Cultural competency in dietetic diabetes care-A qualitative study of the dietician's perspective.

INTRODUCTION: Diabetes type 2 is more prevalent in ethnic minorities in the Netherlands, and outcomes of health care in general are worse compared to other Dutch patients. The purpose of this study is to explore the experiences of dieticians and the knowledge, skills and attitudes they consider to be important for effective dietetic care in migrant patients. METHODS: Semi-structured interviews were held with 12 dieticians, of various ages, ethnic backgrounds and experience. The interview guide was based on Seeleman's cultural competence model and the Dutch dietetic consultation model. Interviews were transcribed, coded and thematically analysed, revealing 7 main themes. RESULTS: Dieticians were uncertain whether their care fulfilled their migrant patients' needs. They experienced language differences as a major barrier for retrieving information and tailoring advice to the patient's needs. Furthermore, dieticians feel they lack cultural knowledge. An open and respectful attitude was considered important for effective care. The communication barrier hindered building a trusting relationship; however, few dieticians mentioned a need for communication training. They expressed a need for cultural competence training, specifically to acquire cultural knowledge. CONCLUSION: Dieticians struggle with providing dietetic care for migrant diabetes patients due to communication barriers and difficulty in building a trusting relationship. They are conscious of their lack of cultural knowledge, and acknowledge the need for an open and respectful attitude and essential communication skills in order to collect and convey information. They seem unaware of the impact of low (health) literacy. Cultural competence training is needed for effective dietetic care for migrants.

Relationship Between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study.

OBJECTIVE: The aim of this study was to establish the relationship between postoperative pain and 30-day postoperative complications. BACKGROUND: Only scarce data are available on the association between postoperative pain and a broad range of postoperative complications in a large heterogeneous surgical population. METHODS: Having postoperative pain was assessed in 2 ways: the movement-evoked pain score on the Numerical Rating Scale (NRS-MEP) and the patients' opinion whether the pain was acceptable or not. Outcome was the presence of a complication within 30 days after surgery. We used binary logistic regression for the total population and homogeneous subgroups to control for case complexity. Results for homogeneous subgroups were summarized in a meta-analysis using inverse variance weighting. RESULTS: In 1014 patients, 55% experienced moderate-to-severe pain on the first postoperative day. The overall complication rate was 34%. The proportion of patients experiencing postoperative complications increased from 0.25 [95% confidence interval (CI) = 0.21-0.31] for NRS-MEP = 0 to 0.45 (95% CI = 0.36-0.55) for NRS-MEP = 10. Patients who found their pain unacceptable had more complications (adjusted odds ratio = 2.17 (95% CI = 1.51-3.10; P < 0.001)). Summary effect sizes obtained with homogeneous groups were similar to those obtained from the total population who underwent very different types of surgery. CONCLUSIONS: Higher actual postoperative pain scores and unacceptable pain, even on the first postoperative day, are associated with more postoperative complications. Our findings provide important support for the centrality of personalized analgesia in modern perioperative care.

Views and experiences of ethnic minority diabetes patients on dietetic care in the Netherlands - a qualitative study.

BACKGROUND: Diabetes type 2 is more prevalent in people from ethnic minorities in the Netherlands, and outcomes of care are worse compared with other Dutch people. Dieticians experience difficulties in managing these groups in self-management and adherence to dietary advice. The aim of this study was to explore the views regarding a healthy diet and dietetic care among ethnic minority type 2 diabetes patients. METHODS: Semi-structured interviews were held with 12 migrants with diabetes from Turkey, Morocco, Iraq and Curacao, who visited a dietician. Inclusion went on until saturation was reached. The interview guide was based on the Attitudes, Social influence and self-Efficacy (ASE) model and Kleinman's explanatory model of illness. Interviews were held in the language preferred by the respondent. Transcripts were coded and thematically analyzed. RESULTS: Several respondents expected a more rigorous, directive and technical approach of the dietician. All respondents acknowledged the importance of a healthy diet. What they considered healthy was determined by culturally influenced ideas about health benefits of specific foods. Important hindrances for dietary change were lack of self-efficacy and social support. Social influences were experienced both as supportive and a hindrance. CONCLUSIONS: Migrant diabetic patients' opinions about healthy food are determined by culturally influenced ideas rather than by dietary guidelines. Dutch dietary care is not tailored to the needs of these patients and should take into account migrants' expectations, cultural differences in dietary habits and specifically address the role of family.

eHealth Apps Replacing or Complementing Health Care Contacts: Scoping Review on Adverse Effects.

