Accountability in healthcare in the Netherlands: A scoping review.

For better serving people's complex needs the subsequent movement to person-centred integrated care, requires inter-organisational cooperation and service provision by domain-overarching networks and alliances. In the development to these networks, it is relevant to explore which accountability approaches are appropriate for local inter-organisational healthcare governance. Therefore, in a scoping review we studied the current state of knowledge and practice of accountability in healthcare in the Netherlands. We found that two of the included 41 studies show characteristics of accountability towards healthcare with characteristics of integration care components, such as integration of services with accompanying accountability arrangements and development of networked accountability. The first studies are found in the literature which report on accountability in integrated care. With this we add to the international discussion about accountability as an aspect of integrated care governance, by providing insight into the current state of art of accountability in Dutch healthcare.

Hospital and home care nurses' experiences and perceptions regarding nutritional care for older adults to prevent and treat malnutrition: A cross-sectional study.

AIMS AND OBJECTIVES: To gain insight into the experiences and perceptions of hospital and home care nurses regarding nutritional care for older adults to prevent and treat malnutrition. BACKGROUND: In-depth knowledge about hospital and home care nurses' experiences and perceptions can contribute to optimise nutritional care for older adults across the care continuum between hospital and home to prevent and treat malnutrition. DESIGN: Multicentre cross-sectional descriptive study. METHOD: A validated questionnaire addressing malnutrition was used. A total of 1,135 questionnaires were sent to hospital and home care nurses. The STROBE statement was followed for reporting. RESULTS: The response rate was 49% (n = 556). Of all the nurses, 37% perceived the prevalence of malnutrition among their care recipients between 10% and 25%. Almost 22% of the nurses neither agreed nor disagreed or disagreed with the statement that prevention of malnutrition is possible. More than 28% of the nurses reported that malnutrition is a small or no problem. Over 95% of the hospital nurses and 52.5% of the home care nurses stated they screened routinely for malnutrition. The nurses considered several interventions for treating malnutrition important. Over 81% of the nurses indicated they wanted to follow further training. CONCLUSION: Most hospital and home care nurses perceived that nutritional care for older adults to prevent and treat malnutrition was important. A fair group of nurses, however, had the opposite perception. RELEVANCE TO CLINICAL PRACTICE: Raising the awareness of all hospital and home care nurses about the importance of nutritional care for older adults is pivotal to increase the chance of successfully providing nursing nutritional care. Nurses should follow training for consolidation of nutritional care. Nurses are well-positioned to take a leadership role to improve continuity and quality of nutritional care across the care continuum between hospital and home.

Using intervention mapping to develop an outpatient nursing nutritional intervention to improve nutritional status in undernourished patients planned for surgery.

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.

Interventions to prevent and treat malnutrition in older adults to be carried out by nurses: A systematic review.

AIMS AND OBJECTIVES: To identify interventions to prevent and treat malnutrition in older adults, which can be integrated in nursing care, and to evaluate the effects of these interventions on outcomes related to malnutrition. BACKGROUND: Older adults are at great risk for malnutrition, which can lead to a number of serious health problems. Nurses have an essential role in nutritional care for older adults. Due to a lack of evidence for nursing interventions, adequate nursing nutritional care still lags behind. DESIGN: Systematic review. METHOD: We searched for and included randomised controlled trials on interventions, which can be integrated in nursing care for older adults, to prevent and treat malnutrition. We assessed the risk of bias with the Cochrane tool and evidence for outcomes with the GRADE. The PRISMA statement was followed for reporting. RESULTS: We included 21 studies of which 14 studies had a high risk of bias. Identified interventions were oral nutritional supplements, food/fluid fortification or enrichment, dietary counselling and educational interventions. In evaluating the effects of these interventions on 11 outcomes related to malnutrition, significant and nonsignificant effects were found. We graded the certainty of evidence as very low to moderate. CONCLUSION: Although slight effects were found in protein intake and body mass index, there is no convincing evidence about the effectiveness of the four identified interventions. There seems no harm in using these interventions, although it should be kept in mind that the evidence is sparse. Therefore, there is a need for high-quality research in building evidence for interventions in nursing nutritional care. RELEVANCE TO CLINICAL PRACTICE: Nurses can safely provide oral nutritional supplements and food/fluid fortification or enrichment, and give dietary counselling and education to older adults, as they are well placed to lead the essential processes of nutritional care to older adults.

