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Abstract Background Antimicrobial Stewardship (AMS), the set of actions to ensure appropriate antimicrobial use, is increasingly considered a multidisciplinary endeavour. However, it is unclear how Dutch hospital-based nurses envision their contribution to AMS. Objective To explore the views and visions of Dutch bedside nurses on their role regarding appropriate antimicrobial use. Methods A qualitative study using semi-structured interviews was conducted. Fourteen bedside nurses in nine different Dutch hospitals participated. Data were analysed using a thematic content analysis. Results Nurses considered their role regarding appropriate use of antibiotics as an integral part of their daily nursing practice. They envisioned their future role as an expansion of their current practice, improving or intensifying this contribution. Prompting review of antimicrobial treatment by nurses was seen as regular practice. Ward rounds were considered the best moment to exert their nursing role, by showing leadership in communicating about different aspects of AMS. Patient advocacy (“striving for the best possible care for their patient”) appears to be a driver of the nursing contribution. Nurses perceived a shared responsibility with prescribers on certain aspects of the antimicrobial treatment and wished for a clarification of this role. Education and cognitive reminders such as antibiotic checklist to be used in ward rounds, can support the uptake of the nurses’ role. Conclusion Nurses envision their future role in AMS as an enhanced, elaborated and empowered version of their current daily practice. Education, formal acknowledgment and increased awareness of the nursing role, may advance the contributing role nurses already have.

Abstract Background Among older people undiagnosed and untreated vision impairment and blindness are common. The leading causes are uncorrected refractive errors and cataracts. Vision problems are associated with a lower quality of life, several health problems, and a higher chance of falling accidents and fractures. To eliminate avoidable vision impairment and blindness, targeted eye screening programs are recommended. Older patients, receiving home healthcare, have not yet been considered as a population at risk who could benefit from eye screening. Methods A cluster-randomized controlled trial will be conducted to investigate the cost-effectiveness and cost-utility of online nurse-assisted eye screening in home healthcare, compared to care as usual, in reducing avoidable vision impairment. A healthcare and societal perspective will be used. The study will be performed in collaboration with several home healthcare organizations in the Netherlands. The online eye screening consists of near and distance visual acuity, followed by an Amsler grading test. Measurements in both groups will take place at baseline and after 6 and 12 months of follow-up. A total of 240 participants will be recruited. Older men and women (65 +), who receive home-based nursing and are cognitively able to participate, will be included. The primary outcome will be the change of two lines or more on the Colenbrander-1 M visual acuity chart between baseline and 12-month follow-up. Discussion An eye screening for populations at risk contributes to the detection of undiagnosed and untreated vision impairment. This may reduce the health-related consequences of vision loss and the high economic burden associated with vision impairment. Trial registration ClinicalTrials.gov NCT06058637. Registered on 27 September 2023.

Abstract Background Thoracic radiotherapy may damage the myocardium and arteries, increasing cardiovascular disease (CVD) risk. Women with a high local breast cancer (BC) recurrence risk may receive an additional radiation boost to the tumor bed. Objective We aimed to evaluate the CVD risk and specifically ischemic heart disease (IHD) in BC patients treated with a radiation boost, and investigated whether this was modified by age. Methods We identified 5260 BC patients receiving radiotherapy between 2005 and 2016 without a history of CVD. Boost data were derived from hospital records and the national cancer registry. Follow-up data on CVD events were obtained from Statistics Netherlands until December 31, 2018. The relation between CVD and boost was evaluated with competing risk survival analysis. Results 1917 (36.4%) received a boost. Mean follow-up was 80.3 months (SD37.1) and the mean age 57.8 years (SD10.7). Interaction between boost and age was observed for IHD: a boost was significantly associated with IHD incidence in patients younger than 40 years but not in patients over 40 years. The subdistribution hazard ratio (sHR) was calculated for ages from 25 to 75 years, showing a sHR range from 5.1 (95%CI 1.2–22.6) for 25-year old patients to sHR 0.5 (95%CI 0.2–1.02) for 75-year old patients. Conclusion In patients younger than 40, a radiation boost is significantly associated with an increased risk of CVD. In absolute terms, the increased risk was low. In older patients, there was no association between boost and CVD risk, which is likely a reflection of appropriate patient selection.