BACKGROUND: The use of eHealth has increased tremendously in recent years. eHealth is generally considered to have a positive effect on health care quality and to be a promising alternative to face-to-face health care contacts. Surprisingly little is known about possible adverse effects of eHealth apps. OBJECTIVE: We conducted a scoping review on empirical research into adverse effects of eHealth apps that aim to deliver health care at a distance. We investigated whether adverse effects were reported and the nature and quality of research into these possible adverse effects. METHODS: For this scoping review, we followed the five steps of Arksey and O'Malley's scoping review methodology. We searched specifically for studies into eHealth apps that replaced or complemented the face-to-face contact between a health professional and a patient in the context of treatment, health monitoring, or supporting self-management. Studies were included when eHealth and adverse effects were mentioned in the title or abstract and when empirical data on adverse effects were provided. All health conditions, with the exception of mental health conditions, all ages, and all sample sizes were included. We examined the literature published between December 2012 and August 2017 in the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and the Cochrane Library. The methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklists. RESULTS: Our search identified 79 papers that were potentially relevant; 11 studies met our inclusion criteria after screening. These studies differed in many ways and the majority were characterized by small research populations and low study quality. Adverse effects are rarely subject to systematic scientific research. So far, information on real adverse effects is mainly limited to incidental reporting or as a bycatch from qualitative pilot studies. Despite the shortage of solid research, we found some indications of possible negative impact on patient-centeredness and efficiency, such as less transparency in the relationship between health professionals and patients and time-consuming work routines. CONCLUSIONS: There is a lack of high-quality empirical research on adverse effects of eHealth apps that replace or complement face-to-face care. While the development of eHealth apps is ongoing, the knowledge with regard to possible adverse effects is limited. The available research often focuses on efficacy, added value, implementation issues, use, and satisfaction, whereas adverse effects are underexplored. A better understanding of possible adverse effects could be a starting point in improving the positive impact of eHealth-based health care delivery.

Identification of influencing factors and strategies to improve communication between general practitioners and community nurses: a qualitative focus group study.

Background: As the number of patients with complex healthcare needs grows, inter-professional collaboration between primary care professionals must be constantly optimized. General practitioners (GPs) and community nurses (CNs) are key professions in primary care; however, poor GP-CN communication is common, and research into the factors influencing its quality is limited. Objective: To explore patient-related GP-CN communication and facilitating and hindering factors, and to identify strategies to enhance this communication. Method: A qualitative focus group design was used to identify the facilitating and hindering factors and strategies for improvement. In a Dutch primary care setting, 6 mono-professional focus group interviews (3 meetings of 13 GPs; 3 meetings of 18 CNs) were organized between June 2015 and April 2016, recorded and transcribed verbatim. Two independent researchers performed the coding of these interviews, identifying their categories and themes. Results: Results show that, despite the regular contact between GPs and CNs, communication was generally perceived as poor in effectiveness and efficiency by both professions. Mutual trust was considered the most important facilitating factor for effective communication. Profession-specific factors (e.g. differences in responsibility and profession-specific language) and organizational factors (e.g. lack of shared care plans, no in-person communication, lack of time) may be of influence on communication. Participants' suggestions for improvement included organizing well-structured and reimbursed team meetings and facilitating face-to-face contact. Conclusion: GP-CN patient-related communication benefits most from trusting inter-personal relationships. Inter-professional training programmes should address both professional and organizational factors and should be evaluated for their effect on quality of care.

The role of the general practitioner in multidisciplinary teams: a qualitative study in elderly care.