Outpatient preoperative oral nutritional support for undernourished surgical patients: A systematic review.

AIMS AND OBJECTIVES: To evaluate the effects of preoperative nutritional support using a regular diet for undernourished surgical patients at the outpatient clinic. BACKGROUND: Undernutrition (or malnutrition) in surgical patients has severe consequences, that is, more complications, longer hospital stay and decreased quality of life. While systematic reviews show the effects of oral nutritional supplements (ONS), enteral and parenteral nutrition in surgical patients, the effects of normal foods and regular diets remain unclear. DESIGN: A systematic review. METHODS: PubMed, CINAHL, Web of Science, PsycINFO, Cochrane Library and EMBASE were searched up to July 24, 2017. Studies on undernourished patients receiving nutritional support using regular or therapeutic diet, performed preoperatively at the outpatient clinic, were considered eligible. Risk of bias was assessed using the Cochrane Risk of Bias tool. Two reviewers independently performed study selection, quality assessment and data extraction. RESULTS: Six studies with moderate risk of bias were included. Interventions were preoperatively performed in mainly oncological outpatients by dieticians and aimed to reach nutrient requirements. Interventions included consults for counselling and advice, follow-up meetings and encouragements, and ONS. Nutritional status, nutrient intake and quality of life improved in supported patients. Improvements were better in counselled patients compared to patients using supplements. Unsupported patients experienced worse outcomes. CONCLUSION: Frequent consults with counselling and advice as nutritional support for undernourished patients before surgery result in improvements to nutritional status, intake and quality of life. This statement is supported by weak evidence due to few studies and inadequate methods. RELEVANCE TO CLINICAL PRACTICE: Nutritional support should be provided to all undernourished surgical patients during preoperative course. Nurses are in key position to provide nutritional support during outpatient preoperative evaluations.

Understanding Older People's Readiness for Receiving Telehealth: Mixed-Method Study.

BACKGROUND: The Dutch Ministry of Health has formulated ambitious goals concerning the use of telehealth, leading to subsequent changes compared with the current health care situation, in which 93% of care is delivered face-to-face. Since most care is delivered to older people, the prospect of telehealth raises the question of whether this population is ready for this new way of receiving care. To study this, we created a theoretical framework consisting of 6 factors associated with older people's intention to use technology. OBJECTIVE: The objective of this study was to understand community-dwelling older people's readiness for receiving telehealth by studying their intention to use videoconferencing and capacities for using digital technology in daily life as indicators. METHODS: A mixed-method triangulation design was used. First, a cross-sectional survey study was performed to investigate older people's intention to use videoconferencing, by testing our theoretical framework with a multilevel path analysis (phase 1). Second, for deeper understanding of older people's actual use of digital technology, qualitative observations of older people executing technological tasks (eg, on a computer, cell phone) were conducted at their homes (phase 2). RESULTS: In phase 1, a total of 256 people aged 65 years or older participated in the survey study (50.0% male; median age, 70 years; Q1-Q3: 67-76). Using a significance level of .05, we found seven significant associations regarding older people's perception of videoconferencing. Older people's (1) intention to use videoconferencing was predicted by their performance expectancy (odds ratio [OR] 1.26, 95% CI 1.13-1.39), effort expectancy (OR 1.23, 95% CI 1.07-1.39), and perceived privacy and security (OR 1.30, 95% CI 1.17-1.43); (2) their performance expectancy was predicted by their effort expectancy (OR 1.38, 95% CI 1.24-1.52); and (3) their effort expectancy was predicted by their self-efficacy (OR 1.55, 95% CI 1.42-1.68). In phase 2, a total of 6 men and 9 women aged between 65 and 87 years participated in the qualitative observation study. Of the primary themes, 5 themes were identified that could provide greater understanding of older people's capacities and incapacities in using digital technology: (1) "self-efficacy and digital literacy," (2) "obstacles to using technology," (3) "prior experience and frequency of use," (4) "sources of support and facilitating conditions," and (5) "performance expectancy." These 5 themes recurred in all 15 observations. CONCLUSIONS: Performance expectancy, effort expectancy, and perceived privacy and security are direct predictors of older people's intention to use videoconferencing. Self-efficacy appeared to play a role in both older people's intention to use, as well as their actual use of technology. The path analysis revealed that self-efficacy was significantly associated with older people's effort expectancy. Furthermore, self-efficacy and digital literacy appeared to play a major role in older people's capacities to make use of digital technology.

