In-hospital elderly mortality and associated factors in 12 Italian acute medical units: findings from an exploratory longitudinal study.

BACKGROUND: Given the progressive demographic ageing of the population and the National Health System reforms affecting care at the bedside, a periodic re-evaluation of in-hospital mortality rates and associated factors is recommended. AIMS: To describe the occurrence of in-hospital mortality among patients admitted to acute medical units and associated factors. Two hypotheses (H) were set as the basis of the study: patients have an increased likelihood to die H1: at the weekend when less nursing care is offered; H2: when they receive nursing care with a skill-mix in favour of Nursing Aides instead of Registered Nurses. METHODS: Secondary analysis of a prospective study of patients >65 years consecutively admitted in 12 Italian medical units. Data on individual and nursing care variables were collected and its association with in-hospital mortality was analysed by stepwise logistic regression analysis. RESULTS: In-hospital mortality occurrence was 6.8 %, and 37 % of the patients died during the weekend. The logistic regression model explained 34.3 % (R 2) of the variance of in-hospital mortality: patients were six times (95 % CI = 3.632-10.794) more likely at risk of dying at weekends; those with one or more AEDs admissions in the last 3 months were also at increased risk of dying (RR 1.360, 95 % CI = 1.024-1.806) as well as those receiving more care from family carers (RR = 1.017, 95 % CI = 1.009-1.025). At the nursing care level, those patient receiving less care by RNs at weekends were at increased risk of dying (RR = 2.236, 95 % CI = 1.270-3.937) while those receiving a higher skill-mix, thus indicating that more nursing care was offered by RNs instead of NAs were at less risk of dying (RR = 0.940, 95 % CI = 0.912-0.969). CONCLUSIONS: Within the limitations of this secondary analysis, in addition to the role of some clinical factors, findings suggest redesigning acute care at weekends ensuring consistent care both at the hospital and at the nursing care levels.

The degree of satisfaction of in-hospital medical patients with nursing care and predictors of dissatisfaction: findings from a secondary analysis.

BACKGROUND: Patient satisfaction with nursing care (NC) is an important predictor of overall satisfaction with the hospital experience. However, the concept of patient satisfaction has been criticised both at the theoretical and at the methodological levels, and more attention on patient dissatisfaction has been called for with the aim of identifying strategies to improve the quality of care. AIMS: To describe dissatisfaction with NC as perceived by acute medical patients and identify predictors. DESIGN AND METHODS: A secondary analysis of longitudinal data involving 12 Italian medical units was performed. A consecutive sample of 1016 patients ≥65 years (2012-2013) was included, and their satisfaction with NC was assessed, administering the Italian version of the Patient Satisfaction Scale (PSS) at the day of discharge. The scale was based on 11 items evaluated on a four-point Likert scale (score ranging from 11 - very dissatisfied to 44 - very satisfied). Patients were defined as 'satisfied with NC' when the score was ≥33, whereas they were considered as 'dissatisfied with NC' when the score was <33. A logistic regression analysis was performed to identify the predictors of patient dissatisfaction with NC. RESULTS: There were 788 (77.6%) patients satisfied (≥33 at the PSS) and 228 (22.4%) dissatisfied with NC (<33). The risk of dissatisfaction was likely to be higher in female patients (RR 1.883, 95% CI 1.359-2.609), in those who developed pressure sores during the in-hospital stay (RR 1.555, 95% CI 1.021-2.368), who received NC with high skill mix (RR 1.072, 95% CI 1.034-1.111) and those who were admitted to a large hospital (RR 1.001, 95% CI 1.001-1.002). In contrast, increased age (RR 0.987, 95% CI 0.975-0.998), increased amount of care offered by Registered Nurses (RR 0.984, 95% CI 0.974-0.994), a higher proportion of baccalaureate nurses on staff (RR 0.975, 95% CI 0.958-0.993) and being admitted to a teaching hospital (RR 0.497, 95% CI 0.130-0.910) all decreased the likelihood of being dissatisfied with NC. CONCLUSIONS: Dissatisfaction with NC was affected by individual, NC and hospital variables, such as the amount of staff resources, nurses education and skill mix. The findings emerged may inform clinicians, managers and policymakers regarding strategies that should be designed and implemented to prevent patient dissatisfaction.

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.