BACKGROUND: In the western world, a growing number of the older people live at home. In the Netherlands, GPs are expected to play a pivotal role in the organization of integrated care for this patient group. However, little is known about how GPs can play this role best. Our aim for this study was to unravel how GPs can play a successful role in elderly care, in particular in multidisciplinary teams, and to define key concepts for success. METHODS: A mixed qualitative research model in four multidisciplinary teams for elderly care in the Netherlands was used. With these four teams, consisting of 46 health care and social service professionals, we carried out two rounds of focus-group interviews. Moreover, we performed semi-structured interviews with four GPs. We analysed data using a hybrid inductive/deductive thematic analysis. RESULTS: According to the health care and social service professionals in our study, the role of GPs in multidisciplinary teams for elderly care was characterized by the ability to 'see the bigger picture'. We identified five key activities that constitute a successful GP role: networking, facilitating, team building, integrating care elements, and showing leadership. Practice setting and phase of multidisciplinary team development influenced the way in which GPs fulfilled their roles. According to team members, GPs were the central professionals in care services for older people. The opinions of GPs about their own roles were diverse. CONCLUSIONS: GPs took an important role in successful care settings for older people. Five key concepts seemed to be important for best practices in care for frail older people: networking (community), facilitating (organization), team building (professional), integrating care elements (patient), and leadership (personal). Team members from primary care and social services indicated that GPs had an indispensable role in such teams. It would be advantageous for GPs to be aware of this attributed role. Attention to leadership competencies and to the diversity of roles in multidisciplinary teams in GP training programmes seems useful. The challenge is to convince GPs to take a lead, also when they are not inclined to take this role in organizing multidisciplinary teams for older people.

What environmental factors influence resumption of valued activities post stroke: a systematic review of qualitative and quantitative findings.

OBJECTIVE: Identify the environmental factors that influence stroke-survivors' reengagement in personally valued activities and determine what specific environmental factors are related to specific valued activity types. DATA SOURCES: PubMed, CINAHL and PsycINFO were searched until June 2016 using multiple search-terms for stroke, activities, disability, and home and community environments. REVIEW METHODS: An integrated mixed-method systematic review of qualitative, quantitative and mixed-design studies was conducted. Two researchers independently identified relevant studies, assessed their methodological quality and extracted relevant findings. To validly compare and combine the various findings, all findings were classified and grouped by environmental category and level of evidence. RESULTS: The search yielded 4024 records; 69 studies were included. Most findings came from low-evidence-level studies such as single qualitative studies. All findings were consistent in that the following factors facilitated reengagement post-stroke: personal adapted equipment; accessible environments; transport; services; education and information. Barriers were: others' negative attitudes and behaviour; long distances and inconvenient environmental conditions (such as bad weather). Each type of valued activity, such as mobility or work, had its own pattern of environmental influences, social support was a facilitator to all types of activities. Although in many qualitative studies others' attitudes, behaviour and stroke-related knowledge were seen as important for reengagement, these factors were hardly studied quantitatively. CONCLUSION: A diversity of environmental factors was related to stroke-survivors' reengagement. Most findings came from low-evidence-level studies so that evidence on causal relationships was scarce. In future, more higher-level-evidence studies, for example on the attitudes of significant others, should be conducted.

Role of Environmental Factors on Resuming Valued Activities Poststroke: A Systematic Review of Qualitative and Quantitative Findings.

OBJECTIVE: To investigate how reengagement in valued activities poststroke is influenced by environmental factors. DATA SOURCES: PubMed, CINAHL, and PsycINFO were searched to June 2015 using multiple search terms for stroke, activities, disability, and home and community environments, with the following constraints: English, humans, and adults. STUDY SELECTION: Studies were included that contained data on how reengagement in valued activities of community-dwelling stroke survivors was influenced by the environment. Two reviewers independently selected the studies. The search yielded 3726 records; 39 studies were eventually included. DATA EXTRACTION: Findings were extracted from qualitative, quantitative, and mixed-design studies. Two reviewers independently assessed study quality using the Oxford Critical Appraisal Skills Programme lists and independently extracted results. DATA SYNTHESIS: Thematic analysis was conducted on qualitative data, revealing 9 themes related to the iterative nature of the process of reengagement and the associated environmental factors. During the process of reengagement, environmental factors interact with personal and disease-related factors in a gradual process of shaping or abandoning valued activities. The sociocultural context in this case determines what activities are valued and can be resumed by stroke survivors. Social support; activity opportunities and obligations; familiar and accessible environments; resources and reminders; and a step-by-step return facilitate stroke survivors to explore, adapt, resume, and maintain their activities. Social support is helpful at all stages of the process and particularly is important in case stroke survivors are fearful to explore their activity possibilities. The quantitative data identified largely endorsed these findings. No quantitative data were found in respect to the iterative nature of the process, familiar environments, or accessibility. CONCLUSIONS: Reengagement in valued activities is a gradual process. In each stage of the process, several environmental factors play a role. During rehabilitation, professionals should pay attention to the role physical and social environmental factors have in reengagement poststroke and find ways to optimize stroke survivors' environments.

