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This paper investigated facilitators and barriers to implementing the European Football Fans in Training program (EuroFIT) in professional sports clubs in England, the Netherlands, Norway, and Portugal. We analyzed qualitative data collected at clubs that delivered EuroFIT, based on semi-structured interviews with coordinating staff (n = 15), coaches (n = 16), and focus group interviews with participants (n = 108), as well as data from clubs that considered delivering EuroFIT in the future, based on interviews with staff (n = 7) and stakeholders (n = 8). Facilitators for implementation related to the content and structure of the program, its evidence-base, and the context for delivery in the football stadia. Financial and human resources were both facilitators and barriers. Further barriers were mostly practical, relating to human resources and infrastructure. Major differences between countries related to experience and commitment to running community projects, and differences in infrastructure, financing, and human resources. Professional football clubs’ ability to support health promotion efforts depended on their ethos and the financial and human resources available to them. Overall, the EuroFIT program was well received by clubs, coaches, participants, and stakeholders, which was reflected by the many facilitators supporting sustained implementation. For sustainable implementation, it is crucial that clubs and their stakeholders engage fully with the EuroFIT program and understand that for an adequate program delivery their views (ethos) and ways of working influence the implementation and thereby the effectiveness of EuroFIT. An important prerequisite for future roll out of EuroFIT would be a strong EuroFIT delivery partner organization to ensure financial and human resources while overseeing and guiding the quality of delivery in clubs. Factors influencing the implementation of the EuroFIT lifestyle change program in professional football clubs in Europe: a qualitative study in four European countries

ObjectivesTo assess the effects of a quality improvement (QI) team training intervention, by measuring the intervention fidelity and the compliance with a surgical site infection (SSI) bundle in the operating theatre (OT).DesignMulticentre before–after study.SettingThis study was performed in four Dutch hospitals.InterventionThe QI team training intervention consisted of four sessions per hospital and stimulated participants to set culture norms and targets, identify barriers, and formulate management activities to improve compliance with four standard operating procedures (SOPs) of a SSI bundle in the OT. Participants were executive board members, top-level managers, leading clinicians and support staff. The four SOPs were: (1) reducing door movements; (2) preoperative antibiotic prophylaxis prescribing; (3) preoperative shaving; and (4) postoperative normothermia.Poissonand logistic regression analyses were performed to analyse the effect of the intervention on compliance with the individual SOPs (primary outcome measure) and on the influence of medical specialty, time of day the procedure took place and time in the OT (secondary outcome measures).ResultsNot all management layers were successfully involved during all sessions in the hospitals. Top-level managers were best represented in all hospitals, leading clinicians the least. The number of implemented improvement activities was low, ranging between 2 and 14. The team training intervention we developed was not associated with improvements in the compliance with the four SOP of the SSI bundle. Medical specialty, time of day, and time in OT were associated with median number of door movements, and preoperative antibiotic prophylaxis administration.ConclusionThis study showed that after the QI team training intervention the overall compliance with the four SOPs did not improve. Minimal involvement of leading clinicians and a low number of self-initiated activities after the team training were important barriers for compliance.

Objective:To assess the extent to which evidence-based practices are regularly used in acute care hospitals in different countries.Design:Cross-sectional survey study. Participants and setting: Infection preventionists in acute care hospitals in the United States (US), the Netherlands, Switzerland, and Japan.Methods:Data collected from hospital surveys distributed between 2015 and 2017 were evaluated to determine the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Descriptive statistics were used to examine hospital characteristics and the percentage of hospitals reporting regular use of each infection prevention practice.Results:Survey response rates were 59% in the United States, 65% in the Netherlands, 77% in Switzerland, and 65% in Japan. Several recommended practices were used in the majority of hospitals: aseptic catheter insertion and maintenance (CAUTI), maximum sterile barrier precautions (CLABSI), semirecumbent patient positioning (VAP), and contact precautions and routine daily cleaning (CDI). Other prevention practices for CAUTI and VAP were used less frequently, particularly in Swiss and Japanese hospitals. Established surveillance systems were also lacking in Dutch, Swiss and Japanese hospitals.Conclusions:Most hospitals in the United States, the Netherlands, Switzerland, and Japan have adopted certain infection prevention practices. Clear opportunities for reducing HAI risk in hospitals exist across all 4 countries surveyed.

