25.0% vs. 22.2%), depression (12.5% vs. 8.3%) and distress (40% vs. 34%) than patients. Higher levels of depression, younger age and having a disease themselves were associated with relatives' need for help., Conclusion: Patients' and relatives' substantial needs and psychological problems require professional support even after completion of the patients' treatment. Continued assessment of the patients' and their relatives' needs and of the patients' symptoms provide the basis for purposeful counselling and education. Rehabilitation programs for patients and their relatives should be developed and implemented in clinical practice., (Copyright © 2009 Elsevier Ltd. All rights reserved.)

Aims: To identify and describe nurses' wishes, needs, knowledge and attitudes to nursing research, as well as perceived barriers to and facilitators of research utilisation in nursing practice in Austria., Background: Research results are not always used in daily nursing practice, despite their potential to improve nursing care quality. A variety of factors impede their implementation and use. Nurses' wishes about research utilisation have scarcely been reported. No data are available yet from an Austrian perspective., Design: Descriptive and exploratory cross-sectional survey., Methods: The study was conducted in an Austrian university hospital in May 2007, including all graduate nurses (n=1825). One thousand and twenty-three nurses returned the self-reported questionnaire. Descriptive analysis was performed initially, then group comparisons (diploma <2001, ≥2001) were computed inferentially using the chi-square test., Results: Nurses' most frequently indicated wishes regarding research implementation were adequate information, structural availability and professional support. Special points of interest were topics concerning nursing phenomena and interventions. Nurses' needs related to education in nursing science/research and its implementations were indicated as being predominantly of an introductory manner. Overall, nurses' attitudes tended to the negative. The top three named barriers to research utilisation were lack of time (69·9%), lack of information/knowledge (45·4%) and lack of interest (25·9%). Ten statistically significant differences were found between nurses of the two compared diploma groups., Conclusions: Participating nurses perceived a lack in sufficient education/information and adequate organisational support, impeding them to use research results in daily practice., Relevance to Clinical Practice: The results provide important insights into the matter of nurses' needs regarding the use and/or implementation of research results in practice, as well as about the promotion of positive attitudes towards research and its utilisation. These findings are of special interest to nurse educators, employers and countries introducing nursing science to improve the clinical outcomes for patients., (© 2011 Blackwell Publishing Ltd.)

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.

Aims: (1) To gain insight into the psychosocial needs and distress of close relatives of women under treatment for breast cancer and identify how they perceive the interpersonal relationship with the patient and (2) to determine factors associated with the relatives' psychosocial needs., Background: Breast cancer affects patients but also close relatives. Relatives need support themselves but there is still a lack of knowledge about their specific needs., Design: Relatives of women newly diagnosed with breast cancer participated in a cross-sectional survey., Method: Relatives were approached by patients, who were contacted by nurses in two Swiss breast cancer clinics. The patients received the questionnaire for their closest relative, who decided independently of the patient about participation. Standardised questionnaires were completed by 107 relatives., Results: The relatives needed help with access to information and health care professionals. They needed information about the patients' treatment (50·9%), honest information (41·6%) and had difficulties with confidence in health care professionals (39·2%). The majority (61·0%) suffered from distress, less (26·1%) from anxiety and depression (10·9%). Distress, anxiety and conflict in their interpersonal relationship were associated with the relatives' unmet psychosocial needs., Conclusions: The findings increase the knowledge of the psychosocial needs of relatives of patients with breast cancer and provide the basis for purposeful support. Distress, anxiety and conflicts in the relationship are important factors that may identify more vulnerable relatives with unmet needs or a higher demand for support., Relevance to Clinical Practice: Assessment of the relatives' specific needs, distress and anxiety is important, and the relatives' perception of their relationship should be addressed. Health care professionals are key persons in contact with relatives and should motivate the patients to involve their relatives in the illness and treatment process. Support programmes for relatives of patients with breast cancer should be developed in Swiss cancer clinics., (© 2010 Blackwell Publishing Ltd.)

Background: Increasingly, policy reform in health care is discussed in terms of changing organizational culture, creating practice teams, and organizational quality management. Yet, the evidence for these suggested determinants of high-quality care is inconsistent., Aims: To determine if the type of organizational culture (Competing Values Framework), team climate (Team Climate Inventory), and preventive pressure ulcer quality management at ward level were related to the prevalence of pressure ulcers. Also, we wanted to determine if the type of organizational culture, team climate, or the institutional quality management related to preventive quality management at the ward level., Methods: In this cross-sectional observational study multivariate (logistic) regression analyses were performed, adjusting for potential confounders and institution-level clustering. Data from 1274 patients and 460 health care professionals in 37 general hospital wards and 67 nursing home wards in the Netherlands were analyzed. The main outcome measures were nosocomial pressure ulcers in patients at risk for pressure ulcers (Braden score ≤ 18) and preventive quality management at ward level., Results: No associations were found between organizational culture, team climate, or preventive quality management at the ward level and the prevalence of nosocomial pressure ulcers. Institutional quality management was positively correlated with preventive quality management at ward level (adj. β 0.32; p < 0.001)., Conclusions and Implications: Although the prevalence of nosocomial pressure ulcers varied considerably across wards, it did not relate to organizational culture, team climate, or preventive quality management at the ward level. These results would therefore not subscribe the widely suggested importance of these factors in improving health care. However, different designs and research methods (that go beyond the cross-sectional design) may be more informative in studying relations between such complex factors and outcomes in a more meaningful way., (Copyright ©2010 Sigma Theta Tau International.)