Acute pain services and postsurgical pain management in the Netherlands: a survey.

BACKGROUND: Acute postoperative pain is still inadequately managed, despite the presence of acute pain services (APSs). This study aimed to investigate the existence, structure, and responsibilities of Dutch APSs and to review the implementation of the Dutch Hospital Patient Safety Program (DHPSP). METHODS: Information was gathered by a digital questionnaire, sent to all 96 Dutch hospitals performing surgical procedures. RESULTS: Completed questionnaires were received from 80 hospitals (83%), of which 90% have an APS. Important duties of the APS are regular patient rounds, checking complex pain techniques (100%), supporting quality improvement of pain management (87%), pain education (100%), and pain research (21%). IMPLEMENTATION OF THE DHPSP: Regular in-hospital pain training is not provided in 46% of the hospitals. Thirteen percent of the hospitals offer no patient information about pain management. CONCLUSIONS: Almost all hospitals have an APS. They differ in both the way they are locally organized, along with the activities they employ. Future research needs to compare the effect of patient and nonpatient-related activities of APSs on outcomes related to pain management.

Nurses' perceptions of proactive palliative care: a Dutch focus group study.

BACKGROUND: Early identification of pain and other problems is an important aspect of palliative care. Although nurses have an important role in palliative care, little is known about nurses' perceptions of proactive palliative care. OBJECTIVES: This study aimed to explore nurses' perceptions and experiences of proactive identification of problems and requirements among patients with palliative care needs. METHODS: This was a qualitative study in which 16 nurses working in palliative care took part in two focus groups. RESULTS: All of the nurses underlined the importance of their early involvement in palliative care. Anticipation of possible future problems, advice and information about end-of-life care and palliative care facilities, and assessment of patients' wishes regarding care and preferred place of death were mentioned as important aspects of the early identification of problems and needs. Four themes were identified: the start of proactive palliative care; communication, support, and guidance; advocating for patients; and cooperation with health professionals. CONCLUSIONS: Nurses' involvement in proactive palliative care is important in supporting patients' palliative care management. Ongoing education, focused on multidisciplinary communication and cooperation, professional development, and empowerment of nurses, remains of utmost importance.

Clinical leadership training in integrated primary care networks: a qualitative evaluation.

Objective: To explore how a clinical leadership training programme contributes to successful implementation of integrated dementia care in local primary care networks. Methods and analysis: A qualitative design was used in local primary care networks in the Netherlands. Twenty-six primary care professionals, nurses (n=22), general practitioners (n=2) and occupational therapists (n=2) followed a 2-year practice-based educational programme including individual coaching and interactive group training. Embedded leadership training created opportunities for direct application of acquired leadership skills. Reports of coaching sessions and transcripts of semi-structured interviews with 20 leadership trainees, 8 network members and a focus group interview with 9 leadership trainees were thematically analysed. Results: They identified 50 learning goals, mostly associated with personal leadership competences. These professionals perceived some improvement in their leadership behaviour and preferred a duo-network leadership arrangement. Individual coaching sessions and group training sessions were perceived as fruitful support. Coaching sessions were found to facilitate learning processes regarding personal competencies, collaboration issues and role clarification. Group meetings were appreciated for exercises on transformational leadership behaviour and exchange of experiences. Network leaders and members observed improved quality of care and mentioned continuity of leadership, perseverance of leaders and a sufficient time period to bring about change as important facilitating factors. Conclusion: Clinical leadership training to stimulate integrated primary care is promising as it was positively valued and contributed to improved perceived leadership competencies. Network leaders and members experienced improved quality of care when at least continuity in leadership was warranted.

The role of the social network during inpatient rehabilitation: A qualitative study exploring the views of older stroke survivors and their informal caregivers.