Objectives Systematically measuring the work environment of healthcare employees is key to continuously improving the quality of care and addressing staff shortages. In this study, we systematically analyse the responses to the one open-ended question posed in the Dutch version of the Culture of Care Barometer (CoCB-NL) to examine (1) if the responses offered new insights into healthcare employees’ perceptions of their work environment and (2) if the original CoCB had any themes missing.Design Retrospective text analysis using Rigorous and Accelerated Data Reduction technique.Setting University hospital in the Netherlands using the CoCB-NL as part of the annual employee survey.Participants All hospital employees were invited to participate in the study (N=14 671). In total, 2287 employees responded to the open-ended question.Results 2287 comments were analysed. Comments that contained more than one topic were split according to topic, adding to the total (n=2915). Of this total, 372 comments were excluded because they lacked content or respondents indicated they had nothing to add. Subsequently, 2543 comments were allocated to 33 themes. Most comments (n=2113) addressed the 24 themes related to the close-ended questions in the CoCB-NL. The themes most commented on concerned questions on ‘organisational support’. The remaining 430 comments covered nine additional themes that addressed concerns about work environment factors (team connectedness, team effectiveness, corporate vision, administrative burden and performance pressure) and themes (diversity and inclusion, legal frameworks and collective bargaining, resilience and work–life balance, and personal matters).Conclusions Analysing responses to the open-ended question in the CoCB-NL led to new insights into relevant elements of the work environment and missing themes in the COCB-NL. Moreover, the analysis revealed important themes that not only require attention from healthcare organisations to ensure adequate improvements in their employees’ work environment but should also be considered to further develop the CoCB-NL.

Abstract Background The clinical decision-making of non-conveyance is perceived as complex and difficult by emergency medical services (EMS) professionals. Patients with a transient loss of consciousness (TLOC) based on syncope constitute a significant part of the non-conveyance population. Risk stratification is the basis of the clinical decision-making process by EMS professionals. This risk stratification is based on various patient factors. This study aimed to explore patient factors significantly associated with conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. Methods A cross-sectional vignette study with a factorial survey design was conducted. Patient factors were derived from the “National Protocol Ambulance Care”, and all possible combinations of these factors and underlying categories were combined, resulting in 256 unique vignettes (2*4*4*4*2 = 256). Patient factors presented either low-risk or high-risk factors for adverse events. Data were collected through an online questionnaire, in which participants received a random sample of 15 vignettes. For each vignette, the respondent indicated whether the patient would need to be conveyed to the emergency department or not. A multilevel logistic regression analysis with stepwise backward elimination was performed to analyse factors significantly associated with conveyance decision-making. In the logistic model, we modelled the probability of non-conveyance. Results 110 respondents were included, with 1646 vignettes being assessed. Mean age 45.5 (SD 9.3), male gender 63.6%, and years of experience 13.2 (SD 8.9). Multilevel analysis showed two patient factors contributing significantly to conveyance decision-making: ‘red flags’ and ‘prehospital electrocardiogram (ECG)’. Of these patient factors, three underlying categories were significantly associated with non-conveyance: ‘sudden cardiac death

Abstract Background Patients with a syncope constitute a challenge for risk stratification in (prehospital) emergency care. Professionals in EMS and ED need to differentiate the high-risk from the low-risk syncope patient, with limited time and resources. Clinical decision rules (CDRs) are designed to support professionals in risk stratification and clinical decision-making. Current CDRs seem unable to meet the standards to be used in the chain of emergency care. However, the need for a structured approach for syncope patients remains. We aimed to generate a broad overview of the available risk stratification tools and identify key elements, scoring systems and measurement properties of these tools. Methods We performed a scoping review with a literature search in MEDLINE, CINAHL, Pubmed, Embase, Cochrane and Web of Science from January 2010 to May 2022. Study selection was done by two researchers independently and was supervised by a third researcher. Data extraction was performed through a data extraction form, and data were summarised through descriptive synthesis. A quality assessment of included studies was performed using a generic quality assessment tool for quantitative research and the AMSTAR-2 for systematic reviews. Results The literature search identified 5385 unique studies; 38 were included in the review. We discovered 19 risk stratification tools, one of which was established in EMS patient care. One-third of risk stratification tools have been validated. Two main approaches for the application of the tools were identified. Elements of the tools were categorised in history taking, physical examination, electrocardiogram, additional examinations and other variables. Evaluation of measurement properties showed that negative and positive predictive value was used in half of the studies to assess the accuracy of tools. Conclusion A total of 19 risk stratification tools for syncope patients were identified. They were primarily established in ED patient care; most are not validated properly. Key elements in the risk stratification related to a potential cardiac problem as cause for the syncope. These insights provide directions for the key elements of a risk stratification tool and for a more advanced process to validate risk stratification tools.

ObjectivesA positive work environment (WE) is paramount for healthcare employees to provide good quality care. To stimulate a positive work environment, employees' perceptions of the work environment need to be assessed. This study aimed to assess the reliability and validity of the Dutch version of the Culture of Care Barometer (CoCB-NL) survey in hospitals.MethodsThis longitudinal validation study explored content validity, structural validity, internal consistency, hypothesis testing for construct validity, and responsiveness. The study was conducted at seven departments in two Dutch university hospitals. The departments were included based on their managers' motivation to better understand their employees' perception of their WE. All employees of participating departments were invited to complete the survey (n = 1,730).ResultsThe response rate was 63.2%. The content of the CoCB-NL was considered relevant and accessible by the respondents. Two factor models were found. First, confirmative factor analysis of the original four-factor structure showed an acceptable fit (X2 2006.49; df 399; p = ConclusionsThe CoCB-NL is a valid and reliable instrument for identifying areas needing improvement in the WE. Furthermore, the CoCB-NL appears to be responsive and therefore useful for longitudinal evaluations of healthcare employees' work environments.

