Factors affecting in-hospital informal caregiving as decided by families: findings from a longitudinal study conducted in acute medical units.

BACKGROUND: Informal caregiving offered by family members has been widely studied in the community setting, but little attention to date has been dedicated to that offered at the hospital level. AIMS: To describe the proportion of patients admitted to acute medical units receiving care from informal caregivers as decided by the family and to identify the factors affecting the numbers of care shifts performed by informal caregivers. DESIGN AND METHODS: A longitudinal study was performed involving 12 acute medical units located in 12 northern Italian hospitals. RESULTS: All patients (N = 1464) admitted to medical units were included, and 77.1% of them received at least one shift of informal care during their in-hospital stay, especially during the mornings and afternoons. At the patient level, those at higher risk of prolonged hospitalisation and difficult discharge at admission, and those reporting higher occurrence of adverse events, such as pressure sores, confusion events and use of physical restraints during hospitalisation, were more likely receiving informal care. At the nursing care level, a higher amount of missed nursing care was associated with an increased number of care shifts offered by informal caregivers during patient hospitalisation, whereas the amount of care offered by staff was a protective factor. CONCLUSIONS: Families play a care role in the care of older patients admitted to acute medical units. They contribute substantially to the care of patients, especially during morning and afternoon shifts.

Hospital-acquired functional decline in older patients cared for in acute medical wards and predictors: Findings from a multicentre longitudinal study.

Describing the trajectories of hospital-associated functional decline in older patients admitted to acute medical units and identifying predictors at the individual, nursing, and hospital levels, were the aims of the study. A longitudinal survey among 12 acute medical units in which 1464 patients were consecutively enrolled and evaluated using the Barthel Index (BI), was performed. Functional decline was defined as a decrease in the BI of at least 5 points from admission to discharge. In all, 17.1% participants (n = 251) demonstrated functional decline. In accordance with multiple logistic regression analysis, 28.8% (R(2)) of the variance in the functional decline was explained by: confusion/disorientation (RR = 4.684; 95% CI = 3.144-6.978), admission from nursing homes (RR = 2.464; 95% CI = 1.642-3.697), daily care expressed in minutes offered by nursing aides (RR = 1.535; 95% CI = 1.275-1.849), higher workforce skill-mix (RR = 2.221; 95% CI = 1.763-2.797), bladder catheter insertion (RR = 1.599; 95% CI = 1.128-2.268), and higher BI score at admission (RR = 1.019; 95% CI = 1.014-1.024). Increasing the amount of care delivered by competent nurses-having a bachelors degree-providing and supervising direct-care activities, may reduce the occurrence of functional decline in older patients admitted to medical units.

[Development and validation of a questionnaire on perception of portfolio by undergraduate medical students]. / Desarrollo y validación de encuesta de percepción del portafolio en estudiantes de medicina de pregrado.

BACKGROUND: Portfolio is an innovative instrument that promotes reflection, creativity and professionalism among students. AIM: To describe the development and validation process of a questionnaire to evaluate the use of portfolio in undergraduate medical students. MATERIAL AND METHODS: Focus groups with students and teachers were employed to identify aspects related with portfolio in undergraduate teaching. The Delphi technique was used to prioritize relevant aspects and construct the questionnaire. The validated questionnaire, consisting of 43 items and 6 factors, was applied to 97 students (response rote of 99.9%) in 2007 and 100 students (99.2%) in 2008. Each question had to be answered using a Likert scale, from 0 (completely disagree) to 4 (completely agree) The validity and reliability of the questionnaire was evaluated. RESULTS: The questionnaire showed a high reliability (Cronbach alpha = 0.9). The mean total scores obtained in 2007 and 2008 were 106.2 ± 21.2 (61.7% of the maximal obtainable score) and 104.6 ± 34.0 (60.8% of the maximal obtainable score), respectively No significant differences were seen in the analysis by factors. Changes in portfolio during 2008 showed differences in items related with organization, evaluation and regulation. CONCLUSIONS: The questionnaire is a valid and highly reliable instrument, measuring perceptions about the portfolio by undergraduate medical students. The students perceived an improvement in their creativity and professionalism as one of the strengths of portfolio. The weaknesses identified during the implementation process helped us to focus changes in organization and evaluation to improve the portfolio as a dynamic process.

[Professionalism and self-care in residents, how should we confront their training?] / Profesionalismo y auto cuidado de los residentes, ¿cómo debemos enfocar su formación?

Professionalism is a well-defined competence in the education of residents. However, it is a complex construct, sensitive to social and cultural variables. It can be defined as the necessary skill, good jud gment and appropriate behavior expected of people trained to do their jobs well. It is a competence that does not remain stable over time and declines when the professional is subjected to high levels of stress, associated with quality of care, education, ethics, moral, philosophy and humanism. It is an essential competence for the professional and therefore we must rethink the curricula to include ways to teach and evaluate professionalism. It is essential to design programs that balance the workload with the well-being of future professionals. We must generate an adequate learning environment where the trainee is an active protagonist, and self-care is made visible as an essential competence to maintain the balance between personal and professional life. This article presents a review and reflects on this topic which is becoming increasingly important in the postgraduate training of future specialists.