Basic nursing care: The most provided, the least evidence based - A discussion paper.

AIMS AND OBJECTIVES: To describe and discuss the "Basic Care Revisited" (BCR) research programme, a collaborative initiative that contributes to evidence-based basic nursing care and raises awareness about the importance of basic nursing care activities. BACKGROUND: While basic nursing care serves nearly all people at some point in their lifetime, it is poorly informed by evidence. There is a need to prioritise and evaluate basic nursing care activities to improve patient outcomes and improve the quality of care. DESIGN: Discussion paper METHOD: The discussion presented in this paper is based on nursing literature and theory and supported by the authors' clinical and research experiences. We present the developmental process and content of a research programme called "Basic Care Revisited" (BCR) as a solution to move forward and improve basic nursing care. DISCUSSION: To prioritise basic nursing care, we propose a research programme entitled "Basic Care Revisited" that aims to create awareness and expand knowledge on evidence-based basic nursing care by addressing four basic nursing care themes (bathing and dressing, communication, mobility, and nutrition) in different settings. The paper discusses a pathway to create a sustainable and productive research collaborative on basic nursing care and addresses issues to build research capacity. RELEVANCE TO CLINICAL PRACTICE: Revaluation of these important nursing activities will not only positively influence patient outcomes, but also have an impact on staff outcomes and organisational outcomes.

In-hospital risk prediction for post-stroke depression: development and validation of the Post-stroke Depression Prediction Scale.

BACKGROUND AND PURPOSE: The timely detection of post-stroke depression is complicated by a decreasing length of hospital stay. Therefore, the Post-stroke Depression Prediction Scale was developed and validated. The Post-stroke Depression Prediction Scale is a clinical prediction model for the early identification of stroke patients at increased risk for post-stroke depression. METHODS: The study included 410 consecutive stroke patients who were able to communicate adequately. Predictors were collected within the first week after stroke. Between 6 to 8 weeks after stroke, major depressive disorder was diagnosed using the Composite International Diagnostic Interview. Multivariable logistic regression models were fitted. A bootstrap-backward selection process resulted in a reduced model. Performance of the model was expressed by discrimination, calibration, and accuracy. RESULTS: The model included a medical history of depression or other psychiatric disorders, hypertension, angina pectoris, and the Barthel Index item dressing. The model had acceptable discrimination, based on an area under the receiver operating characteristic curve of 0.78 (0.72-0.85), and calibration (P value of the U-statistic, 0.96). Transforming the model to an easy-to-use risk-assessment table, the lowest risk category (sum score, <-10) showed a 2% risk of depression, which increased to 82% in the highest category (sum score, >21). CONCLUSIONS: The clinical prediction model enables clinicians to estimate the degree of the depression risk for an individual patient within the first week after stroke.

Development of a microlearning intervention regarding nursing nutritional care for older adults: A multi-methods study.