Background: Adequate staffing is crucial for high quality patient care and nurses’ wellbeing. Nurses’ professional assessment on adequacy of staffing is the gold standard in measuring staffing adequacy. However, available measurement instruments lack reliability and validity. Objectives: To develop and psychometrically test an instrument to measure nurses’ perceived adequacy of staffing (PAS) of general hospital wards. Design: A multicenter cross-sectional psychometric instrument development and validation study using item response theory. Settings: Ten general nursing wards in three teaching hospitals in the Netherlands. Participants: A sample of 881 participants, including third and fourth year nursing students and nurse/care assistants. Methods: The 13-item self-reported questionnaire was developed based on a previous Delphi study and two focus groups. We interviewed five nurses to evaluate the content validity of the instrument. The field test for psychometric evaluation was conducted on ten general wards of three teaching hospitals in the Netherlands. Structural validity of the item bank was examined by fitting a graded response model (GRM) and inspecting GRM fit. Measurement invariance was assessed by evaluating differential item functioning (DIF) of education level and work experience. We examined convergent validity by testing the hypothesis that there was at least a moderate correlation between the PAS instrument and a single item measuring adequacy of staffing. Internal consistency and reliability across the scale were also examined. Results: A total of 881 measurements were included in the analysis. The data fitted the GRM adequately and item fit statistics were good. DIF was detected for work experience for the protocols item, but the impact on total scores was negligible. The hypothesis was confirmed and the item bank reliably measured two standard deviations around the mean. Conclusions: The Nurse Perceived Adequacy of Staffing Scale (NPASS) for nurses of general hospital wards in the Netherlands has sufficient reliability and validity and is ready for use in nurse staffing research and practice.

Introduction In the perioperative period of hospitalization, barriers to food intake are common due to special nutritional needs, compromised nutritional status, and metabolic stress. Good nutritional care call for an interdisciplinary approach. And patients themselves may also play an essential role in managing nutritional care. Objective This study aimed to explore how patients with malnutrition experience nutritional care, their perspectives on patient participation, and their own role in malnutrition care in the perioperative period of hospitalization. Methods A qualitative study was conducted using an interpretive phenomenological approach. To follow patients’ experiences, in-depth longitudinal interviews were undertaken before, during, and after hospitalization. Interview transcripts were analyzed thematically using open, axial, and selective coding and interpreted in an iterative process. Results Fifty-six interviews were undertaken with 26 patients with malnutrition scheduled for surgery and during the perioperative period of hospitalization. Four themes were identified: (1) unawareness and stigmata about being malnourished, (2) feasibility of optimal nutritional care, (3) needs and expectations for self-management, and (4) barriers and facilitators of taking own responsibilities in nutritional care. Conclusion Awareness and responsiveness to patients’ perspectives, motivation, and compliance are prerequisites for patient participation in malnutrition care. This requires good communication between healthcare professionals and patients in all phases of hospitalization.

IntroductionUnderstanding the affordability of healthy eating has always been a critical question but has escalated in importance considering the global context of more recent soaring food prices and the worsening of food and nutrition security indicators since the COVID-19 pandemic. The objective of this study was to evaluate the cost and affordability of basic healthy eating in South Africa and Kenya, through the application of a Basic Healthy Food Basket (BHFB) modeling framework applied within the food intake and nutritional context of the target countries.MethodsThe construction of the BHFB models was based on a number of key considerations (i.e., ‘building blocks’): household demographic (size and composition), socio-economically disaggregated household income levels, minimum wage data, typical food intake patterns, nationally monitored food retail prices and official country-specific nutrient intake and food consumption guidelines. For both countries BHFB’s were compiled and interpreted at a national level, as well as for a ‘more plant-based’ BHFB. The nutritional adequacy of the national BHFB’s was evaluated.ResultsBased on national demographical statistics in Kenya and South Africa, the reference family was defined as a four-member reference household consisting of 2 adults and 2 children. The detailed composition of the national BHFB’s is presented, consisting of 31 food items in Kenya and 24 food items in South Africa – covering all the food groups according to nutritional guidelines. The nutritional adequacy of the various BHFB’s is discussed and were generally deemed adequate for the majority of micro-nutrients – particularly the micro-nutrients of concern in the various countries. In January 2023 the cost of the national BHFB in Kenya and South Africa amounted to KSh33 800 (US$270) and R4 715 (US$ 262) respectively, − potentially excluding approximately 60% of the population from being able to afford a basic healthy food basket. A movement to ‘more plant-based’ BHFB’s (i.e., proportionally less meat/fish/eggs and proportionally more legumes) reduced the cost of the BHFB’s with 15% in Kenya and in South Africa. From a social support perspective, the analyses indicated that social support in the form of child support grants and children benefiting from school feeding programmes could result in the share of households able to afford basic healthy eating to increase by approximately 10 percentage points in the South African context.Conclusions and recommendationsThe study showed that the high (and rising) cost of basic healthy eating prevents large numbers of households in South Africa and Kenya from being able to afford basic healthy eating when considering current income distribution data. The research outcomes of the BHFB methodology applied in this study to monitor and evaluate the cost and affordability of basic healthy eating, should be monitored regularly and taken into consideration to inform food and nutrition policy decisions and actions. However, from a methodological perspective several critical challenges will have to be addressed to improve the measurement accuracy of the BHFB models, including the availability of official food retail price monitoring of a wider range of food items; household demographics, household income data, food intake data and household-level food expenditure data that are more frequently updated, as well as socio-economically and geographically disaggregated data on typical food intake behavior. From the perspective of plant versus animal protein sources, the study suggested that food intake patterns with an increased focus on legumes as a source of plant-based protein could help to improve the affordability of basic healthy eating. However, it is also important to consider consumer acceptability in this context from various perspectives, including sensory acceptability, cultural acceptability, and the available time for food preparation. The study identified the critical need to evaluate the cost of basic healthy eating on a geographically more refined level. This is based on the diversity of food intake behavior in different regions within the target countries as pointed out by in-country experts. However, future research to develop an improved understanding of food intake pattern in different regions/provinces/counties will be a critical enabler, along with geographically disaggregated food retail price data and demographical information.