BACKGROUND: After discharge, stroke survivors and their informal caregivers need support from their social networks to resume their most valued activities. Rehabilitation professionals could help them establish a strong support system. OBJECTIVE: Explore how older stroke survivors and their primary informal caregivers expect to resume their valued activities after discharge, and discover their ideas about involving, informing and educating their family members, friends and important others during inpatient rehabilitation so that, once home, they will have adequate support. METHODS: We conducted semi-structured interviews with stroke survivors from three geriatric rehabilitation centres and their primary informal caregivers, used the pictures of daily activities to elicit their perspectives, and applied a descriptive and interpretive design to data analysis. RESULTS: Many participants had no concrete idea about how to resume their activities after discharge but nevertheless were optimistic they would. They expected help to be available and saw no need for professionals to involve their network during inpatient rehabilitation. However, once they had insight into the challenges to expect after discharge, they often appreciated the idea of professionals contacting their network. To better understand the challenges after discharge, it was helpful if professionals provided concrete, honest information about the stroke's consequences for daily life. Actually doing daily activities also helped gain better insights. CONCLUSIONS: To enhance insight in the need of social support after discharge, we suggest that rehabilitation professionals are honest about what to expect and let stroke survivors explore their valued activities in a realistic context more often.

Activity resumption after acquired brain injury: the influence of the social network as described by social workers.

PURPOSE: To understand how the social network of patients with acquired brain injury facilitates or hinders resumption of their activities, such as social and leisure activities, and how this affects patients' well-being and quality of life. METHODS: Thematic analysis was applied to 70 narratives about family members, friends, neighbors and colleagues helping or hindering patients in resuming their activities. The narratives were derived from social workers with extensive experience with brain-injured patients and their social networks. RESULTS: The narratives show that an available, understanding and well-informed network enhances activity resumption by being inclusive and encouraging patients to develop their skills. This is in line with earlier studies based on patients' experiences. Whereas the patient-based studies emphasize that being unsupportive or overprotective hinders patients from resuming their activities, this study also shows that preventing patients from meeting others or placing too-high demands results in activity loss, social isolation and reduced well-being and quality of life. CONCLUSIONS: Several social network factors play a role in activity resumption, well-being, and quality of life of after brain injury. Early after the brain injury, rehabilitation professionals should work with patients' family members, friends, and others and educate them about how to provide adequate support.IMPLICATIONS FOR REHABILITATIONSince the patient's social network is an important determinant of activity resumption, rehabilitation professionals should analyze its features soon after brain injury, such as whether patients have an understanding network that encourages them and includes them in their activities.Since especially close network members tend to be protective of or place high demands on the patient, rehabilitation professionals should explain to them the importance of activity resumption for the patient's wellbeing and the adverse effects of being overprotective or over-demanding.Rehabilitation professionals should include other network members, such as friends or colleagues, in the rehabilitation process and educate them about how to support patients in resuming their activities.

Observing cultural competence of healthcare professionals: A systematic review of observational assessment instruments.

OBJECTIVE: Observational instruments are preferred for assessment of cultural competence. The aim of the current study is to identify observational instruments to assess cultural competence in healthcare providers and dieticians specifically and assess their psychometric properties. METHODS: A systematic review was conducted in Cinahl, Cochrane, EMBASE, PsycInfo, Pubmed, and Web of Science using search terms related to cultural competency and measurement properties. Methodological quality of the selected studies of observational cultural competence instruments in dieticians, other healthcare professionals and psychological counsellors and the measurement properties of instruments were assessed using the COSMIN checklist. RESULTS: From 11,913 articles, six articles on five instruments were selected. Instruments were targeted at health professionals and counsellors only, and designed for face-to-face communication (n = 4) or verbal responses to videotaped simulated interactions (n = 1). The instruments' content varied largely, with main focus on attitude, and little on knowledge and skills. The measurement properties were suboptimal. CONCLUSION: No observational instrument are available to evaluate cultural competence of dieticians. Studies on psychometric properties of instruments targeted at other health professionals lack methodological rigour. PRACTICE IMPLICATIONS: Future work should focus on developing an instrument that encompasses both 'general' cultural competences necessary for all healthcare professionals and dietetic specific competences.

Communication between Dutch community nurses and general practitioners lacks structure: An explorative mixed methods study .