BACKGROUND: Nutritional care for older adults provided by hospital and home care nurses and nursing assistants is suboptimal. This is due to several factors including professionals' lack of knowledge and low prioritisation. Affecting these factors may promote nurses' and nursing assistants' behavioral change and eventually improve nutritional care. To increase the likelihood of successfully targeting these factors, an evidence-based educational intervention is needed. OBJECTIVES: To develop an educational intervention for hospital and home care nurses and nursing assistants to promote behaviour change by affecting factors that influence current behaviour in nutritional care for older adults. In this paper, we describe the intervention development process. DESIGN: A multi-methods approach using literature and expert input. SETTINGS: Hospital and home care. PARTICIPANTS: Older adults, nurses, nursing assistants, experts, and other professionals involved in nutritional care. METHODS: The educational intervention was based on five principles: 1) interaction between intervention and users, 2) targeting users on both individual and team level, 3) supporting direct and easy transfer to the workplace, and continuous learning, 4) facilitating learning within an appropriate period, and 5) fitting with the context. Consistent with these principles, the research team focussed on developing a microlearning intervention and they established consensus on seven features of the intervention: content, provider, mode of delivery, setting, recipient, intensity, and duration. RESULTS: The intervention consisted of 30 statements about nursing nutritional care for older adults, which nurses and nursing assistants were asked to confirm or reject, followed by corresponding explanations. These can be presented in a snack-sized way, this means one statement per day, five times a week over a period of six weeks through an online platform. CONCLUSIONS: Based on a well-founded and comprehensive procedure, the microlearning intervention was developed. This intervention has the potential to contribute to nursing nutritional care for older adults.

Threats and Interventions on Wellbeing in Asylum Seekers in the Netherlands: A Scoping Review.

Background: Most asylum seekers experience stress, not only due to the reason for fleeing and their travel but also due to their compulsory stay in the asylum seeker center in the Netherlands and the asylum procedure. This often leads to self-medication and addiction which causes lower self-esteem and lower quality of life. Adverse life events, forced migration, and prolonged asylum procedures, in addition to the complexity of the acculturation process, can all contribute to higher levels of psychopathology. Objective: What are the threats to wellbeing in terms of mental health, psychosocial, and addiction problems, and what are the effective interventions for wellbeing for asylum seekers in asylum seeker centers in the Netherlands, reported in the literature? Method: Following the descriptive nature of the research question and the need for identifying knowledge gaps, an overview of existing knowledge was created by executing a scoping review on influencing factors on the mental health of asylum seekers. The Neuman system model was used as a guiding framework to understand the complexity of the issues this population experience and to identify the stressors and the factors which cause the imbalance and also the disease. Results: The literature review resulted in 26 articles that met the criteria for inclusion. The threats included the influence of staying in the environment of an asylum seekers center, drug abuse among asylum seekers, health-care professionals and employees who do not detect or underestimate the underlying suffering of asylum seekers, and frequent relocations of asylum seekers. The two assessment instruments used were the Rapid-Assessment-Response method (RAR method) and the Health Information Assessment Tool Asylum Seeker tool (HIATUS tool). Finally, the five interventions were identified: therapy for asylum seekers diagnosed with post-traumatic stress disorder (PSTD), art therapy, education focused on prevention as intervention, cultural interview, and mindspring. Conclusion: The knowledge on identifying and reducing threats, assessment, and treatment interventions for asylum seekers living in an asylum seekers center found in the literature provided perspectives on improving their wellbeing. The great diversity of cultural aspects and continuous changes in the number and origin of refugees in the Dutch asylum seekers centers disrupted the continuity of care.

Factors Influencing Nurses' Behavior in Nutritional Care for Community-Dwelling Older Adults Before, During, and After Hospitalization: A Delphi Study.

Background To improve nutritional care for community-dwelling older adults before, during, and after hospitalization, factors influencing nurses' current behavior should be targeted. The aim of this study was to obtain expert consensus on which factors influencing the behavior of hospital and home care nurses are most relevant, modifiable, and feasible to influence. Method In a two-round Delphi study, nine pre-selected factors were rated by 26 experts. Results Eight factors were rated as relevant, modifiable, and feasible to influence: (1) lack of sufficient knowledge, (2) mainly neutral attitude, (3) low prioritization, (4) ambiguous motivation to routinely use guidelines and screening tools, (5) moderate awareness about risk factors, (6) lack of sense of involving informal caregivers, (7) ambiguous motivation to follow education and training, and (8) strong focus on medical nutrition. Conclusion The expert panel reached consensus on eight factors influencing nurses' current behavior. To enhance nutritional care to prevent malnutrition in older adults, strategies are needed for targeting these factors in nursing practice, education, and research. [J Contin Educ Nurs. 2022;53(12):545-556.].

