Older patients' motives of whether or not to perform self-management during a hospital stay and influencing factors✰.

Semi-structured in-depth interviews (n = 12) were held to explore older patients' motives of whether or not to perform self-management while hospitalized and to identify factors influencing self-management during hospitalization. These interviews were analyzed using the Quacol method. Self-management during hospitalization is operationalized as: collaboration with the nursing staff, having a proactive role, and having control over personal care. Three main themes, i.e., patients' abilities, expectations and opinions, as well as their perceived behavior of nurses were identified along with eight influencing factors. Results indicate that older inpatients perform self-management when they know that it impacts their recovery, when they perceive that a mistake is impending, when their own personal limits are exceeded, or when they are invited to self-manage by nurses. This study provides several suggestions for developing interventions to support patients' self-management during hospitalization.

Measurement of nurses' attitudes and knowledge regarding acute care older patients: Psychometrics of the OPACS-US combined with the KOP-Q.

In clinical practice, identifying positive and negative attitudes toward older patients is very important to improve quality of care provided to them. The Older People in Acute Care Survey - United States (OPACS-US) is an instrument measuring hospital nurses attitudes regarding older patients. However, psychometrics have never been assessed. Furthermore, knowledge being related to attitude and behavior should also be measured complementing the OPACS-US. The purpose of this study was to assess structural validity and reliability of the OPACS-US and assess whether the OPACS-US can be complemented with the Knowledge about Older Patients-Quiz (KOP-Q). A multicenter cross sectional design was conducted. Registered nurses (n = 130, mean age 39,9 years; working experience 14,6 years) working in four general hospitals were included in the study. Nurses completed the OPACS-US section A: practice experiences, B: general opinion and the KOP-Q online. Findings demonstrated that the OPACS-US is a valid and reliable survey instrument that measures practice experiences and general opinion. Furthermore, the OPACS-US can be combined with the KOP-Q adding a knowledge construct, and is ready for use within education and/or quality improvement programs in the USA.

Predicting functional decline in older patients undergoing cardiac surgery.

BACKGROUND: a growing number of older patients undergo cardiac surgery. Some of these patients are at increased risk of post-operative functional decline, potentially leading to reduced quality of life and autonomy, and other negative health outcomes. First step in prevention is to identify patients at risk of functional decline. There are no current published tools available to predict functional decline following cardiac surgery. OBJECTIVE: to validate the identification of seniors at risk-hospitalised patients (ISAR-HP), in older patients undergoing cardiac surgery. DESIGN AND METHODS: a multicenter cohort study in cardiac surgery wards of two university hospitals with follow-up 3 months after hospital admission. INCLUSION CRITERIA: consecutive cardiac surgery patients, aged ≥65. Functional decline was defined as a decline of at least one point on the Katz ADL Index at follow-up compared with preadmission status. RESULTS: 475 patients were included, 16% of all patients and 20% of patients ≥70+ suffered functional decline. The amended prediction model predicted functional decline using four criteria: preadmission need for daily assistance in instrumental activities of daily living, use of a walking device, need for assistance in travelling and no education after age 14. Area under the receiver operating curve for patients ≥70 it was 0.73. For the amended ISAR-HP sensitivity, specificity, positive and negative predictive values were 85, 48, 29 and 93%, respectively. CONCLUSIONS: the amended ISAR-HP used in older cardiac surgery patients showed good discriminative values at score ≥1, supporting the generalisability of this prediction model for this patient group.

Prevention of functional decline in older hospitalized patients: nurses should play a key role in safe and adequate care.

This paper presents a discussion of knowledge and awareness regarding prevention of functional decline in older hospitalized patients. Functional decline is experienced by 30-60% of the older hospitalized patients, resulting in decreased independence and other adverse health outcomes. One literature study and four cohort studies (total n = 1628) were conducted to develop and validate an instrument to identify older hospitalized patients at risk for functional decline. An evidence-based best practice was developed to improve the quality of care for older patients. This paper shows the relevance and the complexity of this problem and shows that patients at risk can be recognized by four simple questions. Due to their ability to observe and guide patients and their 24-h patient supervision, nurses should play a key role in strategies to prevent functional decline. Nurses should assess the geriatric needs in patients at risk and based on these initiate and coordinate multi-professional interventions. Given the growing number of older people in western society and the growing need for care, action to prevent functional decline cannot be withheld. Knowledge of the ageing process, implementation of an evidence-based programme and a multidisciplinary approach is a basic ingredient to prevent functional decline.

The prediction of functional decline in older hospitalised patients.