Objectives To gain consensus on the items that determine adequacy of shift staffing.Design This was a three-round Delphi study to establish consensus on what defines adequacy of shift staffing in a general hospital ward. A literature review, focus group and five semistructured expert interviews were used to generate items for the Delphi study.Setting Multicentre study in The Netherlands.Participants Nurses, head nurses, nursing managers, and capacity consultants and managers working for Dutch hospitals.Results Twenty-six items were included in the Delphi study. One hundred and sixty-eight, 123 and 93 participants were included in the first, second and third round, respectively. After three rounds, six items were included (mostly related to direct patient care) and nine items were excluded. No consensus was reached on 12 items, including one item that was added after the first round.Conclusions This is the first study to specify items that determine adequacy of staffing. These items can be used to measure adequacy of staffing, which is crucial for enhancing nurse staffing methods. Further research is needed to refine the items of staffing adequacy and to further develop and psychometrically test an instrument for measuring staffing adequacy.

BackgroundSelf-management can increase self-efficacy and quality of life and improve disease outcomes. Effective self-management may also help reduce the pressure on health care systems. However, patients need support in dealing with their disease and in developing skills to manage the consequences and changes associated with their condition. Web-based self-management support programs have helped patients with cardiovascular disease (CVD) and rheumatoid arthritis (RA), but program use has been low. ObjectiveThis study aimed to identify the patient, disease, and program characteristics that determine whether patients use web-based self-management support programs or not. MethodsA realistic evaluation methodology was used to provide a comprehensive overview of context (patient and disease characteristics), mechanism (program characteristics), and outcome (program use). Secondary data of adult patients with CVD (n=101) and those with RA (n=77) were included in the study. The relationship between context (sex, age, education, employment status, living situation, self-management [measured using Patient Activation Measure-13], quality of life [measured using RAND 36-item health survey], interaction efficacy [measured using the 5-item perceived efficacy in patient-physician interactions], diagnosis, physical comorbidity, and time since diagnosis) and outcome (program use) was analyzed using logistic regression analyses. The relationship between mechanism (program design, implementation strategies, and behavior change techniques [BCTs]) and outcome was analyzed through a qualitative interview study. ResultsThis study included 68 nonusers and 111 users of web-based self-management support programs, of which 56.4% (101/179) were diagnosed with CVD and 43.6% (78/179) with RA. Younger age and a lower level of education were associated with program use. An interaction effect was found between program use and diagnosis and 4 quality of life subscales (social functioning, physical role limitations, vitality, and bodily pain). Patients with CVD with higher self-management and quality of life scores were less likely to use the program, whereas patients with RA with higher self-management and quality of life scores were more likely to use the program. Interviews with 10 nonusers, 10 low users, and 18 high users were analyzed to provide insight into the relationship between mechanisms and outcome. Program use was encouraged by an easy-to-use, clear, and transparent design and by recommendations from professionals and email reminders. A total of 5 BCTs were identified as potential mechanisms to promote program use: tailored information, self-reporting behavior, delayed feedback, providing information on peer behavior, and modeling. ConclusionsThis realistic evaluation showed that certain patient, disease, and program characteristics (age, education, diagnosis, program design, type of reminder, and BCTs) are associated with the use of web-based self-management support programs. These results represent the first step in improving the tailoring of web-based self-management support programs. Future research on the interaction between patient and program characteristics should be conducted to improve the tailoring of participants to program components.

