Implementation of a multicomponent intervention to prevent physical restraints in nursing homes (IMPRINT): A pragmatic cluster randomized controlled trial.

BACKGROUND: Despite clear evidence for the lack of effectiveness and safety, physical restraints are frequently applied in nursing homes. Multicomponent interventions addressing nurses' attitudes and organizational culture have been effective in reducing physical restraints. OBJECTIVE: To evaluate the effectiveness of two versions of a guideline and theory-based multicomponent intervention to reduce physical restraints in nursing homes. DESIGN: Pragmatic cluster randomized controlled trial. SETTING: The study was conducted in 120 nursing homes in four regions in Germany. PARTICIPANTS: All residents living in the participating nursing home during follow-up, newly admitted residents were also included. A total of 12,245 residents included in the primary analysis (4126 and 3547 residents in intervention group 1 and 2 and 4572 residents in the control group). METHODS: Intervention group 1 received an updated version of a successfully tested guideline-based multicomponent intervention (comprising brief education for the nursing staff, intensive training of nominated key nurses in each cluster, introduction of a least-restraint policy and supportive material), intervention group 2 received a concise version of the original program and the control group received optimized usual care (i.e. supportive materials only). Primary outcome was physical restraint prevalence at twelve months, assessed through direct observation by blinded investigators. Intervention and control groups were compared using baseline-adjusted linear regression on cluster level, Bonferroni-adjusted for double testing. Secondary outcomes included falls, fall-related fractures, and quality of life. We also described intervention costs and performed a comprehensive process analysis. RESULTS: At baseline, mean physical restraint prevalence was 17.4% and 19.6% in intervention groups 1 and 2, and 18.8% in the control group. After twelve months, mean prevalence was 14.6%, 15.7%, and 17.6%. Baseline-adjusted differences between mean prevalences were 2.0% (97.5% CI, -5.8 to 1.9) lower in intervention group 1 and 2.5% (97.5% CI, -6.4 to 1.4) lower in intervention group 2 compared to controls. Physical restraint prevalence showed a pronounced variation between the different clusters in all study groups. We found no significant differences in the secondary outcomes. According to the process evaluation, the intervention was mainly implemented as planned, but the expected change towards a least restraint culture of care was not achieved in all clusters. CONCLUSIONS: Neither intervention showed a clear advantage compared to control. The pronounced center variation in physical restraint prevalence indicates that other approaches like governmental policies are needed to sustainably change physical restraint practice and reduce center variations in nursing homes. TRIAL REGISTRATION: ClinicalTrials.gov : NCT02341898.

Patients with dementia in acute care hospitals : A cross-sectional study of physicians' experiences and attitudes.

BACKGROUND: Patients with dementia (PwD) are a vulnerable group and caring for these patients in acute care hospitals is challenging. Structural conditions and standardized treatment procedures in hospitals often do not correspond to the needs of this patient group. Physicians may not be well prepared for caring for PwD. OBJECTIVE: This study aimed to ascertain physicians' experiences and attitudes in caring for PwD or cognitive disorders and their subjective workload. This describes physicians' estimation of the share of the overall workload resulting from caring for PwD on the ward. Furthermore, we identified factors that are most likely to contribute to the workload. MATERIAL AND METHODS: An online survey was conducted using a self-developed standardized questionnaire with 29 questions based on a systematic literature review. The questionnaire was pretested in several steps and finally sent out via e­mail to 610 physicians in 9 hospitals in northern Germany. Aspects surveyed were: physicians' confidence in caring for PwD and resulting workload, challenges in caring for PwD, collaboration with relatives and other professionals and educational needs. Important influencing factors were determined by multiple linear regression analyses. RESULTS: A total of 192 hospital physicians completed the questionnaire (response rate 32%). According to respondents the proportion of PwD in acute care hospitals increased significantly during the last 3 years. Only one third of respondents reported feeling confident in caring for PwD and 65% stated that they do not feel confident in caring for PwD especially in situations of nutrition in cases of food refusal and distinguishing between delirium and dementia. The strongest influencing factors were increased efforts in terms of time and support needs, complex medical situations, difficult collaboration with relatives and lack of patient compliance. A successful collaboration with other professionals was associated with increased confidence in caring for PwD. Legal and ethical aspects as well as drug therapies were mentioned as desirable topics for educational programs. CONCLUSION: A relevant number of hospital physicians feel insecure and burdened in caring for PwD. The study provides important information for the design of educational programs and for potential changes in structural and procedural aspects. The results may be used as starting points for improving hospital care for PwD.

The reliability of the German version of the Richards Campbell Sleep Questionnaire.

BACKGROUND: The assessment of sleep quality in critically ill patients is a relevant factor of high-quality care. Despite the fact that sleep disturbances and insufficient sleep management contain an increased risk of severe morbidity for these patients, a translated and applicable instrument to evaluate sleep is not available for German-speaking intensive care settings. AIM: This study aimed to translate the Richards Campbell Sleep Questionnaire (RCSQ), a simple and validated instrument eligible for measuring sleep quality in critically ill patients, and subsequently to evaluate the internal consistency of the German version of the RCSQ. Furthermore, it also aimed to inquire into the perception of sleep in a sample of critically ill patients. METHODS: The RCSQ was translated following established methodological standards. Data were collected cross-sectionally in a sample of 51 patients at 3 intensive care units at a university hospital in Germany. RESULTS: The German version of the RCSQ showed an overall internal consistency (Cronbach's alpha) of 0·88. The mean of the RSCQ in the sample was 47·00 (SD ± 27·57). Depth of sleep was rated the lowest and falling asleep again the highest of the RCSQ sleep items. CONCLUSION: The study demonstrated very good internal consistency of the German version of the RCSQ, allowing for its application in practice and research in German-speaking countries. Quality of sleep perception was generally low in this sample, emphasizing the need for enhanced care concepts regarding the sleep management of critically ill patients. Relevance to clinical practice Assessment of self-perception of sleep is crucial in order to plan an individually tailored care process.

[German hospital nurses' attitudes concerning evidence-based nursing practice]. / Einstellungen Pflegender in deutschen Krankenhäusern zu einer evidenzbasierten Pflegepraxis.

The relevance of nurses' attitudes for establishing an evidence-based nursing practice (EBP) has been proven internationally. For German-speaking countries so far only few data are available. The present survey aims at assessing nurses' perceptions of relevant context factors for implementing an EBP. Therefore, 1384 nurses in 21 hospitals in Northern-Germany received a self-developed questionnaire based on established instruments in March and April 2012. 1023 (74 %) nurses responded. In principal, results show a positive attitude towards EBP. The majority of participants regards research as relevant for nursing practice. Support from superiors and colleagues is seen as important prerequisite. However, implementation remains a challenge. Nurses are not informed about recent research results. Original articles are hardly used. Only a minority is prepared to spend own money on congresses or to start academic nursing training in the near future. For the first time in German-speaking countries, the study provides meaningful data on nurses' attitudes towards EBP. Nurses confirm the value of research for their own practice. However, there is a lack of basic requirements to identify and implement relevant research findings as for example the use of recent scientific evidence. Nursing education in Germany should therefore focus more strongly on building competencies required for EBP, for example through properly designed academic nursing training.