BACKGROUND: thirty to sixty per cent of older patients experience functional decline after hospitalisation, associated with an increase in dependence, readmission, nursing home placement and mortality. First step in prevention is the identification of patients at risk. OBJECTIVE: to develop and validate a prediction model to assess the risk of functional decline in older hospitalised patients. DESIGN: development study: cohort study (n = 492). Validation study: secondary data analysis of a cohort study (n = 484) in an independent population. Both with follow-up after 3 months. Functional decline was defined as a decline of at least one point on the Katz ADL index at follow-up compared with pre-admission status. SETTING: development study: general internal medicine wards of two university hospitals and one regional hospital. Validation study: general internal wards of an university hospital. SUBJECTS: patients ≥65 years acutely admitted and hospitalised for at least 48 h. RESULTS: thirty-five per cent of all patients in the development cohort and 32% in the validation cohort developed functional decline. A four-item model could accurately predict functional decline with an AUC of 0.71. At threshold 2 sensitivity, specificity, positive and negative predictive values were 87, 39, 43 and 85%, respectively. In the validation study, this was, respectively, 0.68, 89, 41, 41 and 89%. CONCLUSION: pre-admission need for assistance in instrumental activities of daily living, use of a walking device, need for assistance in travelling and no education after age 14, are the items of a prediction model to identify older patients at risk for functional decline following hospital admission. The strength of the model is that it relies on four simple questions and this makes it easy to use in clinical practice and easy to administer.

Identification of older hospitalised patients at risk for functional decline, a study to compare the predictive values of three screening instruments.

AIMS AND OBJECTIVES: To establish a screening instrument for identifying older hospitalised patients at risk for functional decline by comparing the predictive values of three screening instruments: identification of seniors at risk, care complexity prediction instrument and hospital admission risk profile. BACKGROUND: After being hospitalised, 30-60% of older patients experience a decline in functioning, resulting in a decreased quality of life and autonomy. DESIGN: A prospective cohort study. METHODS: Included were patients, aged 65 years and older, acutely admitted to a general internal ward of a university teaching hospital. Within 48 hours after hospital admission, baseline data were completed--demographic, cognitive, social and pre-admission functional status and the screening instruments. Three months after discharge, functional status was measured by telephone interview. The Katz index was used to measure functional status (six activities). Functional decline was defined as a decline of at least one point on the Katz index at three months after discharge compared to pre-admission state. RESULTS: Included were 177 patients; mean age was 77.6 years and 51.7 % were male. Functional decline was found in 27.8% of all patients. Sensitivity, specificity and area under receiver operating curve for identification of seniors at risk (ISAR) were 93, 39% and 0.67, respectively. The corresponding results for the care complexity prediction instrument (COMPRI) were 70, 62% and 0.69 and for the hospital admission risk profile (HARP) 21, 89% and 0.56. CONCLUSION: The discriminative values of both identification of seniors at risk and care complexity prediction instrument are fair. Hospital admission risk profile shows the poorest results. Identification of seniors at risk shows the best ability to predict those patients at risk for functional decline and seems to be the easiest instrument in clinical practice. RELEVANCE TO CLINICAL PRACTICE: Identifying patients at risk for functional decline is a first step in prevention, followed by geriatric assessment and targeted interventions. Studying the validity of existing instruments is necessary before implementation in clinical practice.

Comparisons of Knowledge of Dutch Nursing Students and Hospital Nurses on Aging.

BACKGROUND: Although there is a growing population of older adults admitted to hospitals, the literature demonstrates knowledge deficits of nurses regarding older patients. This study investigated knowledge levels of both nursing students and RNs about older hospitalized patients in relation to their educational level and work experience. METHOD: First- and final-year vocational and bachelor nursing students, and associate degree and bachelor degree nurses working in the hospital setting with 0 to 5 years, 6 to 15 years, and more than 15 years of experience, have completed the Knowledge about Older Patients-Quiz (KOP-Q). The KOP-Q has a clearly described theoretical base finding its origin in knowledge regarding nursing care for older patients and shows good content and construct validity. RESULTS: A substantial proportion of participants in all groups demonstrated insufficient knowledge about older patients. A difference in knowledge exists among nurses with different educational qualifications, and a link between years of experience and higher knowledge levels of nurses is found. CONCLUSION: Throughout the nursing career, basic care topics in relation to care for older patients should play a key role in basic nursing education programs, as well as for continuing education programs provided in hospitals for nurses. J Contin Educ Nurs. 2018;49(2):84-90.

The Knowledge-about-Older-Patients - Quiz (KOP-Q) for nurses: Cross-cultural validation between the Netherlands and United States of America.