Aims and Objectives: The objective of this study was to compare fall rates in older hospital inpatients with and without cognitive impairment. Relationships between age, gender, mobility, cognitive impairment, care dependency, urinary incontinence and medical disciplines were investigated., Background: Falls are common in older people with cognitive impairment, but studies in the hospital setting are rare., Design: A secondary analysis of three nationwide prevalence studies in German hospitals from the years 2005, 2006 and 2007 was conducted., Method: Trained staff nurses used a standardised instrument to collect data about accidental falls within the last two weeks in their institutions and about other patient characteristics. Data from 9246 patients aged 65 years or older from 37 hospitals were analysed., Results: The fall rate for cognitively impaired patients was 12·9%, while only 4·2% of older persons without cognitive impairment experienced a fall. Comparison between medical disciplines showed great differences concerning fall risk for confused and non-confused inpatients. In multivariate logistic regression analysis, the odds-ratio association of cognitive impairment and falls was 2·1 (CI 1·7-2·7). Higher age (OR 1·5, CI 1·2-1·9), greater care dependency (OR 1·6, CI 1·1-2·1), reduced mobility (OR 2·6, CI 1·9-3·7) and being a patient on a geriatric ward (OR 1·8, CI 1·1-2·9) were also statistically significant predictors in this model., Conclusions: Cognitively impaired older people constitute a high-risk group for accidental falls in hospitals., Relevance to Clinical Practice: Fall prevention strategies in the hospital setting should address cognitively impaired inpatients as an important high-risk group., (© 2010 Blackwell Publishing Ltd.)

Objectives: Pressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes., Methods: A cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake., Results: Two thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%-10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes., Conclusion: There is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU., ((c) 2010 Elsevier Inc. All rights reserved.)

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.

Objective: Although screening for malnutrition in health care has expanded enormously, a gold standard for the optimal definition and operationalism of malnutrition is still lacking. This report reflects expert opinions on the elements of the definition and operationalism of malnutrition and is meant to trigger further debate within the nutritional societies., Methods: A Delphi study was performed consisting of three phases. After a literature review (phase 1), questions for a semistructured interviews (phase 2) were formulated. Subsequently, the results of these semistructured interviews were used to develop the final list of elements (for defining and operationalism of malnutrition). In phase 3 (final phase), experts were asked to provide written feedback regarding the ranking of elements concerning the importance of these elements., Results: Twenty-two experts (response 73.3%) were included in the final phase of this Delphi study. No overall agreement could be reached. The elements deficiencies of energy or protein and decrease in fat-free mass were most often mentioned to be particularly important in defining malnutrition. Elements mentioned to be important in operationalism of malnutrition were involuntary weight loss, body mass index, and no nutritional intake. Opinions on cutoff points regarding these elements differed strongly among experts., Conclusion: This study shows that there is no full agreement among experts on the elements defining and operationalism of malnutrition. The results of this study may fuel the discussion within the nutritional societies, which will most ideally lead to an international consensus on a definition and operationalism of malnutrition., (Copyright 2010 Elsevier Inc. All rights reserved.)

Aim: The study aimed to give a description analysis of pressure ulcer-related structures, processes and outcomes in nursing homes and acute-care hospitals that participated once, twice and thrice in prevalence surveys., Design: Repeated nationwide, multicentre, cross sectional surveys have been conducted., Methods: A total of 7377 residents in 60 nursing homes and 28,102 patients in 82 acute-care hospitals in Germany participated in annual point prevalence surveys. Because of their strong differences in sampling and in order to be able to display the differences occurring during the repeated (first, second and third) participation of the institutions, they were arranged according to their frequency and order of participation. The percentage of used guidelines and risk assessment scales (structures), prevention devices and measures (processes), and prevalence and nosocomial prevalence (outcomes) among all persons at risk was calculated., Results: The samples within the arranged groups showed no clinically relevant demographical differences. Nosocomial prevalence rates in hospitals dropped from 26.3% in the first year to 11.3% in the last year (nursing homes from 13.7% to 6.4%). The use of pressure ulcer-related structures remarkably increased during each repetition to more than 90%. Regarding the use of preventive measures and devices as an indicator for pressure ulcer-related processes results were more incoherent., Conclusion: Repeated participation in pressure ulcer surveys led to a decrease in outcomes (lower pressure ulcer prevalence rates), to high opposite effects regarding pressure ulcer-related structures (increased use of all guidelines/risk assessment scales) and to moderate adverse effects regarding pressure ulcer-related processes (increased use of most preventive measures and devices).