Prediction models for prolonged intensive care unit stay after cardiac surgery: systematic review and validation study.

BACKGROUND: Several models have been developed to predict prolonged stay in the intensive care unit (ICU) after cardiac surgery. However, no extensive quantitative validation of these models has yet been conducted. This study sought to identify and validate existing prediction models for prolonged ICU length of stay after cardiac surgery. METHODS AND RESULTS: After a systematic review of the literature, the identified models were applied on a large registry database comprising 11 395 cardiac surgical interventions. The probabilities of prolonged ICU length of stay based on the models were compared with the actual outcome to assess the discrimination and calibration performance of the models. Literature review identified 20 models, of which 14 could be included. Of the 6 models for the general cardiac surgery population, the Parsonnet model showed the best discrimination (area under the receiver operating characteristic curve=0.75 [95% confidence interval, 0.73 to 0.76]), followed by the European system for cardiac operative risk evaluation (EuroSCORE) (0.71 [0.70 to 0.72]) and a model by Huijskes and colleagues (0.71 [0.70 to 0.73]). Most of the models showed good calibration. CONCLUSIONS: In this validation of prediction models for prolonged ICU length of stay, 2 widely implemented models (Parsonnet, EuroSCORE), although originally designed for prediction of mortality, were superior in identifying patients with prolonged ICU length of stay.

Older Adults' and Their Informal Caregivers' Experiences and Needs regarding Nutritional Care Provided in the Periods before, during and after Hospitalization: A Qualitative Study.

To enhance prevention and treatment of malnutrition in older adults before, during and after hospitalization, deeper understanding of older adults' and informal caregivers' perspective on nutritional care is important. One-time in-depth interviews were conducted with 15 older adults who had been discharged from hospital, and seven informal caregivers. We explored their experiences and needs regarding nutritional care provided in the periods before, during and after hospitalization. Five themes emerged from the data: (1) dietary intake, (2) food service during hospitalization, (3) nutrition-related activities, (4) whose job it is to give nutritional care, and (5) competing care priorities. Further, several opinions about nutritional issues were identified. Older adults and informal caregivers did not always experience optimal nutritional care. When discussing nutritional care, they mainly focused on the in-hospital period. When providing nutritional care and developing guidelines, older adults' and informal caregivers' perspective on nutritional care should be incorporated. Here, the periods before, during and after hospitalization should be taken into account equally.

Educational intervention to increase nurses' knowledge, self-efficacy and usage of telehealth: A multi-setting pretest-posttest study.

The widespread use of telehealth, providing healthcare remotely, is hampered by various barriers. Dutch nurses currently working in practice never received education in this new way of healthcare delivery. Education is frequently suggested as a strategy to overcome barriers in telehealth use. However, the nature and effectiveness of such education has not yet been specified and tested in practice. In a previous study, we identified 14 nursing telehealth activities and accompanying competencies. In the current study, we established the effectiveness of training in these competencies on nurses' subjective knowledge, self-efficacy and usage of telehealth. A two-day tailored training program in nursing telehealth activities was evaluated in a Dutch context among 37 participants across three settings: (a) twelve primary care (PC), (b) fourteen homecare (HC) and (c) eleven hospital (H) nurses. In each team, telehealth knowledge significantly increased during the training sessions. In each team, nurses' telehealth self-efficacy also significantly increased 6-10 weeks after the training. After the training, the number of remote consultations increased from 2 to 12 in primary care, 12 to 35 in homecare and decreased from 28 to 17 in the hospital setting. We conclude that training nurses in telehealth activities contributes to their knowledge and self-efficacy.

Hospital Nurses' Self-Reported Confidence in Their Telehealth Competencies.