BACKGROUND: Community nurses and general practitioners evaluate their patient-related communication to be poor. However, their actual communication has hardly been investigated and specific strategies for improvement are unclear. OBJECTIVES: To explore actual community nurse-general practitioner communication in primary care and gain insights into communication style, and conversation structure and their determinants. METHODS: A mixed-methods design was applied. Telephone conversations between community nurses and general practitioners in the Netherlands were recorded and transcribed verbatim. We measured structure and the duration of their conversations, and community nurses' self-confidence towards general practitioners and their trust in and familiarity with the conversation partner. A thematic analysis was applied to the transcripts of the conversations. Correlations between these determinants were calculated using Spearman's correlation coefficient. RESULTS: The 18 community nurses recorded 23 conversations with general practitioners. Qualitative analysis revealed that many conversations lacked structure and conciseness, i.e. the nurses started conversations without a clearly articulated question and did not provide adequate background information. The mean duration of their conversations with doctors was 8.8 min. Community nurses with higher self-confidence towards doctors communicated in a more structured way (p = 0.01) and general practitioners were more satisfied about the conversations (p = 0.01). CONCLUSION: This exploratory study of actual community nurse-doctor telephone conversations in primary care identified communication structure and nurse self-confidence towards general practitioners as key targets for the improvement of interprofessional communication, which may increase the effectiveness of community nurse-general practitioner collaboration.

Clinical leadership and integrated primary care: A systematic literature review.

BACKGROUND: Leaders are needed to address healthcare changes essential for implementation of integrated primary care. What kind of leadership this needs, which professionals should fulfil this role and how these leaders can be supported remains unclear. OBJECTIVES: To review the literature on the effectiveness of programmes to support leadership, the relationship between clinical leadership and integrated primary care, and important leadership skills for integrated primary care practice. METHODS: We systematically searched PubMed, CINAHL, Embase, PsycINFO until June 2018 for empirical studies situated in an integrated primarycare setting, regarding clinical leadership, leadership skills, support programmes and integrated-care models. Two researchers independently selected relevant studies and critically appraised studies on methodological quality, summarized data and mapped qualitative data on leadership skills. RESULTS: Of the 3207 articles identified, 56 were selected based on abstract and title, from which 20 met the inclusion criteria. Selected papers were of mediocre quality. Two non-controlled studies suggested that leadership support programmes helped prepare and guide leaders and positively contributed to implementation of integrated primary care. There was little support that leaders positively influence implementation of integrated care. Leaders' relational and organizational skills as well as process-management and change-management skills were considered important to improve care integration. Physicians seemed to be the most adequate leaders. CONCLUSION: Good quality research on clinical leadership in integrated primary care is scarce. More profound knowledge is needed about leadership skills, required for integrated-care implementation, and leadership support aimed at developing these skills.

Valued activities and informal caregiving in stroke: a scoping review.

Purpose: Map the literature about valued activities and informal caregiving post stroke and determine the nature, extent, and consequences of caregivers' activity changes. Methods: A scoping review was undertaken, searching Pubmed, Cinahl, PsycInfo, and Google Scholar. Two researchers independently identified relevant articles, extracted study characteristics and findings, and assigned codes describing the topics and outcomes. Using thematic analysis, the main study topics and study outcomes were described. Results: The search yielded 662 studies, 30 of which were included. These were mainly qualitative and cross-sectional studies assessing caregivers' activity changes and related factors, or exploring caregivers' feelings, needs and strategies to deal with their activity challenges. Although caregivers often lost their social and leisure activities, which made them feel unhappy and socially isolated, we found no studies about professional interventions to help caregivers maintain their activities. Over the years, caregivers' activity levels generally increased. However, some caregivers suffered from sustained activity loss, which, in turn, relates to depression. Conclusion: Loss of valued activities is common for stroke caregivers. Although high-level evidence is lacking, our results suggest that sustained activity loss can cause stroke caregivers to experience poor mental health and wellbeing. Suggestions to help caregivers maintain their valued activities are presented. Implications for rehabilitation Not only stroke survivors but also their informal caregivers tend to lose their valued activities, such as their social and leisure activities. Although many caregivers manage to resume their valued activities over time, others suffer from sustained activity loss up to at least two years post stroke. Loss of valued activities in stroke caregivers can result in lower levels of wellbeing, depression, and social isolation. Rehabilitation professionals should screen stroke caregivers for activity loss and assist them in resuming their valued activities and maintaining their social contacts.