BackgroundPatients with severe mental illness with repeated interpersonal trauma and post-traumatic stress disorder (PTSD) have a negative illness progression. Traumas are often not treated because of their vulnerability. Narrative exposure therapy (NET) is an effective trauma therapy. It is unknown whether NET is effective and tolerable in these patients receiving community mental healthcare.ObjectivesThe objectives of this study are (1) to gain insights into patients’ experiences before, during, and after NET concerning changes in PTSD, dissociative and severe mental ill symptoms, care needs (CAN), quality of life, and global functioning; (2) to identify factors that influence diagnostic changes after NET as compared to patients’ experiences. These insights will help to decide whether NET should be incorporated in usual care for these patients.DesignA mixed methods convergent design consists of a grounded theory approach with thematic analysis followed by a merged analysis, comparing quantitative, and qualitative data for each participant and by means of a joint matrix.ParticipantsAdult psychiatric outpatients (age, 21–65) with post-traumatic stress disorder (PTSD) related to repeated interpersonal trauma were indicted for the study.MethodsBaseline demographics and clinical characteristics were assessed. Qualitative data were collected 3 months after NET using individual semi-structured in-depth interviews. The merged analysis compared quantitative and qualitative results for each participant.ResultsTwenty-three outpatients (female, 82%) with a mean age of 49.9 years (SD 9.8) participated in the study. Participants experienced NET as intensive, and most of them tolerated it well. Afterward, eighteen participants perceived less symptoms. Mixed analysis showed substantial congruency between quantitative scores and participants’ perceptions of PTSD, dissociative symptoms, and CAN (Cohen’s kappa > 0.4). Remission of PTSD was associated with sufficient experienced support.ConclusionOutpatients with severe mental illness underwent intensive NET, and most of them tolerate it well. This therapy is clearly efficacious in this group.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NL5608 (NTR5714)].

Abstract Background Various breast cancer (BC) treatments, such as chemotherapy and targeted therapies, increase cardiotoxicity-risk and lead to premature ischemic heart disease and heart failure among survivors. Reducing this adverse risk through early recognition and (preventive) treatment is therefore important. Conversely, we feel that screening for cardiotoxicity is currently insufficiently standardized in daily practice. A fundamental first step in identifying areas of improvement is providing an overview of current practice. Objective This study aims to describe current cardiac surveillance for women with BC during and after cardiotoxic cancer treatment, using routinely collected hospital data in the Netherlands. The study also describes hospital variation in cardiac surveillance. Methods This observational study was performed on claims data provided by Statistics Netherlands. From the data, newly diagnosed BC patients in 2013 (N = 16,040) were selected and followed up until 2015. Healthcare utilization analyses were performed for all cardiac and oncologic healthcare activities but with a specific focus on cardiac surveillance healthcare activities. In addition, differences between types and individual hospitals were evaluated. Results Almost one third of all BC patients received high risk cardiotoxic treatments (N = 5157), but cardiac surveillance was rarely performed. Cardiac care provided to patients mainly consisted of ECGs (52.0%) and MUGA scans (26.5%). Cardiac MRI was performed in 0.7% of the patients, echocardiography in 17.7%, and measurement of Troponin and NT-proBNP in 5.1 and 5.8%, respectively. Moreover, we observed a substantial variation in cardiac surveillance between different hospital types and between individual hospitals. Conclusion This study shows that women treated for BC with cardiotoxic treatments do not receive recommended cardiac surveillance. Standardized approaches in clinical care are lacking, resulting in low rates of diagnostic testing and a substantial variation in surveillance between hospitals. A structured approach and increased interprofessional collaboration could lead to tailored cardiac surveillance for early detection of cardiotoxicity and therefore start of treatment.

Abstract 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 ).

Abstract Background Undernutrition in surgical patients leads to a higher risk of postoperative complications like infections and delayed recovery of gastrointestinal functions, often resulting in a longer hospital stay and lower quality of life. Nurses at outpatient clinics can deliver nutritional care during outpatient preoperative evaluation of health status to ensure that patients are properly fed in preparation for hospital admission for surgery. However, nutritional nursing care was not determined in research yet. This paper describes the structural development of an Outpatient Nursing Nutritional Intervention (ONNI). Methods A project group followed the steps of the Intervention Mapping. The needs assessment included assessment of delivery of nutritional care and nutritional care needs at two anaesthesia outpatient clinics of an academic and a teaching hospital. Also, outpatient clinic nurses and patients at risk for undernutrition were interviewed. Determinants resulted from these methods were matched with theories on behaviour change and nutritional support. Results Both patients and nurses were unaware of the consequences of undernutrition, and nurses were also unaware of their roles with regard to nutritional support. The intervention goals were: 1) enabling surgical patients to improve or maintain their nutritional status before hospital admission for surgery, and 2) enabling nurses to deliver nutritional support. The ONNI was developed for outpatients at risk for or with undernutrition. A training was developed for nurses. The ONNI included the five following components: 1) identification of the causes of undernutrition; 2) provision of a nutritional care plan including general and individually tailored advice; 3) self-monitoring of nutrient intake; 4) counselling and encouragement; and 5) support during a telephone follow-up meeting. The intervention and training were tested. A multifaceted implementation strategy was used to deliver the intervention in daily practice. Conclusions Despite the unique position of the nurses at outpatient clinics, nurses were unaware of their role with regard to nutritional care. The ONNI was developed and implemented along with a training program for nurses. The test confirmed that the training can improve nurses’ knowledge, skills, and sense of responsibility for nutritional support. The intervention may empower patients to actively improve their nutritional status.