Background Elderly residents in long-term care facilities (LTCFs) are vulnerable to healthcare-associated infections. Although hand hygiene is a leading measure for preventing infection, the compliance of healthcare workers is low. The aim of this study is to identify determinants that influence hand hygiene compliance of nursing staff in LTCFs. This information on determinants can eventually be used to develop a tailored implementation strategy for LTCFs. Methods This is an explorative, descriptive study using qualitative methods. We performed semi-structured focus group discussions with 31 nurses and nurse assistants from five Dutch LTCFs. Our focus group discussions continued until no new information could be identified from the data. We used Flottorps’ comprehensive checklist for identifying determinants of practice (the TICD checklist) to guide data collection and analysis. The audiotapes were transcribed verbatim and two authors independently analysed the transcripts with Atlas.ti software. Results LTCFs for the elderly have setting specific determinants that are decisive in explaining hand hygiene compliance. Most of these determinants are related to the residents with whom nurses build close relationships and for whom they want to create a homelike atmosphere. Residents can complicate the provision of care with unpredictable behaviour, being unwilling to receive care or use shared facilities. Our study also discovered setting-transcending determinants related to knowledge, professional interactions, guidelines, and incentives/resources. Conclusions Nurses in LTCFs are constantly pursuing a balance between working hygienically, responding adequately to acute care needs, and maintaining a homelike environment for their residents. As a result, setting-specific determinants affect hand hygiene compliance, as do the known determinants that are important in other care settings. To improve compliance in LTCFs, interventions should be selected on a theoretical base while linking these determinants to change interventions. Trial registration Registration number 50-53000-98-113, Compliance With Hand Hygiene in Nursing Homes: Go for a Sustainable Effect (CHANGE) on ClinicalTrials.gov. Date of registration 28-6-2016.

Contains fulltext : 225847.pdf (Publisher’s version ) (Closed access) To re-evaluate the adherence to clinical practice guidelines recommended disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice, among Dutch rheumatologists in the past decade. In 2007, disease activity was measured in only 16% of outpatient visits. All rheumatologists that participated in the 2007 study were invited to re-enter our study in 2016/2017. If necessary, data were supplemented with data from other rheumatologists. For all 26 rheumatologists who agreed to participate in our study, data were collected from 30 consecutive patients that visited the outpatient clinic. Per patient, data from four consecutive rheumatologist outpatient visits were collected. Since 2007, disease activity was measured more frequently in Dutch daily clinical practice, increasing from 16 to 79% of visits (2440/3081 visits). In addition, intensification of medication based on disease activity scores increased from 33 to 50% of visits (260/525 visits). DAS/DAS28 was the most frequently used disease activity measure (1596/2440 visits). There was a wide variation among rheumatologists in measuring disease activity and intensification of medication, 20-100% and 0-75% respectively. Over the past years, there has been a large improvement in disease activity assessment in daily clinical practice. Disease activity-based medication intensifications, also called tight control or treat to target, increased to a lesser extent. Large variation between different rheumatologists and clinics indicates that there is still room for improvement. Key Points • Following guideline dissemination disease activity is assessed more frequently (79%). • There is large variation between rheumatologists, indicating room for improvement. • Finding factors that explain variation is necessary to improve tight control in daily practice.

Contains fulltext : 251380.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To evaluate the effect of an intervention to improve disease activity-based management of RA in daily clinical practice by addressing patient level barriers. METHODS: The DAS-pass strategy aims to increase patients' knowledge about DAS28 and to empower patients to be involved in treatment (decisions). It consists of an informational leaflet, a patient held record and guidance by a specialized rheumatology nurse. In a Randomized Controlled Trial, 199 RA patients were randomized 1:1 to intervention or control group. Outcome measures were patient empowerment (EC-17; primary outcome), attitudes towards medication (BMQ), disease activity (DAS28) and knowledge about DAS28. RESULTS: Our strategy did not affect EC-17, BMQ, or DAS28 use. However it demonstrated a significant improvement of knowledge about DAS28 in the intervention group, compared to the control group. The intervention had an additional effect on patients with low baseline knowledge compared to patients with high baseline knowledge. CONCLUSION: The DAS-pass strategy educates patients about (the importance of) disease activity-based management, especially patients with low baseline knowledge. PRACTICE IMPLICATIONS: The strategy supports patient involvement in disease activity-based management of RA and can be helpful to reduce inequalities between patients in the ability to be involved in shared decision making.

Background The acceptability of innovative medical strategies among healthcare providers and patients affects their uptake in daily clinical practice. Objectives To explore experiences of healthcare providers and patients with culture-based antibiotic prophylaxis in transrectal prostate biopsy with three swab-screening scenarios: self-sampling at home, self-sampling in the hospital and sampling by a healthcare provider. Methods We performed focus group interviews with urologists and medical microbiologists from 11 hospitals and six connected clinical microbiological laboratories. We used Flottorp’s comprehensive checklist for identifying determinants of practice to guide data collection and analysis. The experiences of 10 laboratory technicians from five laboratories and 452 patients from nine hospitals were assessed using a questionnaire. Results Overall, culture-based prophylaxis strategies were experienced as feasible in daily clinical practice. None of the three swab-screening scenarios performed better. For urologists (n = 5), implementation depended on the effectiveness of the strategy. In addition, it was important to them that the speed of existing oncology care pathways is preserved. Medical microbiologists (n = 5) and laboratory technicians (n = 8) expected the strategy to be fairly easy to implement. Patients (n = 430; response rate 95.1%) were generally satisfied with the screening scenario presented to them. To meet the various patients’ needs and preferences, multiple scenarios within a hospital are probably needed. Conclusions This multi-method study has increased our understanding of the acceptability of culture-based prophylaxis strategies in prostate biopsy, which can help healthcare providers to offer high-quality patient-centred care. The strategy seems relatively straightforward to implement as overall acceptance appears to be high.

