Task redistribution from general practitioners to nurses in acute infection care: A prospective cohort study.

AIM: To examine the impact of implementing nurse-led consultations compared to physician-led consultations on the frequency of follow-up contacts within 14 days following an acute infectious consultation. DESIGN: Monocentric, prospective cohort study. METHODS: The study was conducted in a multidisciplinary, capitation-based general practice in Belgium. Through analysis of patient files, the number of follow-up contacts within 14 days after an infection consultation was investigated to determine any difference between physician-led or nurse-led consultations. Secondary outcomes included pharmacological interventions and the prescribing behaviour of medical leave certificates. RESULTS: A total of 352 consultations were analysed, of which 174 conducted by physicians and 178 by nurses. No significant difference was found in the number of follow-up contacts. However, the probability of a pharmacological intervention by a physician was revealed to be significantly higher. The presence or absence of such pharmacological intervention did not significantly influence the number of follow-up contacts. CONCLUSION: This study demonstrates that nurses can be safely and efficiently utilized in acute infection care within a general practice setting. Although these results are promising, more extensive research is needed which incorporates the experiences of patients and healthcare providers. Furthermore, it is advisable to consider the experience and education of the nurses and incorporate them into the analyses. IMPACT: This study addressed the high workload on general practitioners by researching a task shift in the acute infectious, primary health care. The results demonstrate the feasibility of this task shift, which may have an impact on primary health care professionals (whose workload may be reorganized), as well as on patients for whom primary care may become more accessible. PATIENT OR PUBLIC CONTRIBUTION: This study includes direct patient data from people who presented themselves with acute infectious complaints in a primary healthcare practice.

Strategies and Interventions to Support Quality Outcomes in the Home Care Setting: A Longitudinal Multilevel Study.

BACKGROUND: The relationship between the practice environment, empowerment, and outcomes such as quality of care, job satisfaction, and intent to stay has been extensively studied in healthcare settings, including hospitals and long-term care facilities. Research consistently demonstrates that a positive practice environment, characterized by supportive leadership, adequate resources, and opportunities for professional growth, are associated with better quality of care, increased job satisfaction, and higher intent to stay among healthcare professionals. Limited knowledge exists regarding the specific relationship between the practice environment, empowerment, and these outcomes within home care organizations. OBJECTIVE: This study assesses the impact of strategies on nurse practice environment, social capital, decision latitude, workload, care quality, job satisfaction, and retention in a Belgian home healthcare organization. METHODS: A longitudinal survey was conducted in a home healthcare organization, with data collected at 3 time points: baseline (T1) (2015), T2 (2018), and T3 (2021). RESULTS: In T3, respondents reported significantly higher scores for departmental and general management compared with T1. The interventions led to significant improvements in social capital and decision latitude. Self-reported quality of care at the department level showed a significant increase, whereas no significant change was observed for quality of care during the last round. CONCLUSION: The implementation of strategies and interventions as part of a broader healthcare transformation process had a positive impact. Improvements were observed in nurse-reported quality of care, job satisfaction, and intent to stay in nursing. These findings emphasize the effectiveness of the implemented measures in enhancing nursing practice and creating a positive work environment. Continuous efforts to implement and evaluate such strategies are essential for enhancing the satisfaction and retention of nursing teams within healthcare organizations.

Development of a competency framework for advanced practice nurses: A co-design process.