Abstract Background Current guidelines recommend that every person with Parkinson’s disease (PD) should have access to Parkinson’s disease nurse specialist (PDNS) care. However, there is little scientific evidence of the cost-effectiveness of PDNS care. This hampers wider implementation, creates unequal access to care, and possibly leads to avoidable disability and costs. Therefore, we aim to study the (cost-)effectiveness of specialized nursing care provided by a PDNS compared with usual care (without PDNS) for people with PD in all disease stages. To gain more insight into the deployed interventions and their effects, a preplanned subgroup analysis will be performed on the basis of disease duration (diagnosis 10 years ago). Methods We will perform an 18-month, single-blind, randomized controlled clinical trial in eight community hospitals in the Netherlands. A total of 240 people with PD who have not been treated by a PDNS over the past 2 years will be included, independent of disease severity or duration. In each hospital, 30 patients will randomly be allocated in a 1:1 ratio to receive either care by a PDNS (who works according to a recent guideline on PDNS care) or usual care. We will use two co-primary outcomes: quality of life (measured with the Parkinson’s Disease Questionnaire-39) and motor symptoms (measured with the Movement Disorders Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale part III). Secondary outcomes include nonmotor symptoms, health-related quality of life, experienced quality of care, self-management, medication adherence, caregiver burden, and coping skills. Data will be collected after 12 months and 18 months by a blinded researcher. A healthcare utilization and productivity loss questionnaire will be completed every 3 months. Discussion The results of this trial will have an immediate impact on the current care of people with PD. We hypothesize that by offering more patients access to PDNS care, quality of life will increase. We also expect healthcare costs to remain equal because increases in direct medical costs (funding additional nurses) will be offset by a reduced number of consultations with the general practitioner and neurologist. If these outcomes are reached, wide implementation of PDNS care will be warranted. Trial registration ClinicalTrials.gov, NCT03830190. Registered February 5, 2019 (retrospectively registered).

Objectives: In the post-surgical setting, active involvement of family caregivers has the potential to improve patient outcomes by prevention of surgical complications that are sensitive to fundamental care. This paper describes the development of a theoretically grounded program to enhance the active involvement of family caregivers in fundamental care for post-surgical patients. Methods: We used a quality improvement project following a multi-phase design. In Phase 1, an iterative method was used to combine evidence from a narrative review and professionals’ preferences. In Phase 2, the logic model underlying the program was developed guided by four steps: (1) confirm situation, intervention aim, and target population; (2) documented expected outcomes, and outputs of the intervention; (3) identify and describe assumptions, external factors and inputs; and (4) confirm intervention components. Results: Phase 1 identified a minimum set of family involvement activities that were both supported by staff and the narrative review. In Phase 2, the logic model was developed and includes (1) the inputs (e.g. educational- and environmental support), (2) the ultimate outcomes (e.g. reduction of postoperative complications), (3) the intermediate outcomes (e.g. behavioural changes), and (4) immediate outcomes (e.g. improved knowledge, skills and attitude). Conclusions: We demonstrated how we aimed to change our practice to an environment in which family caregivers were stimulated to be actively involved in postoperative care on surgical wards, and how we took different factors into account. The description of this program may provide a solid basis for professionals to implement the family involvement program in their own setting. Keywords: Family caregivers, Hospital surgery department, Nursing care, Nursing models, Quality improvement

Abstract Background E-mental health holds promise for people with severe mental illness, but has a limited evidence base. This study explored the effect of e-health added to face-to-face delivery of the Illness Management and Recovery Programme (e-IMR). Method In this multi-centre exploratory cluster randomized controlled trial, seven clusters (n = 60; 41 in intervention group and 19 in control group) were randomly assigned to e-IMR + IMR or IMR only. Outcomes of illness management, self-management, recovery, symptoms, quality of life, and general health were measured at baseline (T0), halfway (T1), and at twelve months (T2). The data were analysed using mixed model for repeated measurements in four models: in 1) we included fixed main effects for time trend and group, in 2) we controlled for confounding effects, in 3) we controlled for interaction effects, and in 4) we performed sub-group analyses within the intervention group. Results Notwithstanding low activity on e-IMR, significant effects were present in model 1 analyses for self-management (p = .01) and recovery (p = .02) at T1, and for general health perception (p = .02) at T2, all in favour of the intervention group. In model 2, the confounding covariate gender explained the effects at T1 and T2, except for self-management. In model 3, the interacting covariate non-completer explained the effects for self-management (p = .03) at T1. In model 4, the sub-group analyses of e-IMR-users versus non-users showed no differences in effect. Conclusion Because of confounding and interaction modifications, effectiveness of e-IMR cannot be concluded. Low use of e-health precludes definite conclusions on its potential efficacy. Low use of e-IMR calls for a thorough process evaluation of the intervention. Trial registration The Dutch Trial Register (NTR4772)