BACKGROUND: The diffusion of telehealth into hospital care is still low, partially because of a lack of telehealth competence among nurses. In an earlier study, we reported on the knowledge, skills, and attitudes (KSAs) nurses require for the use of telehealth. The current study describes hospital nurses' confidence in possessing these telehealth KSAs. METHOD: In a cross-sectional study, we invited 3,543 nurses from three hospitals in the Netherlands to rate their self-confidence in 31 telehealth KSAs on a 5-point Likert scale, using an online questionnaire. RESULTS: A total of 1,017 nurses responded to the survey. Nine KSAs were scored with a median value of 4.0, 19 KSAs with a median value of 3.0, and three KSAs with a median value of 2.0. CONCLUSION: Given that hospital nurses have self-confidence in only nine of the 31 essential telehealth KSAs, continuing education in additional KSAs is recommended to support nurses in gaining confidence in using telehealth. [J Contin Educ Nurs. 2019;50(1):26-34.].

Implementation, Mechanisms of Effect and Context of an Integrated Care Intervention for Vulnerable Families in Central Sydney Australia: A Research and Evaluation Protocol.

INTRODUCTION: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. In response, a family-centred, population-based, integrated care initiative for vulnerable families and their children in Sydney, Australia was developed. The initiative was called Healthy Homes and Neighbourhoods. A realist translational social epidemiology programme of research and collaborative design is at the foundation of its evaluation. THEORY AND METHOD: The UK Medical Research Council (MRC) Framework for evaluating complex health interventions was adapted. This has four components, namely 1) development, 2) feasibility/piloting, 3) evaluation and 4) implementation. We adapted the Framework to include: critical realist, theory driven, and continuous improvement approaches. The modified Framework underpins this research and evaluation protocol for Healthy Homes and Neighbourhoods. DISCUSSION: The NSW Health Monitoring and Evaluation Framework did not make provisions for assessment of the programme layers of context, or the effect of programme mechanism at each level. We therefore developed a multilevel approach that uses mixed-method research to examine not only outcomes, but also what is working for whom and why.

Validity of a screening method for delirium risk in older patients admitted to a general hospital in the Netherlands.

OBJECTIVE: Delirium is an impactful, frequently occurring complication in older hospital patients. Consequently, risk stratification of delirium was included in a set of mandatory safety measures in general hospitals in the Netherlands. This risk stratification contains three consensus-based questions that have not been validated. Therefore, we evaluated their predictive performance and examined whether other routinely collected patient data can improve the prediction of delirium. METHOD: Using data from a continuous data registry from a general hospital, the prediction of the three questions was compared with the occurrence of delirium in 3786 older patients. Regression models were fitted that included other patient-related delirium risk factors. The performance was expressed by discrimination and calibration. RESULTS: Delirium occurrence was 16.8%. The three questions, a regression model with the three questions, a full model and a reduced model - including the three questions, age, use of glasses, number of medications and Katz-ADL - showed sensitivities of 0.88, 0.88, 0.92 and 0.91 and specificities of 0.52, 0.52, 0.53 and 0.54, when treated as dichotomous models respectively. The three risk models had C-statistics of 0.81, 0.86 and 0.86, with excellent p-values of the U-statistics. CONCLUSION: The three risk-stratification questions show promising results but substantial overprediction (49% predicting positive). Further validation should be done outside the Netherlands, given the potential bias as a result of clinical activities following the risk stratification. The reduced model shows excellent calibration performance, indicating good prediction in each individual patient. In clinical practice, this advantage adds to clinical reasoning.

Increasing value and reducing waste by optimizing the development of complex interventions: Enriching the development phase of the Medical Research Council (MRC) Framework.