[Reflective writing in nursing education: background, experiences and methods]. / La scrittura riflessiva nella formazione infermieristica: background, esperienze e metodi.

INTRODUCTION: In the nursing field, writing one's own educational/professional experience has been utilized for a long time, to develop reflection and therefore learning. Reflective writing has been fostered to sustain the development of nurses' clinical, relational and ethical competence, and to promote self knowledge. AIM: To de scribe reflective writing experiences published in the literature, focussing on the educational contexts and the writing strategies used in the nursing field. Method. Narrative analysis of the international literature, based on the MedLine and Cinahl data sources. RESULTS: Reflective writing is used in undergraduate, post-graduate and continuing nursing education, to develop clinical learning or a professional and/or personal growth. In the former, short written assignments (also starting from scenarios) are given, while diaries and journals, with prompts focalizing on specific aspects of the experience, support a more global growth of the student/professional. These prompts are useful with individuals not used to write. Critical incidents or meaningful episodes from the clinical practice are also used. Many papers underline the importance of sharing writings with peers and/or a teacher/facilitator. CONCLUSIONS: Nursing students/professionals can be effectively supported by reflective writing in their experiential learning. However, their attitude to reflective writing should be considered with care and a feedback by peers and/or a facilitator must be provided. Since giving feedback requires adequate human resources, the implementation of writing activities in the nursing training should be carefully evaluated.

[Teaching methods for clinical settings: a literature review]. / Metodi di insegnamento clinico: una revisione della letteratura.

. Teaching Methods for clinical settings: a review. INTRODUCTION: The teaching process during internship requires several methods to promote the acquisition of more complex technical skills such as relational, decisional and planning abilities. OBJECTIVE: To describe effective teaching methods to promote the learning of relational, decisional and planning skills. METHODS: A literature review of the teaching methods that have proven most effective, most appreciated by students, and most frequently used in Italian nursing schools. RESULTS: Clinical teaching is a central element to transform clinical experiences during internship in professional competences. The students are gradually brought to become more independent, because they are offered opportunities to practice in real contexts, to receive feedback, to have positive role models, to become more autonomous: all elements that facilitate and potentiate learning. CONCLUSIONS: Clinical teaching should be based on a variety of methods. The students value a gradual progression both in clinical experiences and teaching strategies from more supervised methods to methods more oriented towards reflecting on clinical practice and self-directed learning.

[The Italian instrument evaluating the nursing students clinical learning quality]. / Lo strumento italiano di misurazione della qualitàdell'apprendimento clinico degli studenti infermieri.

. The Clinical Learning Quality Evaluation Index for nursing students. INTRODUCTION: The Italian nursing programs, the need to introduce tools evaluating the quality of the clinical learning as perceived by nursing students. Several tools already exist, however, several limitations suggesting the need to develop a new tool. AIM: A national project aimed at developing and validating a new instrument capable of measuring the clinical learning quality as experience by nursing students. METHODS: A validation study design was undertaken from 2015 to 2016. All nursing national programs (n=43) were invited to participate by including all nursing students attending regularly their clinical learning. The tool developed based upon a) literature, b) validated tools already established among other healthcare professionals, and c) consensus expressed by experts and nursing students, was administered to the eligible students. RESULTS: 9606 nursing in 27 universities (62.8%) participated. The psychometric properties of the new instrument ranged from good to excellent. According to the findings, the tool consists in 22 items and five factors: a) quality of the tutorial strategies, b) learning opportunities; c) safety and nursing care quality; d) self-direct learning; e) quality of the learning environment. CONCLUSIONS: The tool is already used. Its systematic adoption may support comparison among settings and across different programs; moreover, the tool may also support in accrediting new settings as well as in measuring the effects of strategies aimed at improving the quality of the clinical learning.

[Validation of the Italian Clinical Learning Environment Instrument (SVIAT):study protocol]. / Strumento di Valutazione Italiano degli Ambienti di Tirocinio per gli studenti infermieri (SVIAT): protocollo di validazione.

UNLABELLED: . Validation of the Italian Clinical Learning Environment Instrument (SVIAT): study protocol. INTRODUCTION: Nursing students obtain most of their university credits in internship environments whose quality can affect their clinical learning. Several tools are available to measure the quality of the clinical learning environment (CLE) as perceived by students: these instruments developed in other countries, were validated in Italian but do not discriminate those CLEs capable (or not) to promote significant clinical learning. AIM: To validate an instrument to measure the capability of the CLE to generate clinical learning; the secondary aim is to describe the learning environments as perceived by nursing students according to individual course site and tutorial models adopted. METHODS: The study will be developed in three phases: a) instrument development and pilot phase, b) validation of the psychometric properties of the instrument and c) description of the CLEs as perceived by the students including factors/item confirmed in the validation process. Expected outcomes. A large validation, with more than 8,000 participating students is expected; the construct under lying will be confirmed through exploratory and confirmatory factor analysis and will report high internal consistency; the instrument will report also a high test-retest and inter-rater reliability; in addition, the instrument will demonstrate predictive ability by discriminating those units able (or not) to activate effective learning processes.