Background Interpersonal trauma and post-traumatic stress disorder (PTSD) in patients with severe mental illness (SMI) negatively affect illness course. Narrative exposure therapy (NET) is effective in vulnerable patient groups, but its efficacy and applicability has not been studied in out-patients with SMI. Aims We aimed to evaluate the efficacy and applicability of NET in SMI on changes in PTSD, dissociation, SMI symptoms, care needs, quality of life, global functioning and care consumption. Method The study had a single-group, pre-test–post-test, repeated-measures design and was registered in The Netherlands National Trial Register (identifier TR571). Primary outcomes were assessed at pre-treatment (T0), 1 month post-treatment (T1) and 7 months’ follow-up (T2), with a structured interview for PTSD and dissociation screening. Secondary outcomes followed routinely SMI measurements and medical data. Mixed models were used for data analysis. Results The majority of the 23 participants was female (82%). Mean age was 49.9 years (s.d. 9.8) and mean PTSD duration was 24.1 years (s.d. 14.5). Mean PTSD severity decreased from 37.9 at T0 to 31.9 at T1 (−6.0 difference, 95%CI −10.0 to −2.0), and decreased further to 24.5 at T2 (−13.4 difference, 95%CI −17.4 to −9.4). Dissociation, SMI symptoms, duration of contacts, and medication decreased; global functioning increased; and quality of life and perceived needs did not change. Eleven participants were in remission for PTSD at T2, of which five were also in remission for major depression. Conclusions NET appeared efficacious and applicable to out-patients with SMI and PTSD, and was well tolerated.

IntroductionThe work environment of healthcare professionals is important for good patient care and is receiving increasing attention in scientific research. A clear and unambiguous understanding of a positive work environment, as perceived by healthcare professionals, is crucial for gaining systematic objective insights into the work environment. The aim of this study was to gain consensus on the concept of a positive work environment in the hospital.MethodsThis was a three-round Delphi study to establish consensus on what defines a positive work environment. A literature review and 17 semi-structured interviews with experts (transcribed and analyzed by open and thematic coding) were used to generate items for the Delphi study.ResultsThe literature review revealed 228 aspects that were clustered into 48 work environment elements, 38 of which were mentioned in the interviews also. After three Delphi rounds, 36 elements were regarded as belonging to a positive work environment in the hospital.DiscussionThe work environment is a broad concept with several perspectives. Although all 36 elements are considered important for a positive work environment, they have different perspectives. Mapping the included elements revealed that no one work environment measurement tool includes all the elements.ConclusionWe identified 36 elements that are important for a positive work environment. This knowledge can be used to select the right measurement tool or to develop interventions for improving the work environment. However, the different perspectives of the work environment should be considered.

Breast cancer (BC) patients have an increased risk of developing cancer therapy-related cardiac dysfunction (CTRCD) and cardiovascular morbidity, which seems to have a substantial prognostic impact. Oncologists, in collaboration with dedicated cardiologists, have the opportunity to perform cardiovascular risk stratification. Despite guideline recommendations, strategies to detect cardiac damage at an early stage are not structurally implemented in clinical practice. The perspectives of oncology professionals regarding cardiac surveillance in BC patients have not been qualitatively evaluated. We aim to explore the perceptions of oncology professionals regarding cardiac surveillance in BC patients and, more specifically, the influencing factors of delivering cardiac surveillance. A qualitative study with semi-structured interviews was conducted and thematically analyzed. Twelve oncology professionals participated in this study. Four themes were selected to answer the study objectives: (1) sense of urgency, (2) multidisciplinary collaboration, (3) patient burden, and (4) practical tools for cardiac surveillance. Most professionals did not feel the need to deliver cardiac surveillance as they considered the incidence of CTRCD as rare. Multidisciplinary collaboration was also perceived as unnecessary, and cardiac surveillance was considered disproportionately burdensome with respect to its benefits. Nevertheless, professionals affirmed the need for practical tools to deliver cardiac surveillance. Most professionals are currently unaware of CTRCD incidence and cardiac surveillance benefits. Encouraging multidisciplinary collaboration and improving their knowledge of cardiotoxic effects of treatments and possibility of early detection can lead to structured cardiac surveillance for breast cancer patients.

Patients with stroke admitted at the neurology/neurosurgery ward of the Academic Medical Centre in Amsterdam, The Netherlands, may experience problems in communication, such as aphasia, severe confusion/delirium or severe language barriers. This may prevent self-reported pain assessment; therefore, pain behaviour observation scales are needed. In this project, we therefore aimed to implement the Rotterdam Elderly Pain Observation Scale (REPOS) by video training.We used a stepped-wedge cluster design with clusters of four to five nurses with intervals of 2 weeks, for a total study duration of 34 weeks. Primary endpoint was the proportion of shifts in which nurses used the REPOS when caring for an eligible patient. A questionnaire was send biweekly to assess self-perceived competence and attitude on pain measurement in patients able or unable to self-report pain intensity. No other strategies were used to promote the use of the REPOS.Though the proportion of shifts in which trained nurses cared for eligible patients increased from 0% at baseline to 83% at the end of the study, the proportion of cumulative shifts where the REPOS was used decreased from 14% to 6%, respectively. Process evaluation suggests that this decrease can (in part) be attributed to low and varying prevalence of eligible patients and opportunities for practice. In total, 24 (45.3%) nurses had used the REPOS at least once after 34 weeks, with a median of two times (1–33). Nurses perceived themselves 'competent' to 'very competent' in pain behaviour observation. There was no negative attitude towards pain measurement.This study shows that education alone may not be effective when implementing a pain behaviour observation scale for non-communicative patients with Acquired Brain Injury. Individual motivation of health professionals and individual patient factors may be of influence for the use of the REPOS.