Background/Aims: Power and sample size calculation formulas for stepped-wedge trials with two levels (subjects within clusters) are available. However, stepped-wedge trials with more than two levels are possible. An example is the CHANGE trial which randomizes nursing homes (level 4) consisting of nursing home wards (level 3) in which nurses (level 2) are observed with respect to their hand hygiene compliance during hand hygiene opportunities (level 1) in the care of patients. We provide power and sample size methods for such trials and illustrate these in the setting of the CHANGE trial. Methods: We extend the original sample size methodology derived for stepped-wedge trials based on a random intercepts model, to accommodate more than two levels of clustering. We derive expressions that can be used to determine power and sample size for p levels of clustering in terms of the variances at each level or, alternatively, in terms of intracluster correlation coefficients. We consider different scenarios, depending on whether the same units in a particular level are repeatedly measured as a cohort sample or whether different units are measured cross-sectionally. Results: A simple variance inflation factor is obtained that can be used to calculate power and sample size for continuous and by approximation for binary and rate outcomes. It is the product of (1) variance inflation due to the multilevel structure and (2) variance inflation due to the stepped-wedge manner of assigning interventions over time. Standard and non-standard designs (i.e. so-called “hybrid designs” and designs with more, less, or no data collection when the clusters are all in the control or are all in the intervention condition) are covered. Conclusions: The formulas derived enable power and sample size calculations for multilevel stepped-wedge trials. For the two-, three-, and four-level case of the standard stepped wedge, we provide programs to facilitate these calculations.

Contains fulltext : 238610.pdf (Publisher’s version ) (Open Access) OBJECTIVE: The systematic development of an intervention to improve disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice that is based on patient-level barriers. METHODS: The self-management strategy was developed through a step-wise approach, in a process of co-design with all stakeholders and by addressing patient level barriers to RA management based on disease activity. RESULTS: The resulting DAS-pass strategy consists of decision supportive information and guidance by a specialised rheumatology nurse. It aims to increase patients' knowledge on DAS28, to empower patients to be involved in disease management, and to improve patients' medication beliefs. The decision supportive information includes an informational leaflet and a patient held record. The nurse individualises the information, stimulates patients to communicate about disease activity, and offers the opportunity for questions or additional support. CONCLUSION: The DAS-pass strategy was found helpful by stakeholders. It can be used to improve RA daily clinical practice. Our systematic approach can be used to improve patient knowledge and self-management on other RA related topics. Also, it can be used to improve the management of other chronic conditions. We therefore provide a detailed description of our methodology to assist those interested in developing an evidence-based strategy for educating and empowering patients.

Objectives We aimed to evaluate the use of an eHealth platform and a self-management outpatient clinic in patients with RA in a real-world setting. The effects on health-care utilization and disease activity were studied. Methods Using hospital data of patients with RA between 2014 and 2019, the use of an eHealth platform and participation in a self-management outpatient clinic were studied. An interrupted time series analysis compared the period before and after the introduction of the eHealth platform. The change in trend (relative to the pre-interruption trend) for the number of outpatient clinic visits and the DAS for 28 joints (DAS28) were determined for several scenarios. Results After implementation of the platform in April 2017, the percentage of patients using it was stable at ∼37%. On average, the users of the platform were younger, more highly educated and had better health outcomes than the total RA population. After implementation of the platform, the mean number of quarterly outpatient clinic visits per patient decreased by 0.027 per quarter (95% CI: −0.045, −0.08, P = 0.007). This was accompanied by a significant decrease in DAS28 of 0.056 per quarter (95% CI: −0.086, −0025, P = 0.001). On average, this resulted in 0.955 fewer visits per patient per year and a reduction of 0.503 in the DAS28. Conclusion The implementation of remote patient monitoring has a positive effect on health-care utilization, while maintaining low disease activity. This should encourage the use of this type of telemedicine in the management of RA, especially while many routine outpatient clinic visits are cancelled owing to COVID-19.

Objective The aim was to develop two disease- and treatment-related knowledge about RA (DataK-RA) short forms using item response theory-based linear optimal test design. Methods We used the open source Excel add-in solver to program a linear optimization algorithm to develop two short forms from the DataK-RA item bank. The algorithm was instructed to optimize precision (i.e. reliability) of the scores for both short forms, subject to a number of constraints that served to ensure that each short form would include unique items and that the short forms would have similar psychometric properties. Agreement among item response theory scores obtained from the different short forms was assessed using the Bland–Altman method and Student’s paired t-test. Construct validity and relative efficiency of the short forms was evaluated by relating the score to age, sex and educational attainment. Results Two short forms were derived from the DataK-RA item bank that satisfied all content constraints. Both short forms included 15 unique items and yielded reliable scores (r > 0.70), with low ceiling and floor effects. The short forms yielded statistically indistinguishable mean scores according to Student’s paired t-test and Bland–Altman analysis. Scores on short forms 1 and 2 were associated with age, sex and educational attainment to a similar extent. Conclusion In this study, we developed two DataK-RA short forms with unique items, yet similar psychometric properties, that can be used to assess patients pre- and post-test interventions aimed at improving disease-related knowledge in RA patients.