Prevalence and incidence density of unavoidable pressure ulcers in elderly patients admitted to medical units.

To describe the prevalence and incidence density of hospital-acquired unavoidable pressure sores among patients aged ≥65 years admitted to acute medical units. A secondary analysis of longitudinal study data collected in 2012 and 2013 from 12 acute medical units located in 12 Italian hospitals was performed. Unavoidable pressure ulcers were defined as those that occurred in haemodynamically unstable patients, suffering from cachexia and/or terminally ill and were acquired after hospital admission. Data at patient and at pressure ulcer levels were collected on a daily basis at the bedside by trained researchers. A total of 1464 patients out of 2080 eligible (70.4%) were included. Among these, 96 patients (6.5%) hospital-acquired a pressure ulcer and, among 19 (19.7%) were judged as unavoidable. The incidence of unavoidable pressure ulcer was 8.5/100 in hospital-patient days. No statistically significant differences at patient and pressure ulcers levels have emerged between those patients that acquired unavoidable and avoidable pressure sores. Although limited, evidence on unavoidable pressure ulcer is increasing. More research in the field is recommended to support clinicians, managers and policymakers in the several implications of unavoidable pressure ulcers both at the patient and at the system levels.

Post-hoc validation of the Conley Scale in predicting the risk of falling with older in-hospital medical patients: findings from a multicentre longitudinal study.

BACKGROUND: The Conley Scale is one of the most widespread fall-risk screening tools in medical unit settings, despite the lack of data regarding its validity in patients currently admitted to these units. AIMS: Establishing the validity of the Conley Scale in identifying patients at risk of falling in an acute medical setting. METHODS: A 6-months longitudinal study in 12 acute medical units from September 2012 to March 2013, a total of 1464 patients with ≥65 years of age were consecutively enrolled and evaluated with the Conley Scale within 24 h of admission. A construct validity, internal consistency, and a priori and a posteriori predictive validity study was performed. RESULTS: The explorative factor analysis showed a two-factor structure explaining a total variance of 48.3 %: previous history (30.41 %), and physical and cognitive impairment (17.9 %). The scale reported a poor internal consistency (Cronbach's α = 0.465) and the capability to correctly identify 18/649 patients as being at risk of falling, whereas the negative predictive value was 98.5 %. The sensitivity and specificity values were 60.0 and 55.9 %, respectively. No difference emerged between patients scored as at risk and those scored as not at risk in the time elapsed from admission to the first fall (HR = 0.600, 95 % CI 0.289-2.247 p = .166). DISCUSSION: The Conley Scale is not able to predict falls in elderly acute medical patients, and has reported poor internal consistency and accuracy. CONCLUSIONS: More studies are needed to develop appropriate tools to predict the risk of falling in elderly individuals admitted to an acute medical setting.

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.

Nursing effectiveness in Italy: findings from a grounded theory study.

AIM: The aim of the present study was to conceptualize the basic social process by which nursing intervention affects patient outcomes in Italian daily practice. BACKGROUND: Different frameworks explain the relationship between nursing care and patient outcomes. However, several authors have suggested the need to develop further theory in order to understand this relationship. METHOD: A qualitative study based on a grounded theory approach was undertaken to generate a conceptual description of nursing care in Italy and its relationship to patient outcomes. Data collection and analysis processes were conducted simultaneously in an Italian Teaching Hospital from 2007 to 2009. FINDINGS: Nursing effectiveness (the core variable) expresses the positive effects of the nursing system on patient outcomes, on patient safety and on the multi-disciplinary outcomes. The two interdependent social processes that assure nursing effectiveness are: creating a supportive environment for potentially effective nursing (causative factors); and performing organizational, clinical and collaborative intervention (nursing strategies and consequences). CONCLUSIONS: The factors determining a potentially supportive environment for nursing effectiveness are similar to those documented in the literature but the need for clinical nurses to compensate systematically when this support is not available seems to be unique. IMPLICATIONS FOR NURSING MANAGEMENT: Understanding the basic processes involved in the determination of nursing effectiveness in one country has implications for nursing leaders' decision-making, on National Health Service policy recommendations and on professional development both at national and international levels.

[Criteria for delegating the safe hospital administration of drug therapy via natural route to nurses aids in hospital]. / I criteri per affidare in sicurezza la somministrazione della terapia per via naturale agli operatori sanitari con formazione complementare in ospedale.