Clinical guidelines and best practice standards are designed to improve the quality of patient care, yet their sole existence is no guarantee that they will be transferred into practice. The aim of this study was to examine which parts of the implementation process have an effect on pressure ulcer prevalence. The setting took place in ten German nursing homes that had taken part in the annual German pressure ulcer surveys in 2005, 2006 and 2007, where staff members who are involved in implementing best practice standards for pressure ulcer prevention into practice were interviewed. The implementation process of each home was assessed with a scale and the nursing homes were then sorted by their scale scores as well as by the order of their prevalence rates. These results were compared. Nursing homes whose implementation had higher scores had low pressure ulcer prevalence rates. Homes with lower scores had higher prevalence rates. A stringent implementation plan based on a systematic and continuing analysis as well as on evidence-based interventions has the potential to lower pressure ulcer prevalence rates. We therefore recommend the use of change management strategies that improve staff communication and increase their incentive, include continuing staff education and the use of efficient evaluation instruments. These measures lead to more efficient nursing practice and improve the quality of care.

Background: Urinary incontinence (UI) is a prevalent problem in aging adults and is associated with significant psychosocial, physical, and economic consequences. In order to improve continence care, it is important to understand nurses' knowledge, beliefs, and attitudes about UI. This study examined the relationship between knowledge, beliefs, attitudes, and continence-related practice., Methods: A cross-sectional design was used to gather self-reported data from 315 nurses and nursing assistants., Instrument: Participants completed a questionnaire consisting of 3 parts: (1) the Knowledge and Practice Instrument, (2) the German version of Henderson's Attitude and Belief Scale, and (3) demographic data., Results: Results demonstrate that knowledge and attitude are related to practice. In contrast, beliefs showed no relation to either practice, or to knowledge, or to attitudes. The practice subscales, which can best be influenced by knowledge and behavioral attitude, are "assessment and information" and "drinking habit and excretion.", Conclusions: It is worth making an effort to increase nurses' knowledge about UI assessment via continuing education. In addition, nurses' and nursing assistants' attitudes can be positively influenced by cooperation with advanced practice geriatric nurses.

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.

Quality-of-life (QoL) assessment is crucial for the evaluation of a palliative care outcome. This article investigates the applicability of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) on a German sample of terminally ill cancer patients receiving palliative care in different settings. Patients were randomly selected in 10 palliative homecare services and one palliative care unit in a general hospital and 'evaluated' among the consecutively 'registered' patients. The random sample of patients (n-121) was representative of the general patient population cared for by the palliative care services in Germany. The EORTC QLQ-C30 was administered to the terminally ill cancer patients on their first day in hospital or upon their first contact with the specialized palliative homecare team. The clinical variable assessed was the Karnofsky performance status. The questionnaire was well accepted in the present patient population. In addition, the questionnaire was found to be useful in detecting the effectiveness of palliative treatment over a period of time. This study shows that QoL measures can be used to assess the outcome in palliative care.

Introduction: Urinary incontinence (UI) is a major health problem mostly affecting older people. With the shift toward healthcare delivery in the home setting, it is necessary for home healthcare workers to know how to manage UI in the elderly. Little is known about the care for patients receiving home care suffering from UI. The aim of this study was to assess the prevalence of UI in older adults receiving home care and to gain insight into caring for patients with UI., Method: A cross-sectional survey using data from the Dutch National Prevalence Measurement of Health Care Problems was conducted., Results: Of the 2866 patients, 46% were suffering from UI. In 49% of these patients the type of UI was diagnosed. Patients with a diagnosis suffered more from their UI and were offered more strategies when compared with patients without a diagnosis. Most patients used pads. Relatively few patients were offered bladder training or pelvic floor muscle exercises (PFME)., Discussion: Urinary incontinence is a highly prevalent condition in older patients receiving home care. In half of the patients with UI no diagnosis regarding the type of incontinence was made. However, to treat or manage UI it is essential to assess the type of UI, as UI is treatable even in older people. As this study had a cross-sectional design, only strategies being offered at a fixed point in time are documented., Conclusion: Despite studies reporting the success of behavioural interventions for adults suffering from UI, most patients use pads. With the aging of the population and the increasing number of older adults suffering from UI, home care agencies need to acquire the knowledge and skills to address UI.