Moving beyond pain scores: Multidimensional pain assessment is essential for adequate pain management after surgery.

BACKGROUND: Clinical experience teaches us that patients are willing to accept postoperative pain, despite high pain intensity scores. Nevertheless, relationships between pain scores and other methods of pain assessment, e.g. acceptability of pain or its interference with physical functioning, are not fully established. Our aims were to examine these relationships. METHODS: A cross-sectional study was conducted on patients who underwent major surgery between January 2008 and August 2013. Using logistic regression, we quantified the relationships between movement-evoked pain scores on the numerical rating scale (NRS-MEP) and three dichotomous dependent variables: patient's opinion on acceptability of pain (PO: acceptable or unacceptable pain); nurses' observation of patient's performance of necessary activities to expedite recovery (NO: good or bad performance); a compound measure judging the presence of the clinically desirable situation of acceptable pain associated with good patients' performance (PONO: present or not). Using Receiver Operating Characteristics (ROC) analysis, NRS cut-off points were determined such that they best discriminate between patients having one versus the other outcome for PO, NO and PONO. RESULTS: 15,394 assessments were obtained in 9,082 patients in the first three postoperative days. Nine percent of the patients had unacceptable pain while having an NRS-MEP of 0-4. An estimated 47% (95%CI = 45%-49%) of patients with an NRS-MEP of 7 described their pain as acceptable on day one. Moreover, 33% (31%-35%) performed all required physical activities, and 22% (21%-24%) combined acceptable pain with appropriate movement. NRS cut-off points for PO, NO and PONO were five, four and four, respectively, but had insufficient discriminatory power. CONCLUSIONS: Our results suggest pain management should be guided by the many dimensions of the patient's pain experience, not solely by NRS cut-off points. Future research should evaluate the impact of such multidimensional pain assessment on patients' functional outcome.

Comparison of Epidural or Regional Analgesia and Patient-controlled Analgesia: A Critical Analysis of Patient Data by the Acute Pain Service in a University Hospital.

OBJECTIVES: A large number of patients still experience pain after surgery. This study investigates if epidural or regional analgesia (continuous infusion peripheral nerve blocks [CPNB]) provide superior pain relief compared with patient-controlled analgesia (PCIA) and identifies the incidence of minor and major adverse effects or complications of these techniques. MATERIALS AND METHODS: Prospectively collected data of postoperative patients from an online data registration system of a special dedicated nurse-based acute pain service were analyzed. The acute pain service consultations were documented from January 2008 to August 2013 in a university hospital in The Netherlands. RESULTS: An analysis was applied on data of 12,399 consecutive patients. Results showed that patients who received epidural analgesia and CPNB reported lower pain scores than those who received PCIA, after undergoing the same procedures. In addition, pain scores at rest were significantly lower than movement-evoked pain scores, in abdominal surgery. Severe nausea was mostly observed in patients with PCIA and itching was most common in patients with epidural analgesia. Opioid-induced respiratory depression was found in 5 patients with PCIA. DISCUSSION: Epidural analgesia and CPNB provide better pain relief to patients than PCIA, especially in dynamic pain scores of patients. Evaluating real patient data on every patient visit is important for further improvement of the quality of postoperative pain management. Pain scores may vary widely between patients with similar surgical procedures. Therefore, we recommend that future research focuses on personalized pain measurement and pain management, to improve clinical practice more intensely.

[Advice from the Health Council of the Netherlands: wish and reality]. / Gezondheidsraadadvies: wens en werkelijkheid.

On 18 January of this year the Health Council of the Netherlands presented its research agenda for innovative medical products to the Dutch Minister of Health, Welfare and Sports. In its report 'Medical products; new and necessary' the Council describes fifteen health areas in which patients, doctors and nurses believe innovations are necessary. A 'metaprogram' is recommended to stimulate partnership of industry and research. Some comments can be made regarding the way end-users, i.e. patients and health care providers, were consulted concerning the priorities for innovation and the recommended incentives. In addition, these end-users might have assisted in discovering ways to repair 'market failure' of new medical products.