AIM: To assess if and how many patients admitted to hospital could receive the drug therapy via natural route by specialized nurses aids (OSSc). METHODS: Focus group to identify the items of an assessment instrument to select patients eligible to receive drug therapy from OSSc, validation (face validity, test retest, interrater reliability and factorial analysis) and implementation on 227 patients admitted to medical and surgical wards. RESULTS: During admission 106/227 patients (46.5%) could receive the therapy from OSSc for at least one day: 21 (9.2%) at admission, 73 (32.1%) after 4 days and 12 (11.3%) in the following days, but 29/106 (27.3%) formerly eligible patients change their condition and therapy should be administered by nurses. On average in medical wards 7.7 patients/day would be eligible while only 2.6 in surgery. CONCLUSIONS: The delegation of drug therapy in acute hospitals to OSSc seems unlikely for patients complexity and the need of daily assessments and adjustments. Nurses should each time select eligible patients guaranteeing the necessary supervision. This extra workload is not affordable.

[Assessing the trend in the aging of the nursing staff at two hospitals of the Friuli Venezia Giulia region: application of a deterministic mathematical model]. / Stima del trend di invecchiamento della popolazione infermieristica di due ospedali del Friuli Venezia Giulia: applicazione di un modello matematico deterministico.

BACKGROUND: The aging of the nursing workforce is a phenomenon that several industrialized countries has been facing for at least a decade. In Italy, for the period between 2011 and 2021, the issue associated with the nursing workforce will not be one of shortage but rather one of aging. AIMS: The main objective of this study was to estimate the employed nurse population aging trends for the period 2009-2035 in two Teaching Hospitals (TH1 and TH2) located in the North of Italy. METHODS: A deterministic mathematical model has been developed in order to obtain aging projections for the nursing workforce from 2009 until 2035. RESULTS: Within the next six years, the aging trend of nurse populations, with respect to 2008, at the TH 1 and 2 will show a steady increase of nurses aged over 45; specifically, a 29.4% vs. 34.1% increase and a 21.6% vs. 41.4% respectively. It is hypothesized that the TH 1 will have the highest proportion of nurses aged over 45 in 2014, whereas it is estimated that for the TH 2 this trend will continue until 2021 when the proportion of nurses aged over 45 will make up 48.8% out of the nurse population. DISCUSSION: The trend may lead to an increase in the number of experienced nurses; however, such a trend should be looked at with concern, with respect to the physical unsuitability. Nurses aged over 45 represent 20% of the workforce at both TH. Conclusions/implications for management and research. If the trend predicted by the model were to occur in the coming years, the problem of nursing workforce ageing will have to be addressed because it involves different expectations but also the perception of different work skills. The nursing direction is called to test new strategies for managing the staff and the career of nurses will also need to be redesigned, because contract law looks primarily at the initial stage of working life (specializations, university education, career opportunities) neglecting the final one (from the 50th year of age to retirement).

[Recommendations and Italian standards for setting safe staff nursing levels in hospitals: results of a consensus conference]. / Raccomandazioni e standard italiani per dotazioni infermieristiche ospedaliere sicure: esiti di una consensus conference.

Nurse staffing levels have always been an issue and the optimal level and mix of nurses required to deliver quality care as cost-effectively as possible continues to be discussed at both national and international levels. In Italy, a network of experts rom ten local health and hospital authorities was set up in June 2010. The, main objectives of the network were to define, validate and approve a panel of relevant indicators, identify minimum standards of safety and develop recommendations to guide decision-making regarding hospital nurse staffing levels. The indicators and recommendations developed by the network are presented in this paper.

[Nursing outcomes in medical wards (ESAMED Study): the results of a multicenter longitudinal study]. / Esiti dell'assistenza infermieristica in medicina:risultati di uno studio longitudinale multicentrico (studio ESAMED).