Aggression challenges and burdens caregivers face when working in nursing homes. The research questions in this review were (1) what types of residents' aggressive behavior do caregivers experience in nursing homes and how often? (2) In what situations does aggressive behavior occur? (3) What strategies do caregivers employ to manage aggressive behavior? Twenty one publications in English and/or German from 1996 to 2006 were identified by search strategies conducted in Medline, CINAHL, PsycINFO, and supplemented by screening citations, references, and unpublished manuscripts. Results show that all types of aggressive behavior occur in nursing homes with verbal and physical aggressive behavior combined. Personal care of the residents was the most frequent context in which aggressive behavior occurs. Strategies for preventing and dealing with aggressive behavior used by caregivers ranged from behavioral strategies aiming to prevent aggression, to medical treatment, or following written institutional guidelines for reducing aggressive behavior. Some care providers demonstrated predominantly positive and others predominantly negative strategies. Furthermore, there was a lack of information about "triggering" factors and interactive events during personal care in the referenced publications.

Aim: This paper is a report of a review conducted to identify and summarize specific risk factors for falls in older people with dementia or cognitive impairments as documented by prospective or case-control studies., Background: People with dementia have a doubled to threefold risk for falls, but the reasons for this have not yet been fully explained. Several integrative literature reviews discuss possible specific fall risk factors. However, there is lack of a systematic evaluation of studies., Data Sources: The CINAHL, PubMed, EMBASE and PsychInfo databases were searched for the period between 1980 and May 2007., Review Methods: A systematic review was conducted. Cohort or case-control studies published in English or German were included if they investigated risk factors for falls or fall-related injuries in a sample consisting of participants with dementia or cognitive impairment. Two reviewers independently assessed study quality., Results: Six prospective studies were included in the review. These differed concerning samples, settings, follow-up periods and examined variables. Therefore, meta-analysis was not possible. Eight categories of risk factors emerged: disease-specific motor impairments, impaired vision, type and severity of dementia, behavioural disturbances, functional impairments, fall history, neuroleptics and low bone mineral density., Conclusion: There is lack of sound studies examining fall risk factors in cognitively impaired elders. Well-known risk factors such as motor impairment show particular characteristics in people with dementia. In addition, behavioural disturbances contribute to their high risk for falls. Further prospective studies are needed.

Objective: In most health care organizations there is still insufficient awareness for recognizing and treating malnourished patients. To gain more insight into nutritional care policies in Dutch health care organizations, this study investigated screening, treatment, and other quality indicators of nutritional care., Methods: In 2007 a cross-sectional multicenter study was performed that included 20 255 patients (hospitals, n = 6021; nursing homes, n = 11 902; home care, n = 2332). A standardized questionnaire was used to study nutritional screening and treatment at the patient level and quality indicators at institutional and ward levels (e.g., malnutrition guidelines/protocols, nutritional education, and weighing policy)., Results: Nutritional screening was performed more often in nursing homes (60.2%) than in hospitals (40.3%) and home care (13.9%, P < 0.001). In general, one in every five patients was malnourished, and nutritional treatment was applied in fewer than 50% of all malnourished patients in nursing homes, hospitals, and home care. At ward level nursing homes focused more on the quality of nutritional care than did hospitals and home care, especially with respect to controlling the use of nutritional guidelines (54.6%, P < 0.03), weighing at admission (82.9%, P < 0.01), and mealtime ambiance (91.8%, P < 0.01)., Conclusion: This large-scale study shows that malnutrition is still a considerable problem in one of every five patients in all participating health care settings. It furthermore demonstrates that recognizing and treating malnutrition continues to be problematic. To target the problem of malnutrition adequately, more awareness is needed of the importance of nutritional screening, appropriate treatment, and other nutritional quality indicators.

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

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

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.

Background: The education of nurses has influenced the way of nursing practice for a long time. Nurse educators are required to offer up-to-date educational material, and textbooks are the most frequently used sources of knowledge during a nurse's education., Aim: In this study, researchers investigated the extent to which textbooks were evidence based regarding preventing pressure ulcers and knowing what recommendations to make for nursing students and publishers of nursing textbooks., Method: Educators at nursing schools in Germany were contacted by telephone to identify the most often used nursing textbooks. The recommendations of the German Expert Standard of Pressure Ulcer Prevention were compared with the content of the textbooks in a content analysis. Additionally, teachers were asked what additional material they were using to help prepare lectures., Results: Only one of the four analysed textbooks complied with the recommendations of the German Expert Standard. Contents of the other books were incomplete. The authors of some books did not mention any up-to-date scientific evidence. The teachers often used additional material such as the German Expert Standard and research articles to prepare their lectures., Discussion: German nursing textbooks were classified into research-based and authoritative texts. Because of the fast development and availability of research findings, one recommendation is that new forms of "textbooks" such as CD ROMs should be considered.

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