BackgroundOne-third of all medication errors causing harm to hospitalized patients occur in the medication preparation and administration phase, which is predominantly a nursing activity. To monitor, evaluate and improve the quality and safety of this process, evidence-based quality indicators can be used.ObjectivesThe aim of study was to identify evidence-based quality indicators (structure, process and outcome) for safe in-hospital medication preparation and administration.MethodsMEDLINE, EMBASE and CINAHL were searched for relevant studies published up to January 2015. Additionally, nine databases were searched to identify relevant grey literature. Two reviewers independently selected studies if (1) the method for quality indicator development combined a literature search with expert panel opinion, (2) the study contained quality indicators on medication safety, and (3) any of the quality indicators were applicable to hospital medication preparation and administration. A multidisciplinary team appraised the studies independently using the AIRE instrument, which contains four domains and 20 items. Quality indicators applicable to in-hospital medication preparation and administration were extracted using a structured form.ResultsThe search identified 1683 studies, of which 64 were reviewed in detail and five met the inclusion criteria. Overall, according to the AIRE domains, all studies were clear on purpose; most of them applied stakeholder involvement and used evidence reasonably; usage of the indicator in practice was scarcely described. A total of 21 quality indicators were identified: 5 structure indicators (e.g. safety management and high alert medication), 11 process indicators (e.g. verification and protocols) and 5 outcome indicators (e.g. harm and death). These quality indicators partially cover the 7 rights.ConclusionDespite the relatively small number of included studies, the identified quality indicators can serve as an excellent starting point for further development of nursing specific quality indicators for medication safety. Especially on the right patient, right route, right time and right documentation there is room future development of quality indicators.

BACKGROUND: Hospitals are constantly being challenged to provide high-quality care despite ageing populations, diminishing resources, and budgetary restraints. While the costs of care depend on the patients' needs, it is not clear which patient characteristics are associated with the demand for care and inherent costs. The aim of this study was to ascertain which patient-related characteristics or models can predict the need for medical and nursing care in general hospital settings. METHODS: We systematically searched MEDLINE, Embase, Business Source Premier and CINAHL. Pre-defined eligibility criteria were used to detect studies that explored patient characteristics and health status parameters associated to the use of hospital care services for hospitalized patients. Two reviewers independently assessed study relevance, quality with the STROBE instrument, and performed data analysis. RESULTS: From 2,168 potentially relevant articles, 17 met our eligibility criteria. These showed a large variety of factors associated with the use of hospital care services; models were found in only three studies. Age, gender, medical and nursing diagnoses, severity of illness, patient acuity, comorbidity, and complications were the characteristics found the most. Patient acuity and medical and nursing diagnoses were the most influencing characteristics. Models including medical or nursing diagnoses and patient acuity explain the variance in the use of hospital care services for at least 56.2%, and up to 78.7% when organizational factors were added. CONCLUSIONS: A larger variety of factors were found to be associated with the use of hospital care services. Models that explain the extent to which hospital care services are used should contain patient characteristics, including patient acuity, medical or nursing diagnoses, and organizational and staffing characteristics, e.g., hospital size, organization of care, and the size and skill mix of staff. This would enable healthcare managers at different levels to evaluate hospital care services and organize or reorganize patient care.

Medication administration errors are common, costly and the cause of adverse events in clinical practice. Interruptions during medication administration rounds are thought to be a prominent causative factor of these medication errors. In this observational study, data were collected on the number and duration of several different sources of verbal and non-verbal interruptions using unobtrusive structured observations on 32 medication administration rounds. Interruptions occurred very often (6.9 times per nurse each hour), differed in frequency among the medication administration rounds and were from a variety of sources. The most frequent interruptions were caused by nursing colleagues (43%) and non-verbal interruptions from the ward environment (25%), such as noises from pagers, conversations in the vicinity of the nurse, the work of cleaners, or stock management by pharmacy staff. The longest durations of interruptions were from nursing colleagues’ verbal interrup- interruptions. When comparing the medication rounds, more and longer interruptions were observed during the morning rounds than those at noon. A comparison between surgical and non-surgical units showed that interruptions occurred more often and lasted longer in non-surgical units than those in surgical units. But the observed differences were not statistically significant. In conclusion, interruptions during medication administration rounds are frequent and originated from different human and environmental sources. Interventions should target not only interruptions by colleagues, but should also consider ways to reduce self-initiated interruptions and those arising from the immediate ward environment.