BackgroundThe clinical landscape of prostate biopsy (PB) is evolving with changes in procedures and techniques. Moreover, antibiotic resistance is increasing and influences the efficacy of pre-biopsy prophylactic regimens. Therefore, increasing antibiotic resistance may impact on clinical care, which probably results in differences between hospitals. The objective of our study is to determine the (variability in) current practices of PB in the Netherlands and to gain insight into Dutch urologists’ perceptions of fluoroquinolone resistance and biopsy related infections.MethodsAn online questionnaire was prepared using SurveyMonkey® platform and distributed to all 420 members of the Dutch Association of Urology, who work in 81 Dutch hospitals. Information about PB techniques and periprocedural antimicrobial prophylaxis was collected. Urologists’ perceptions regarding pre-biopsy antibiotic prophylaxis in an era of antibiotic resistance was assessed. Descriptive statistical analysis was performed.ResultsOne hundred sixty-one responses (38.3%) were analyzed representing 65 (80.3%) of all Dutch hospitals performing PB. Transrectal ultrasound guided prostate biopsy (TRUSPB) was performed in 64 (98.5%) hospitals. 43.1% of the hospitals (also) used other image-guided biopsy techniques. Twenty-three different empirical prophylactic regimens were reported among the hospitals. Ciprofloxacin was most commonly prescribed (84.4%). The duration ranged from one pre-biopsy dose (59.4%) to 5 days extended prophylaxis. 25.2% of the urologists experienced ciprofloxacin resistance as a current problem in the prevention of biopsy related infections and 73.6% as a future problem.ConclusionsThere is a wide variation in practice patterns among Dutch urologists. TRUSPB is the most commonly used biopsy technique, but other image-guided biopsy techniques are increasingly used. Antimicrobial prophylaxis is not standardized and prolonged prophylaxis is common. The wide variation in practice patterns and lack of standardization underlines the need for evidence-based recommendations to guide urologists in choosing appropriate antimicrobial prophylaxis for PB in the context of increasing antibiotic resistance.

Background In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. Methods PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the ‘Cochrane Effective Practice and Organisation of Care’ (EPOC) taxonomy was used to categorize de-implementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel–Haenszel risk ratios (95% CI) were calculated using a random effects model. Results Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20). Conclusions The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used. Trial registration The review is registered in Prospero (CRD42018105100).

ObjectivesSelf-monitoring the disease course is a relatively new concept in the management of patients with inflammatory rheumatic diseases (IRDs). The aims of this pilot study were to obtain patients’ experiences with online self-monitoring, to assess information about the agreement between the disease course assessed with patient-reported outcome measures (PROMs) and an objectively measured Disease Activity Score 28 (DAS28) by the rheumatologist, and to assess adherence to predetermined PROM frequency intervals.DesignObservational study using qualitative and quantitative methods.SettingThe rheumatology outpatient clinic of a teaching hospital in The Netherlands (secondary care).Participants47 patients with an IRD who regularly attended the outpatient clinic.MethodsPatients completed PROMs by using an online self-monitoring program. Their experiences regarding self-monitoring were qualitatively assessed through a focus group discussion and telephone interviews using a thematic analysis approach. Adherence to the predefined PROM frequency (completed PROM assessments within the predetermined frequency) and the agreement between the DAS28 course and PROM values (Rheumatoid Arthritis Disease Activity Index-5 and the Rheumatoid Arthritis Impact of Disease (RAID)) were quantitatively assessed using descriptives.ResultsForty-seven patients participated, most of them diagnosed with rheumatoid arthritis (n=38, 80.9%). Three themes were identified: knowledge about and insight into the disease (activity), patient–professional interaction and functionality of the program. Mean adherence to the predetermined PROM frequency was 68.1%. The RAID showed the best agreement with the DAS28 course. Mean participation time was 350 days.ConclusionPatients were predominantly positive about online self-monitoring. They indicated that they gained more knowledge about their disease, felt less dependent on the healthcare professional and valued the insight into their long-term disease course. Barriers were mostly related to technical factors. Patients were able to and willing to self-monitor their disease, which could contribute to a more efficient allocation of outpatient consultations in the future.