. Factors associated to patients' outcomes in medical units: lessons learnt from an Italian multicentric longitudinal study design (ESAMED study). INTRODUCTION: Research on nursing outcomes attempted to identify the associated factors, however, with mainly retrospective or descriptive studies. In 2011, an Italian network was established and a multicentric longitudinal study aimed at exploring factors associated with nursing outcomes among in-hospital medical patients was started. AIMS: To summarise (a) how the research project was originated, (b) which patients have been involved, variables and instruments used, (c) the main findings, and (d) the lessons learnt. METHOD: 12 acute medical units from 11 Italian hospitals were involved. A consecutive sample was adopted: on a daily basis, data has been collected at the (a) patient; (b) nursing care, and (c) hospital levels. RESULTS: The effect of the variability in the amount of nursing care and skill mix in medical units was explored on the following outcomes: (a) hospital-acquired functional dependence, (b) prevalence and incidence of (i) episodes of hyperactive delirium, (ii) avoidable pressure ulcers; (iii) peripheral venous catheter phlebitis; (c) dissatisfaction with the nursing care; and (d) in-hospital mortality; 1464 out of 2082 eligible patients were involved. The frequency and reasons of Missed Nursing Care (MNC), as well as the presence of family caregivers at the bedside were also measured. CONCLUSIONS: The study confirmed that (a) the amount of nursing care provided by graduate nurses improves patient outcomes; (b) a skill mix in favour of nursing aides, negatively impacts on patients' outcomes; and (c) a higher frequency of MNC threatens patient outcomes.

[Validity and reliability of a questionnaire to assess patients' satisfaction for home care]. / Validità e affidabilità di un questionario per la valutazione della soddisfazione per i'assistenza infermieristica domiciliare.

AIM: Specific instruments to measure patients satisfaction for home care are missing in Italy. A questionnaire was devised, based on two well known and validated instruments (La Monica-Oberst Patient Satisfaction Scale (LOPSS) and the The Patient Satisfaction With Health Care Provider Scale (PSHCPS) and validated. METHODS: The questionnaire was discussed with nurses and psychologists. The questionnarie was initially administered to a sample of 25 patients home care patients, not cognitively impaired, and to their caregivers. The concordance was measured with the K di Cohen, Sperman tau of Cograduation and tau of Kendall coefficiencies, with very satisfactory results (K = 0.68, p = 0.72, tau = 0.61). After 30 days the questionnaire was administered to the same patients and relatives, to test stability/reliability and internal coherence. Finally, it was administered to a stratified sample of 139 patients (or to their relatives) to assess validity with factorial analysis, and again internal coherence. RESULTS: The final questionnaire has 20 closed ended and three open questions. Concordance between patients and relatives on closed questions was good, therefore the questionnaires can be administered to patients or relatives. The test retest showed also a good stability (K 0.83). The factorial analysis identified two sub scales: one that measures patients satisfaction for the organization and for the interpersonal relationship between patients and nurses. CONCLUSIONS: The questionnaire has good psychometric properties and can be reliably administered also to caregivers. Some questions with higher number of missing answers could be improved.

Overcoming redundancies in bedside nursing assessments by validating a parsimonious meta-tool: findings from a methodological exercise study.

RATIONALE: There is growing interest in validating tools aimed at supporting the clinical decision-making process and research. However, an increased bureaucratization of clinical practice and redundancies in the measures collected have been reported by clinicians. Redundancies in clinical assessments affect negatively both patients and nurses. METHODS: To validate a meta-tool measuring the risks/problems currently estimated by multiple tools used in daily practice. A secondary analysis of a database was performed, using a cross-validation and a longitudinal study designs. In total, 1464 patients admitted to 12 medical units in 2012 were assessed at admission with the Brass, Barthel, Conley and Braden tools. Pertinent outcomes such as the occurrence of post-discharge need for resources and functional decline at discharge, as well as falls and pressure sores, were measured. Explorative factor analysis of each tool, inter-tool correlations and a conceptual evaluation of the redundant/similar items across tools were performed. Therefore, the validation of the meta-tool was performed through explorative factor analysis, confirmatory factor analysis and the structural equation model to establish the ability of the meta-tool to predict the outcomes estimated by the original tools. RESULTS: High correlations between the tools have emerged (from r 0.428 to 0.867) with a common variance from 18.3% to 75.1%. Through a conceptual evaluation and explorative factor analysis, the items were reduced from 42 to 20, and the three factors that emerged were confirmed by confirmatory factor analysis. According to the structural equation model results, two out of three emerged factors predicted the outcomes. CONCLUSIONS: From the initial 42 items, the meta-tool is composed of 20 items capable of predicting the outcomes as with the original tools.