BACKGROUND: The Knowledge about Older Patients-Quiz (KOP-Q) is designed as a unidimensional scale measuring knowledge of hospital nurses about older patients. Furthermore, the KOP-Q measures a second unidimensional construct, certainty of hospital nurses about their knowledge. The KOP-Q is developed and validated in the Netherlands. Whether the KOP-Q can be used in other countries is unknown given the cultural and language differences. OBJECTIVES: Investigate the level of measurement invariance of the KOP-Q between the Netherlands and United States of America (USA). DESIGN: A multicenter international cross-sectional design. SETTINGS: Four general hospitals in the Netherlands and four general hospitals in the USA. PARTICIPANTS: Nurses from the Netherlands (n=201) and the USA (n=130) were invited to participate by email from the ward manager, distributing flyers and present messages on the online hospital communication boards. Questions of the KOP-Q were completed online. METHOD: The level of measurement invariance (configural, metric or scalar invariance) across countries was tested by running increasingly constrained structural equation models, and testing whether these models fitted the data. RESULTS: Both the knowledge and certainty construct of the KOP-Q proved unidimensional in the Netherlands and USA sample. Test results of the measurement invariance across the Netherlands and USA indicated a stable, partial scalar invariance (15 items full scalar invariance) for the knowledge items and full scalar invariance for the certainty items. CONCLUSIONS: The KOP-Q shows to function uniformly across both language groups and can therefore be used to assess nurses' knowledge and their certainty about this knowledge which can be important for educational and/or quality improvement programs in the USA. Furthermore, the KOP-Q is suitable to make comparisons between the Netherlands and the USA using latent variable models. Before the KOP-Q can be used in other countries, cross-cultural tests should again be performed.

Content Validity and Psychometric Characteristics of the "Knowledge about Older Patients Quiz" for Nurses Using Item Response Theory.

OBJECTIVES: To assess the content validity and psychometric characteristics of the Knowledge about Older Patients Quiz (KOP-Q), which measures nurses' knowledge regarding older hospitalized adults and their certainty regarding this knowledge. DESIGN: Cross-sectional. SETTING: Content validity: general hospitals. Psychometric characteristics: nursing school and general hospitals in the Netherlands. PARTICIPANTS: Content validity: 12 nurse specialists in geriatrics. Psychometric characteristics: 107 first-year and 78 final-year bachelor of nursing students, 148 registered nurses, and 20 nurse specialists in geriatrics. MEASUREMENTS: Content validity: The nurse specialists rated each item of the initial KOP-Q (52 items) on relevance. Ratings were used to calculate Item-Content Validity Index and average Scale-Content Validity Index (S-CVI/ave) scores. Items with insufficient content validity were removed. Psychometric characteristics: Ratings of students, nurses, and nurse specialists were used to test for different item functioning (DIF) and unidimensionality before item characteristics (discrimination and difficulty) were examined using Item Response Theory. Finally, norm references were calculated and nomological validity was assessed. RESULTS: Content validity: Forty-three items remained after assessing content validity (S-CVI/ave = 0.90). Psychometric characteristics: Of the 43 items, two demonstrating ceiling effects and 11 distorting ability estimates (DIF) were subsequently excluded. Item characteristics were assessed for the remaining 30 items, all of which demonstrated good discrimination and difficulty parameters. Knowledge was positively correlated with certainty about this knowledge. CONCLUSION: The final 30-item KOP-Q is a valid, psychometrically sound, comprehensive instrument that can be used to assess the knowledge of nursing students, hospital nurses, and nurse specialists in geriatrics regarding older hospitalized adults. It can identify knowledge and certainty deficits for research purposes or serve as a tool in educational or quality improvement programs.

Construct development, description and initial validation of the Knowledge about Older Patients Quiz (KOP-Q) for nurses.

BACKGROUND: Literature shows that nurses have a negative attitude toward older patients. Increasing nurses' knowledge (part of attitudes) may affect hospital nurses' attitudes and improve the quality of care for older patients. A first step is understanding nurses' current knowledge. This can be achieved by using a measurement instrument with good validity and reliability. OBJECTIVES: This study explains the content development and initial validation of the 'Knowledge about Older Patients Quiz' (KOP-Q) for nurses, describing the first step in developing a valid and reliable instrument. DESIGN: Qualitative method followed by 2 pilot studies. METHODS: Open interviews were conducted with 7 scientific experts and 10 nurse specialists in gerontology, geriatrics, and/or nursing and 5 older patients, 70+ with hospital experience in the last two years. The data were analyzed using thematic analysis. Items were generated from literature on themes derived from interviews. A Delphi round with three nurse specialists and two researchers was organized for item reduction. Two pilot survey studies were conducted for measuring readability and face validity of the KOP-Q. Readability was examined by a Dutch language specialist and 7 nurses working on a cardiovascular ward. Face validity was tested in two hospitals with 22 nurses working on geriatric wards. RESULTS: Identified themes were: normal aging, geriatric conditions, signaling problems in old age, interventions, family interventions, vulnerable patients versus older patients and internal motivation for learning and reflection. 185 questions on these themes were developed. After conceptualization, generation and reduction of questions in the Delphi round 52 questions remained eligible for use. Readability and face validity of this initial version of the KOP-Q proved good. CONCLUSIONS: Content development of the KOP-Q is of good methodological rigor and each step is carefully described, therefore it can be of use for future diagnostic instrument developers, curriculum developers and educators.

Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: a prospective cohort study.

BACKGROUND: The aim of this research was to study the clinical characteristics and mortality and disability outcomes of patients who present distinct risk profiles for functional decline at admission. METHODS: Multicenter, prospective cohort study conducted between 2006 and 2009 in three hospitals in The Netherlands in consecutive patients of ≥65 years, acutely admitted and hospitalized for at least 48 hours. Nineteen geriatric conditions were assessed at hospital admission, and mortality and functional decline were assessed until twelve months after admission. Patients were divided into risk categories for functional decline (low, intermediate or high risk) according to the Identification of Seniors at Risk-Hospitalized Patients. RESULTS: A total of 639 patients were included, with a mean age of 78 years. Overall, 27%, 33% and 40% of the patients were at low, intermediate or high risk, respectively, for functional decline. Low-risk patients had fewer geriatric conditions (mean 2.2 [standard deviation [SD] 1.3]) compared with those at intermediate (mean 3.8 [SD 2.1]) or high risk (mean 5.1 [SD 1.8]) (p<0.001). Twelve months after admission, 39% of the low-risk group had an adverse outcome, compared with 50% in the intermediate risk group and 69% in the high risk group (p<0.001). CONCLUSION: By using a simple risk assessment instrument at hospital admission, patients at low, intermediate or high risk for functional decline could be identified, with distinct clinical characteristics and outcomes. This approach should be tested in clinical practice and research and might help appropriately tailor patient care.

Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline.

BACKGROUND: To study the prevalence of eighteen geriatric conditions in older patients at admission, their reporting rate in discharge summaries and the impact of these conditions on mortality and functional decline one year after admission. METHOD: A prospective multicenter cohort study conducted between 2006 and 2008 in two tertiary university teaching hospitals and one regional teaching hospital in the Netherlands. Patients of 65 years and older, acutely admitted and hospitalized for at least 48 hours, were invited to participate. Eighteen geriatric conditions were assessed at hospital admission, and outcomes (mortality, functional decline) were assessed one year after admission. RESULTS: 639 patients were included, with a mean age of 78 years. IADL impairment (83%), polypharmacy (61%), mobility difficulty (59%), high levels of primary caregiver burden (53%), and malnutrition (52%) were most prevalent. Except for polypharmacy and cognitive impairment, the reporting rate of the geriatric conditions in discharge summaries was less than 50%. One year after admission, 35% had died and 33% suffered from functional decline. A high Charlson comorbidity index score, presence of malnutrition, high fall risk, presence of delirium and premorbid IADL impairment were associated with mortality and overall poor outcome (mortality or functional decline). Obesity lowered the risk for mortality. CONCLUSION: Geriatric conditions were highly prevalent and associated with poor health outcomes after admission. Early recognition of these conditions in acutely hospitalized older patients and improving the handover to the general practitioner could lead to better health outcomes and reduce the burden of hospital admission for older patients.

A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline.

AIMS AND OBJECTIVES: To determine a valid, reliable and clinical user-friendly instrument, based on predictors of functional decline, to identify older patients at risk for functional decline. The predictors of functional decline are initially considered and, subsequently, the characteristics and psychometric qualities of existing screening instruments are investigated. BACKGROUND: Functional decline is a common and serious problem in older hospitalized patients, resulting in a change in quality of life and lifestyle. Studies have shown that 30-60% of older people develop new dependencies in activities of daily living (ADL) during their hospital stay. Adverse health outcomes such as mortality, a prolonged hospital stay, nursing home placement and increased dependency of older people at home are the results. Not only are the personal costs high but also, in a rapidly growing older population, the impact on health-care costs is also high. RESULTS: Age, lower functional status, cognitive impairment, preadmission disability in instrumental activities of daily life (IADL), depression and length of hospital stay were identified as predictors of functional decline. Three screening instruments to identify hospitalized patients at risk for functional decline were found in the literature: the Hospital Admission Risk Profile, the Identification of Seniors at Risk and the Care Complexity Prediction Instrument. The reported validity was moderate. Reliability and the ease of use in the clinical setting were not well described. CONCLUSION: These three instruments should be further tested in a hospitalized older population. RELEVANCE TO CLINICAL PRACTICE: Screening is a first step to identify patients at risk for functional decline and this will make it possible to treat patients who are identified so as to prevent functional decline. Because of their ability to observe and to guide the patients and the overall view they have, nurses play a key role in this process.