Objective To examine the extent to which acute care hospitals in the Netherlands have adopted recommended practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Methods Between 18 July 2017 and 31 October 2017, we surveyed the infection prevention teams of all acute care hospitals in the Netherlands. The survey instrument was based on the ‘Translating Healthcare-Associated Infection Prevention Research into Practice’ (TRIP) questionnaire and adapted to the Dutch context. Descriptive statistics were used to examine the reported regular use of CAUTI, CLABSI, VAP, and CDI prevention practices as well as the hospital characteristics. Results Out of 72 eligible hospitals, 47 (65.3%) responded. Surveillance systems for monitoring CAUTI, CLABSI, VAP, and CDI were present in 17.8, 95.4, 26.2, and 77.3% of hospitals, respectively. Antimicrobial stewardship programs have been established in 91.5% of participating hospitals. For CAUTI, the majority of hospitals regularly used aseptic technique during catheter insertion (95%) and portable bladder ultrasound scanners (86.1%). Intermittent catheterization and catheter stop-orders were regularly used by 65.8 and 62.2% of hospitals. For CLABSI, all hospitals regularly used maximum sterile barrier precautions and chlorhexidine gluconate for insertion site antisepsis. Avoidance of the femoral site for central line insertions was regularly used by 65.9% of hospitals. Urinary catheters and central-lines impregnated with antibiotics or antiseptics were rarely used (≤ 5%). Selective decontamination strategies for preventing VAP were used in 84% of hospitals. With the exception of disposable thermometers (31.8%), all prevention practices to prevent CDI were regularly used by more than 80% of hospitals. Conclusions Most Dutch hospitals report regular use of recommended practices for preventing CLABSI and CDI. Several specific practices to prevent CAUTI and VAP were less frequently used, however, providing an opportunity for improvement.

Objectives: Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice.Design: Systematic review. PROSPERO registration number: CRD42018104615.Data sources: We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles.Review methods: Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patient-related nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the 'Cochrane risk of bias tool' for controlled studies, and the 'Newcastle-Ottawa Quality Assessment form' for cohort studies.Results: A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled before-after studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n = 9) and infection prevention (n = 7). Studies were predominantly performed in hospitals (n = 34) and nursing homes (n = 11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n = 36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n = 52), followed by deployment of local opinion leaders (54.7%, n = 29) and audit and feedback (41.5%, n = 22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.Conclusions: A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes. (c) 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Background Home-based nursing care continues to expand, delivering care to increasingly older clients with multiple, chronic and complex conditions that require the use of additional and more numerous invasive medical devices. Therefore, the prevention of infections poses a challenge for nurses, professional caregivers and clients. Objective This article explores infection prevention practices and related behavioural factors in both nurses and clients to identify barriers and facilitators of infection prevention practices in home-based nursing care. Design A qualitative, exploratory design. Setting Four healthcare organisations providing home-based nursing care in the Netherlands. Methods Participant observations were used as the main source of data collection complemented with focus group discussions and semi-structured interviews. Participants Participant observations: 16 nurses, three professional caregivers and 80 clients. Semi-structured interviews: 11 clients. Focus group discussions: 15 nurses and four professional caregivers. Results A total of 87 unique care delivery situations were observed for 55 h, complemented with three focus group discussions and 11 individual semi-structured client interviews. Infection prevention practices in home-based nursing care appeared to be challenged by 1. The specific context or environment in which the care occurred, which is more autonomous, less structured, less controlled and less predictable than other care settings; 2. Suboptimal and considerable variation in professional performance concerning the application of hand hygiene and the proper use of personal protective equipment such as face masks, barrier gowns and disposable gloves; 3. Extensive use in and outside the client's surroundings of communication devices that are irregularly cleaned and tend to interrupt nursing procedures; and 4. Inadequate organisational support in the implementation and evaluation of new information or policy changes and fragmentation, variation and conflicting information regarding professional guidelines and protocols. Conclusions From a first-hand observational viewpoint, this study showed that the daily practice of infection prevention in home-based nursing care appears to be suboptimal. Furthermore, this research revealed considerable variation in the work environment, the application of hand hygiene, the proper use of personal protective equipment, the handling of communication devices and organisational policies, procedures and support. Finally, the study identified a number of important barriers and facilitators of infection prevention practices in the work environment, professional and team performance, clients and organisations.

Summary Background Healthcare workers (HCWs) face specific challenges in infectious disease outbreaks, which provide unusual, new events with exposure risk. The fear of infection or new, unknown tasks in an unfamiliar setting, for example, may complicate outbreak management. Aim To gain insight into how healthcare organizations can prepare to meet the needs of their HCWs by capturing the experiences of HCWs with patients with suspected Ebola virus disease. Methods We conducted 23 in-depth interviews with HCWs, of whom 20 worked in a Dutch university hospital and three worked in a regional ambulance service. We invited HCWs who cared for patients with suspected Ebola or who were on the team preparing for admission of such patients in the period 2014–2015. Findings The HCWs were stressed and anxious, but most rated their overall experience as positive. We categorized the reported experiences in three main themes, namely, experiences related to: (i) the novelty of the threat, (ii) the risk of infection and fear of transmission, and (iii) the excessive attention. Our results underline the importance of a supportive working environment suitable for crises. Conclusion The experiences of HCWs dealing with patients with suspected Ebola can direct improvements in generic preparedness for highly transmissible diseases.