[Continuity of care: community care in Italy and Sweden. A comparison]. / Continuità assistenziale: analisi e confronto tra un servizio infermieristico di assistenza domiciliare italiano ed uno svedese, in base ai criteri del Canadian Council on Health Accreditation.

One of the objectives of the Health 21 document, approved by the World Health Association, European Region, is to create by the year 2010 an integrate sanitary system, where the population of the region count on a better access to the health services aimed at the family and the community. In accordance with the tendencies of the European nation, which are more and more open to confrontation, the research has, as main objective, the parallel analysis of the welfare continuity and integration of the Italian Nursing Home Care Service compared to the Swedish Health Care Service. The research has been structured from a sanitary accreditation project that the Veneto Region has started with the collaboration of the Ottawa Council On Health Services Accreditation (Cchsa). The analysis puts in evidenced the completion of the offer of the territory home services present in Padua. The comparison with the Swedish situation however puts in evidence some gaps and some possible developments of the Italian service involving above all the complete transcription of the patient information and the continuity of its communication, in particular in the nursing field. Another possible development of the Italian service concerns the method continuity, between the working units themselves and with the territory, which could be achieved using common nursing guide lines and protocols to manage standard caring situations. From the analysis of the european services it results that it is the nurse who has the most relevant role for the care quality improvement.

Missed nursing care and predicting factors in the Italian medical care setting.

Missed nursing care (MNC), such as nursing care omitted or delayed, has not been measured in the Italian context where several cost containment interventions affect the care offered in medical units. The aim of the study is to identify the amount, type, and reasons for MNC in the Italian medical care setting and to explore the factors that affect the occurrence of MNC. A 3-month longitudinal survey was carried out followed by a cross-sectional study design in 12 north eastern acute medical units. A total of 314 nursing staff members were involved. Multivariate logistic regression was performed to identify the predictors of MNC. Patient ambulation (91.4 %), turning the patient every 2 h (74.2 %), and right timing in administering medications (64.6 %) were the most perceived MNC. Among the most frequent reasons were the unexpected rise in patient volume or critical conditions (95.2 %), inadequate numbers of staff (94.9 %), and large numbers of admissions/discharges (93.3 %). The R (2) 33.2 % of the variance in MNC were explained by a full-time position (OR 4.743, 95 % CI 1.146-19.629), communication tensions between Registered Nurses and Nurses' Aides (OR 1.601, 95 % CI 1.020-2.515), the amount of experience in medical unit (OR 1.564, 95 % CI 1.021-2.397), and the amount of daily care offered by Nurses' Aides (1.039, 95 % CI 1.011-1.067). A substantial amount of basic and clinically relevant nursing interventions was perceived to be missed, and this may lead to an increase in negative outcomes for patients admitted to a medical unit. Appropriate standards of nursing care should be adopted urgently in medical units aiming to protect frail patients.

[The integration process between nurses and support figures. Experience at the AULSS 16 in Padua]. / Il percorso di integrazione tra infermieri e figure di supporto. L'esperienza nella AULSS 16 di Padova.

In the last decade, Italian Nursing history had an important normative development that completely redesigned profile, responsibility, autonomy and education, giving a push to the professionalism process. The article discuss how introduce new support figures, what tasks to delegate and what procedure are necessary to better care.

[A survey on working satisfaction of nurses]. / La soddisfazione lavorativa dell'infermiere di assistenza domiciliare: un indagine conoscitiva.

A descriptive survey was performed in the home care service of Azienda ULSS 16 of Padova at a sample of nurses. The aim of this study was to identify working experience aspects which represent satisfaction or dissatisfaction factors. A questionnaire was administered to the 63 nurses of the service, in the same day. 53 nurses (84%) declare themselves satisfied or very satisfied for the way their job stimulates the development of new capabilities, the same for freedom of choice the way of working, while 43 (68%) are satisfied or very satisfied for profession in general. 55 (87%) state to be unsatisfied or not much satisfied for the relation between wages and responsibility, and 42 (67%) for career opportunity. Working satisfaction is mainly caused by the quality of the relation with patient and his family for 45 nurses (71%); this aspect also prevails satisfaction linked to the opportunity of working in autonomy (29, 46%).