Medicina Basada en Evidencia: ¿podemos confiar en los resultados de los estudios clínicos aleatorizados bien diseñados? / Evidence-based medicine: Can we trust the results of well-designed randomized trials?

Evidence based medicine assists in clinical decision-making by integrating critically appraised information with patient's values and preferences within an existing clinical context. A fundamental concept in this paradigm is the hierarchy of information. The randomized clinical trial is recognized as one of the designs that is less prone to bias and therefore of higher methodological quality. Clinical guidelines are one of the principal tools that evidence based medicine uses to transfer scientific information to clinical practice and many of their recommendations are based on these type of studies. In this review we present some of the limitations that the results can have, in even well designed and executed randomized clinical trials. We also discuss why valid results in these types of studies could not necessarily be extrapolated to the general population. Although the randomized clinical trial continues to be one of the best methodological designs, we suggest that the reader be careful when interpreting its results.

La Medicina Basada en Evidencia es una propuesta que asiste en la toma de decisiones clínicas integrando la información críticamente analizada con los valores y preferencias del paciente en el contexto clínico existente. Un concepto fundamental en este paradigma es la jerarquización de la información. El estudio clínico aleatorizado es reconocido como uno de los diseños metodológicos con menor probabilidad de sesgo y por ende de la más alta calidad metodológica. En este tipo de estudios se basan muchas de las recomendaciones de las guías clínicas, que son uno de los principales instrumentos que utiliza la medicina basada en evidencia para transferir la información a la práctica clínica. En esta revisión se exponen algunas de las limitaciones que pueden tener los resultados de estudios clínicos aleatorizados incluso cuando han sido bien diseñados y ejecutados. Se discute también el porqué resultados validos pueden no necesariamente ser extrapolables a la población general en este tipo de estudios. Si bien el estudio clínico aleatorizado sigue siendo uno de los mejores diseños metodológicos, se sugiere que el usuario de la información sea cuidadoso al interpretar sus resultados.

Incontinence pad use in patients admitted to medical wards: an Italian multicenter prospective cohort study.

PURPOSE: The purpose of the study was to evaluate the incidence of incontinence pad use among patients admitted to medical wards, the reasons why nurses decide to use an incontinence pad, the extent to which the use of pads is avoidable, and the outcome of inappropriate pad use after discharge from the hospital. METHODS: A prospective cohort study was conducted; patients admitted to medical wards were observed during hospitalization and a 7-day follow-up period after discharge. SUBJECTS AND SETTING: The study was conducted in 2 acute-care units in Northern Italy. All new patients admitted to the units were recruited. RESULTS: At the time of admission to the hospital, in addition to the 120 patients who already used incontinence pads, there was a 34% incidence of new cases (98/286). The most frequent reason why nurses decided to use this aid was incontinence caused by space-time disorientation, followed by limited mobility, incontinence, patient request, nursing shortage, and involuntary urine leakage not perceived by patient. Seventy patients out of 208 used incontinence pads unnecessarily for a total of 544 days. CONCLUSIONS: Decisions about the use of the incontinence pads are not always consistent with research-based or literature-based suggestions. Nurses should develop clinical guidelines or protocols for the appropriate use of incontinence pads.

Desarrollo y validación de encuesta de percepción del portafolio en estudiantes de medicina de pregrado / Development and validation of a questionnaire on perception of portfolio by undergraduate medical students

Background: Portfolio is an innovative instrument that promotes reflection, creativity and professionalism among students. Aitn: To describe the development and validation process of a questionnaire to evalúate the use of portfolio in undergraduate medical students. Material andMethods: Focus groups with students and teachers were employed to identify aspects related with portfolio in undergraduate teaching. The Delphi technique was used to prioritize relevant aspects and construct the questionnaire. The validated questionnaire, consistingin 43 Ítems and 6factors, was appliedto 97students (response rote of99.9 percent) in2007and 100students (99.2 percent) in 2008. Each question had to be answered using a Likert scale,from 0 (completely disagree) to 4 (completely agree) The validity and reliability of the questionnaire was evaluated. Results: The questionnaire showed a high reliability (Cronbach alpha = 0.9). The mean total scores obtained in 2007 and 2008 were 106.2 ± 21.2 (61.7 percent ofthe maximal obtainable score) and 104.6 ± 34.0 (60.8 percent ofthe maximal obtainable score), respectively No significant differences were seen in the analysis by factors. Changes in portfolio during 2008 showed differences in Ítems related with organization, evaluation and regulation. Conclusions: The questionnaire is a valid and highly reliable instrument, measuringperceptions about the portfolio by undergraduate medical students. The students perceived an improvement in their creativity and professionalism as one ofthe strengths of portfolio. The weaknesses identified during the implementation process helped us to focus changes in organization and evaluation to improve the portfolio as a dynamic process.