Objective: To develop a Disease and treatment associated Knowledge in RA item bank (DataK-RA) based on item response theory. Methods: Initial items were developed from a systematic review. Rheumatology professionals identified relevant content trough a RAND modified Delphi scoring procedure and consensus meeting. RA patients provided additional content trough a focus group. Patients and professionals rated readability, feasibility and comprehensiveness of resulting items. Cross-sectional data were collected to evaluate psychometric properties of the items. Results: Data of 473 patients were used for item reduction and calibration. Twenty items were discarded based on corrected item-total point biserial correlation

Contains fulltext : 218897.pdf (Publisher’s version ) (Closed access) AIMS AND OBJECTIVE: To gain insight into nurse practitioners' (NP) leadership roles in Dutch hospital care, by exploring the perceptions regarding their current leadership role and the differences with their previous role as a registered specialised nurse. BACKGROUND: To meet today's challenges of the increasing healthcare demands, the employment of NPs is proliferating. NPs have the ideal position to play a pivotal role within healthcare reforms, yet full expansion of their scope of practice and expertise is having limited success. Long-term sustainability of NPs depends on the ability to perform and develop a leading role. DESIGN AND METHODS: This qualitative descriptive study was conducted in fifteen Dutch hospitals. Data were collected from April-July 2018, and purposive sampling was used for eighteen semi-structured interviews. This study is conducted and reported according to the COREQ checklist. RESULTS: Three main themes concerning NPs' current leadership role emerged, and they were all linked to a successful positioning of NPs. All themes seemed to be of influence on NPs' scope of daily practice. Direct patient care was emphasised, and leadership on other levels appeared to be underused. Most NPs desired to reshape their profession. However, unprofitable use of their leadership skills especially on professional and organisational level and lack of supportive factors seemed to hinder them. CONCLUSIONS: An adequate use of leadership is crucial for role development and positioning of NPs. Further development of the NP profession can help to better differentiate between the tasks of registered specialised nurses and NPs. RELEVANCE TO CLINICAL PRACTICE: Leadership in nursing contributes to the improvement of the quality and efficiency of health care. Further positioning of the NP profession depends on a profitable use of leadership competencies. Besides, NPs should collaborate with healthcare organisations, educational institutions and professional associations to value the NP profession in the current healthcare system.

We studied trends in the incidence of health care-associated infections (HAIs) in LTCFs between 2009 and 2015 and determined the effect of participation in our network. Elder-care physicians reported weekly the number of cases of influenza-like illness, gastroenteritis, (probable) pneumonia, urinary tract infections (UTIs) and all-cause mortality. Trends in the incidence of infection and mortality in relation to LTCF characteristics were calculated using multilevel univariate and multivariate logistic regression. Thirty LTCF participated for 3 years or more, 16 for 2 years and the remaining 12 LTCF for 1 year. During the study period, the median number of beds decreased from 158 to 139, whereas the percentage of residents with private bedrooms increased from 14% to 87%. UTIs were the most frequently reported infections, followed by (probable) pneumonia and gastroenteritis. Adjusted for calendar year and season, we observed a statistically significant decrease in the incidence of influenza-like illness (odds ratio (OR) = 0.8, P < 0.01) and (probable) pneumonia (OR = 0.8, P < 0.01) for each extra year an LTCF participated. Although there are other likely contributors, such as more private rooms and enhanced infection control measures, the decreasing trend of HAI in LTCFs participating in surveillance implies that surveillance is a valuable addition to current strategies to optimise infection control.

textabstractAim: To establish what leadership competencies are expected of master level‐edu‐ cated nurses like the Advanced Practice Nurses and the Clinical Nurse Leaders as described in the international literature. Background: Developments in health care ask for well‐trained nurse leaders. Advanced Practice Nurses and Clinical Nurse Leaders are ideally positioned to lead healthcare reform in nursing. Nurses should be adequately equipped for this role based on internationally defined leadership competencies. Therefore, identifying leadership competencies and related attributes internationally is needed. Design: Integrative review. Methods: Embase, Medline and CINAHL databases were searched (January 2005– December 2018). Also, websites of international professional nursing organizations were searched for frameworks on leadership competencies. Study and framework selection, identification of competencies, quality appraisal of included studies and analysis of data were independently conducted by two researchers. Results: Fifteen studies and seven competency frameworks were included. Synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, pro‐ fessional, health systems. and health policy leadership domains. Most competencies fitted in one single domain the health policy domain contained the least competencies. Conclusions: This synthesis of 30 core competencies within four leadership domains can be used for further development of evidence‐based curricula on leadership. Next steps include further refining of competencies, addressing gaps, and the linking of knowledge, skills, and attributes. Impact: These findings contribute to leadership development for Advanced Practice Nurses and Clinical Nurse Leaders while aiming at improved health service delivery and guiding of health policies and reforms.