BACKGROUND: In recent years there has been much emphasis on 'research waste' caused by poor question selection, insufficient attention to previous research results, and avoidable weakness in research design, conduct and analysis. Little attention has been paid to the effect of inadequate development of interventions before proceeding to a full clinical trial. OBJECTIVE: We therefore propose to enrich the development phase of the MRC Framework by adding crucial elements to improve the likelihood of success and enhance the fit with clinical practice METHODS: Based on existing intervention development guidance and synthesis, a comprehensive iterative intervention development approach is proposed. Examples from published reports are presented to illustrate the methodology that can be applied within each element to enhance the intervention design. RESULTS: A comprehensive iterative approach is presented by combining the elements of the MRC Framework development phase with essential elements from existing guidance including: problem identification, the systematic identification of evidence, identification or development of theory, determination of needs, the examination of current practice and context, modelling the process and expected outcomes leading to final element: the intervention design. All elements are drawn from existing models to provide intervention developers with a greater chance of producing an intervention that is well adopted, effective and fitted to the context. CONCLUSION: This comprehensive approach of developing interventions will strengthen the internal and external validity, minimize research waste and add value to health care research. In complex interventions in health care research, flaws in the development process immediately impact the chances of success. Knowledge regarding the causal mechanisms and interactions within the intended clinical context is needed to develop interventions that fit daily practice and are beneficial for the end-user.

Internet-Generation Nursing Students' View of Technology-Based Health Care.

BACKGROUND: Today's nursing school applicants are considered "digital natives." This study investigated students' views of new health care technologies. METHOD: In a cross-sectional survey among first-year nursing students, 23 common nursing activities and five telehealth nursing activities were presented along with three statements: "I consider this a core task of nursing," "I look forward to becoming trained in this task," and "I think I will do very well in performing this task." RESULTS: Internet-generation nursing students (n = 1,113) reported a significantly (p ⩽ .001) less positive view of telehealth activities than of common nursing activities. Median differences were 0.7 (effect size [ES], -0.54), 0.4 (ES, -0.48), and 0.3 (ES, -0.39), measured on a 7-point scale. CONCLUSION: Internet-generation nursing students do not naturally have a positive view of technology-based health care provision. The results emphasize that adequate technology and telehealth education is still needed for nursing students. [J Nurs Educ. 2017;56(12):717-724.].

HELP! Problems in executing a pragmatic, randomized, stepped wedge trial on the Hospital Elder Life Program to prevent delirium in older patients.

BACKGROUND: A pragmatic, stepped wedge trial design can be an appealing design to evaluate complex interventions in real-life settings. However, there are certain pitfalls that need to be considered. This paper reports on the experiences and lessons learned from the conduct of a cluster randomized, stepped wedge trial evaluating the effect of the Hospital Elder Life Program (HELP) in a Dutch hospital setting to prevent older patients from developing delirium. METHODS: We evaluated our trial which was conducted in eight departments in two hospitals in hospitalized patients aged 70 years or older who were at risk for delirium by reflecting on the assumptions that we had and on what we intended to accomplish when we started, as compared to what we actually realized in the different phases of our study. Lessons learned on the design, the timeline, the enrollment of eligible patients and the use of routinely collected data are provided accompanied by recommendations to address challenges. RESULTS: The start of the trial was delayed which caused subsequent time schedule problems. The requirement for individual informed consent for a quality improvement project made the inclusion more prone to selection bias. Most units experienced major difficulties in including patients, leading to excluding two of the eight units from participation. This resulted in failing to include a similar number of patients in the control condition versus the intervention condition. Data on outcomes routinely collected in the electronic patient records were not accessible during the study, and appeared to be often missing during analyses. CONCLUSIONS: The stepped wedge, cluster randomized trial poses specific risks in the design and execution of research in real-life settings of which researchers should be aware to prevent negative consequences impacting the validity of their results. Valid conclusions on the effectiveness of the HELP in the Dutch hospital setting are hampered by the limited quantity and quality of routine clinical data in our pragmatic trial. Executing a stepped wedge design in a daily practice setting using routinely collected data requires specific attention to ethical review, flexibility, a spacious time schedule, the availability of substantial capacity in the research team and early checks on the data availability and quality. TRIAL REGISTRATION: Netherlands Trial Register, identifier: NTR3842 . Registered on 24 January 2013.