Patient-reported outcome measures (PROMs) are increasingly used in the assessment of patients with rheumatoid arthritis (RA). The aim of this study was to assess the construct validity and reproducibility of four types of PROMs (numerical rating scale (NRS), visual analogue scale (VAS), verbal rating scale (VRS), and Likert scale). In addition, patients’ preference for one of these PROMs was measured. Patients with stable RA and no change in pain medication or steroid medication (n = 211) were asked to complete a questionnaire directly following, and 5 days after their outpatient visit. The questionnaire measured the validity of the PROMs in four domains (pain, fatigue, experienced disease activity, and general well-being). To assess construct validity, Pearson correlation coefficients were calculated using the Disease Activity Score-3. To assess reproducibility, intraclass correlation coefficients (ICCs) were calculated. Correlation coefficients between the different PROMs within each domain were compared. There were no differences regarding construct validity between the different PROM scale types. Regarding reproducibility, VAS and NRS scored better in the domains pain and experienced disease activity. Patients chose NRS as preferred measurement method, with the VAS in second place. The four scale types of PROMs appeared to be equally valid to assess pain, fatigue, experienced disease activity, and general well-being. VAS and NRS appeared to be more reliable for measuring pain and experienced disease activity. The patients favoured NRS. In combination with other practical advantages of NRS over VAS, we do advise the NRS as the preferred scale type for PROMs.

Background Inflammatory rheumatic diseases (IRDs) such as Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA) are characterised by a fluctuating disease course. Because of these fluctuations, the disease activity in between outpatient visits can be different from the disease activity objectively measured at outpatient visits. In order to capture the in between disease activity and to encourage patients to take an active role in their disease management, iMonitor1 was developed. This online self-monitoring tool allows patients to complete Patient-Reported Outcome Measures (PROMs) in order to get insight in their disease activity. Objectives To gather patient experiences regarding online remote monitoring in IRDs and to provide recommendations in order to efficiently arrange and optimise self-monitoring. Methods This mixed-method study was conducted at a teaching hospital (Bernhoven, Uden, the Netherlands) from April 2016 until August 2017. Adult patients with RA or PsA were eligible to participate and were recruited by means of purposive sampling. Four instruction classes were organised in which patients received instructions regarding how to use iMonitor. Patients indicated which PROM(s) they preferred to complete (HAQ, RAID, and/or RADAI-5) and at which frequency (one-, two-, four-, six-, or eight-weeks). The system generated an alert email accordingly, adherence was determined by checking whether the PROM was completed within the time interval. Level of congruence between DAS28-scores and PROM-values (very poor – very good) were independently determined by two researchers (LR and PvR). Facilitators and barriers with regard to using iMonitor were collected by means of a focus group discussion and four telephone interviews. Results Seven patients with PsA and 32 with RA participated in this study. Most were female (n=23, 59%). Mean (±SD) age was 56.6 (10.7) years. RAID was chosen most often (29 times). Most patients (n=25) chose a four-week PROM-frequency. Mean adherence was 52.9%, patients with a one-week frequency were most compliant (73.8%). Regarding the congruence between DAS28 and PROMs, RAID scored best. Overall, patients were positive about iMonitor. They felt more aware about their disease and its consequences, felt supported in handling their disease, and gained more knowledge about their disease (activity). Based on our first experiences, recommendations for optimal self-monitoring are: 1) Patients need to be actively recruited 2) Tailored education (e.g. instruction class) is useful for some patients in order to get familiar with the program. 3) Patients need to get feedback from their healthcare provider regarding their outcomes. 4) Working with a stand-alone system such as iMonitor is not feasible, it should be integrated in an existing (hospital) system. Conclusions Self-monitoring is a first step towards personalised healthcare. Patients become more aware about their disease and gain more knowledge about their disease (activity), which can result in increased self-management. Future research should investigate the possibility of skipping outpatient visits for those patients with stable disease activity. Reference [1] iMonitor, developed and funded by Pfizer http://www.imonitor-med.co.uk Disclosure of Interest None declared

Background Patient education can be used to support and enable people with Rheumatoid Arthritis (RA) to optimise health and wellbeing. It has been recommended as an integral part in management of RA in order to undertake self-management activities or to adhere to treatments. Disease-specific knowledge can be measured with a Patient Knowledge Questionnaire (PKQ). Because PKQs in RA are outdated, de Jonge et al. developed the Disease and Treatment Associated Knowledge in Rheumatoid Arthritis (DataK-RA) item bank and provided preliminary evidence to support its construct validity. It was developed with input from patients and rheumatology experts. DataK-RA contains 42 multiple choice items with 2–4 response alternatives per item and was calibrated using the two parameter item response model for dichotomous responses. IRT scores are corrected for item characteristics, which allows scores to be compared between measures that include different items. IRT models also provide detailed information about the precision of scores at different levels of knowledge. Various methods are available that can help select optimal items to be administered to patients, given certain criteria. Objectives The objective of this study was to develop two DataK-RA short forms using linear optimal test design. Methods The open source excel add in “solver” was used to program a linear optimisation algorithm to develop two short forms. The algorithm was instructed to optimise precision (i.e. reliability) of the scores for both short forms, subject to the constraints that: 1) each item could only be included in one short form 2) each short form should include 15±1 items, 3) reliability for each short form should be >0.70 for all patients who are within 1 SD of the mean of knowledge scores, and 4) scores on each short form should be similarly precise, defined as maximum allowable difference in information of 0.15. Results Two short forms were derived from the DataK-RA item bank that satisfied all content constraints. The short forms include respectively 15 and 16 unique items. Reliabilities across different score levels ranged from 0.71–0.80 for both short forms, and the maximum difference in information between the short forms was 0.13. Conclusions DataK-RA is a new and promising tool that can be used by healthcare providers to measure disease and treatment related knowledge in patients with RA. The short forms can be used in pre/posttest intervention studies in which disease related knowledge is one of the outcomes Because each short form includes unique items and IRT scores are adjusted for item characteristics, the application of these short forms will allow users of DataK-RA to avoid learning effects commonly associated with using the same items at two occasions. Furthermore, the equal and high reliabilities of both forms ensure that the observed score distributions for both versions will have similar variances. Disclosure of Interest None declared

Various technologies have been developed to improve hand hygiene (HH) compliance in inpatient settings; however, little is known about the feasibility of machine learning technology for this purpose in outpatient clinics.To assess the effectiveness, user experiences, and costs of implementing a real-time HH notification machine learning system in outpatient clinics.In our mixed methods study, a multi-disciplinary team co-created an infrared guided sensor system to automatically notify clinicians to perform HH just before first patient contact. Notification technology effects were measured by comparing HH compliance at baseline (without notifications) with real-time auditory notifications that continued till HH was performed (intervention I) or notifications lasting 15 s (intervention II). User experiences were collected during daily briefings and semi-structured interviews. Costs of implementation of the system were calculated and compared to the current observational auditing programme.Average baseline HH performance before first patient contact was 53.8%. With real-time auditory notifications that continued till HH was performed, overall HH performance increased to 100% (P 0.001). With auditory notifications of a maximum duration of 15 s, HH performance was 80.4% (P 0.001). Users emphasized the relevance of real-time notification and contributed to technical feasibility improvements that were implemented in the prototype. Annual running costs for the machine learning system were estimated to be 46% lower than the observational auditing programme.Machine learning technology that enables real-time HH notification provides a promising cost-effective approach to both improving and monitoring HH, and deserves further development in outpatient settings.

Contains fulltext : 170104.pdf (Publisher’s version ) (Open Access) BACKGROUND: Preparedness is considered essential for healthcare organizations to respond effectively to outbreaks. In the current study we aim to capture the views of first responders on what they consider key recommendations for high quality preparedness. Furthermore, we identified the recommendations with the highest urgency from the perspective of first responders. METHODS: We chose a multistep approach using a systematic Delphi procedure. Previously extracted recommendations from scientific literature were presented to a national and two international expert panels. We asked the experts to score the recommendations based on relevance for high quality preparedness. In addition we asked them to choose the ten most urgent recommendations. RESULTS: Starting with 80 recommendations from scientific literature, 49 key recommendations were selected by both international expert panels. Differences between both panels were mainly on triage protocols. In addition, large differences were found in the selection of the ten most urgent recommendations. CONCLUSIONS: In this study infectious disease experts selected a set of key recommendations representing high quality preparedness and specified which ones should be given the highest urgency when preparing for a future crisis. These key recommendations can be used to shape their preparedness activities.

Item does not contain fulltext BACKGROUND: There is evidence that meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia can be reduced with improved infection control and antibiotic stewardship. AIM: To survey infection control and antibiotic stewardship practices within European hospitals and to identify initiatives that correlate with reduced MRSA prevalence. METHODS: Online questionnaires were sent to European hospitals about their surveillance, hand hygiene, intravenous device management, admission screening, isolation, antibiotic prescribing, hospital demographics and MRSA blood culture isolates during 2010. FINDINGS: In all, 269 replies were received from hospitals in 29 European countries. Lower MRSA prevalence showed significant association with presence of incidence surveillance, performance of root cause analysis, mandatory training requirements for hand hygiene, accountability measures for persistent non-compliance, and multi-stakeholder teamwork in antibiotic prescribing. Presence of policies on intravenous catheter insertion and management showed no variation between different MRSA prevalence groups. However, low-prevalence hospitals reported more competency assessment programmes in insertion and maintenance of peripheral and central venous catheters. Hospitals from the UK and Ireland reported the highest uptake of infection control and antibiotic stewardship practices that were significantly associated with low MRSA prevalence, whereas Southern European hospitals exhibited the lowest. In multiple regression analysis, isolation of high-risk patients, performance of root cause analysis, obligatory training for nurses in hand hygiene, and undertaking joint ward rounds including microbiologists and infectious disease physicians remained significantly associated with lower MRSA prevalence. CONCLUSION: Proactive infection control and antibiotic stewardship initiatives that instilled accountability, ownership, teamwork, and validated competence among healthcare workers were associated with improved MRSA outcomes.