AIMS: The aim of the study was to develop a comprehensive competency framework for advanced practice nurses in Belgium. DESIGN: A co-design development process was conducted. METHODS: This study consisted of two consecutive stages (November 2020-December 2021): (1) developing a competency framework for advanced practice nurses in Belgium by the research team, based on literature and (2) group discussions or interviews with and written feedback from key stakeholders. 11 group discussions and seven individual interviews were conducted with various stakeholder groups with a total of 117 participants. RESULTS: A comprehensive competency framework containing 31 key competencies and 120 enabling competencies was developed based on the Canadian Medical Education Directions for Specialists Competency Framework. These competencies were grouped into seven roles: clinical expert and therapist, organizer of quality care and leader in innovation, professional and clinical leader, collaborator, researcher, communicator and health promoter. CONCLUSION: The developed competency framework has resemblance to other international frameworks. This framework emphasized the independent role of the advanced practice nurse and provided guidance in a clear task division and delegation to other professionals. It can provide a solid foundation for delivering high-quality, patient-centred care by advanced practice nurses in the years to come. IMPLICATIONS FOR THE PROFESSION: This competency framework can guide further development of advanced practice nursing education in Belgium and represents a starting point for future evaluation of its feasibility and usability in education and clinical practice. Advanced practice nurses and healthcare managers can also use the framework as an instrument for personal and professional development, performance appraisal, and further alignment of these function profiles in clinical practice. Finally, this framework can inform and guide policymakers towards legal recognition of advanced practice nursing in Belgium and inspire the development of advanced practice nursing profiles in countries where these profiles are still emerging. IMPACT: What problem did the study address? The absence of a detailed competency framework for advanced practice nurses complicates legal recognition, role clarification and implementation in practice in Belgium. A rigorously developed competency framework could clarify which competencies to integrate in future advanced practice nursing education, mentorship programs and practice. What were the main findings? The competency framework outlined seven roles for advanced practice nurses: clinical expert and therapist, organizer of quality care and leader in innovation, professional and clinical leader, collaborator, researcher, communicator, and health promoter. Differentiation from other expert nursing profiles and clinical autonomy of advanced practice nurses were pivotal. Where and on whom will the research have impact? The comprehensive competency framework for advanced practice nurses and the collaborative methodology used can inspire other countries where these profiles are still emerging. The competency framework can be used as an instrument for role clarification, performance appraisals, continuous professional development, and professional (e-)portfolios. The competency framework can guide policymakers when establishing Belgian's legal framework for advanced practice nurses. REPORTING METHOD: The authors have adhered to CONFERD-HP: recommendations for reporting COmpeteNcy FramEwoRk Development in health professions. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution in the design of the study. A patient advisory panel commented on the developed competency framework.

Access to palliative care in patients with advanced cancer of the uterine cervix in the low- and middle-income countries: a systematic review.

BACKGROUND: Women with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known. OBJECTIVES: To understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families. METHODS: We conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization. RESULTS: Overall there was limited access to palliative care with the few available facilities located in cities, far from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access. CONCLUSION: Concerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs.

How do people living with chronic conditions and their informal caregivers experience primary care? A phenomenological-hermeneutical study.

AIMS AND OBJECTIVES: Gaining insight in how people living with chronic conditions experience primary healthcare within their informal network. BACKGROUND: The primary healthcare system is challenged by the increasing number of people living with chronic conditions. To strengthen chronic care management, literature and policy plans point to a person-centred approach of care (PCC). A first step to identify an appropriate strategy to implement PCC is to gain more insight into the care experiences of these people and their informal caregivers. DESIGN: A phenomenological-hermeneutical philosophy is used. The study is in line with the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ). METHOD: In-depth, semi-structured interviews with people living with chronic conditions and informal caregiver dyads (PCDs) (n = 16; 32 individuals) were conducted. An open-ended interview guide was used to elaborate on the PCDs' experiences regarding primary care. A purposive, maximal variation sampling was applied to recruit the participants. RESULTS: Based on sixteen PCDs' reflections, ten themes were identified presenting their experiences with primary care and described quality care as listening and giving attention to what people with chronic conditions want, to what they strive for, and above all to promote their autonomy in a context wherein they are supported by a team of formal caregivers, family and friends. CONCLUSION: To meet the PCDs' needs, self-management should be addressed in an interprofessional environment in which the PCD is an important partner. The findings may facilitate a shift to encourage PCDs in their strengths by enabling them to share their personal goals and by working towards meaningful activities in team collaboration. RELEVANCE TO CLINICAL PRACTICE: Three strategies-self-management support, goal-oriented care, and interprofessional collaboration-have been suggested to improve the PCDs' primary care experiences. These strategies could guide nursing practice in using more and improve high-quality nursing care.

Burnout, stress and Type D personality amongst hospital/emergency physicians.

INTRODUCTION: In previous studies, physicians have been identified as a high-risk group for burnout. Although the work environment has received more attention than specific determinants of personality traits, the latter might contribute to burnout. STUDY OBJECTIVE: We aimed to investigate the association of Type D personality, job and organizational determinants with burnout, stress and work engagement as outcome factors among emergency physicians and hospital physicians working in intensive care and surgery departments. We specifically focused on our group of emergency physicians. METHODS: In this cross-sectional study, self-report questionnaires were distributed via social media using a specific survey link to 531 Belgian hospital physicians working at the Emergency Department, Intensive Care, and Surgery Department between October 21, 2018, and April 11, 2019. The survey instrument included questions about sociodemographic characteristics, job characteristics, organizational factors, job satisfaction, social support by supervisors and colleagues (Leiden Quality of Work Questionnaire for Medical Doctors) and Type D personality (Distress Scale-14) and as outcomes burnout (Oldenburg Burnout Inventory) and work engagement (Utrecht Work Engagement Scale). A multiple regression analysis was used to examine the associations between the determinants and each of the outcomes with emergency physicians as the study population. RESULTS: Eligible data were available for 436 questionnaires and involved 212 emergency physicians, 162 other hospital physicians (Intensive Care and Surgery Department) and 62 residents concerning both groups of physicians. Type D personality ranged from 28.5 to 29.1% in emergency physicians and other hospital physicians. Additionally, even after correcting for job-related and organizational factors, emergency physicians with Type D personality were seven times more likely to have a high risk for burnout. CONCLUSION: As a result, this study offers a new perspective on the associations between burnout, stress and Type D personality. Type D personality might be a personality-related risk factor for burnout among emergency physicians. Therefore, we recommend enhanced prevention measures that take into account this individual factor in the further development of coaching programs. Improving the professional well-being of emergency physicians is necessary, especially in the scope of the recent COVID-19 pandemic, which has put a high demand on acute and emergency care departments.

Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards.

BACKGROUND: Early warning systems (EWS) and rapid response systems (RRS) have been implemented internationally in acute hospitals to facilitate early recognition, referral and response to patient deterioration as a solution to address suboptimal ward-based care. EWS and RRS facilitate healthcare decision-making using checklists and provide structure to organisational practices through governance and clinical audit. However, it is unclear whether these systems improve patient outcomes. This is the first update of a previously published (2007) Cochrane Review. OBJECTIVES: To determine the effect of EWS and RRS implementation on adults who deteriorate on acute hospital wards compared to people receiving hospital care without EWS and RRS in place. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and two trial registers on 28 March 2019. We subsequently ran a MEDLINE update on 15 May 2020 that identified no further studies. We checked references of included studies, conducted citation searching, and contacted experts and critical care organisations. SELECTION CRITERIA: We included randomised trials, non-randomised studies, controlled before-after (CBA) studies, and interrupted time series (ITS) designs measuring our outcomes of interest following implementation of EWS and RRS in acute hospital wards compared to ward settings without EWS and RRS. DATA COLLECTION AND ANALYSIS: Two review authors independently checked studies for inclusion, extracted data and assessed methodological quality using standard Cochrane and Effective Practice and Organisation of Care (EPOC) Group methods. Where possible, we standardised data to rates per 1000 admissions; and calculated risk differences and 95% confidence intervals (CI) using the Newcombe and Altman method. We reanalysed three CBA studies as ITS designs using segmented regression analysis with Newey-West autocorrelation adjusted standard errors with lag of order 1. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: We included four randomised trials (455,226 participants) and seven non-randomised studies (210,905 participants reported in three studies). All 11 studies implemented an intervention comprising an EWS and RRS conducted in high- or middle-income countries. Participants were admitted to 282 acute hospitals. We were unable to perform meta-analyses due to clinical and methodological heterogeneity across studies. Randomised trials were assessed as high risk of bias due to lack of blinding participants and personnel across all studies. Risk of bias for non-randomised studies was critical (three studies) due to high risk of confounding and unclear risk of bias due to no reporting of deviation from protocol or serious (four studies) but not critical due to use of statistical methods to control for some but not all baseline confounders. Where possible we presented original study data which reported the adjusted relative effect given these were appropriately adjusted for design and participant characteristics. We compared outcomes of randomised and non-randomised studies reported them separately to determine which studies contributed to the overall certainty of evidence. We reported findings from key comparisons. Hospital mortality Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in hospital mortality (4 studies, 455,226 participants; results not pooled). The evidence on hospital mortality from three non-randomised studies was of very low certainty (210,905 participants). Composite outcome (unexpected cardiac arrests, unplanned ICU admissions and death) One randomised study showed that an EWS and RRS intervention probably results in no difference in this composite outcome (adjusted odds ratio (aOR) 0.98, 95% CI 0.83 to 1.16; 364,094 participants; moderate-certainty evidence). One non-randomised study suggests that implementation of an EWS and RRS intervention may slightly reduce this composite outcome (aOR 0.85, 95% CI 0.72 to 0.99; 57,858 participants; low-certainty evidence). Unplanned ICU admissions Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in unplanned ICU admissions (3 studies, 452,434 participants; results not pooled). The evidence from one non-randomised study is of very low certainty (aOR 0.88, 95% CI 0.75 to 1.02; 57,858 participants). ICU readmissions No studies reported this outcome. Length of hospital stay Randomised trials provided low-certainty evidence that an EWS and RRS intervention may have little or no effect on hospital length of stay (2 studies, 21,417 participants; results not pooled). Adverse events (unexpected cardiac or respiratory arrest) Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in adverse events (3 studies, 452,434 participants; results not pooled). The evidence on adverse events from three non-randomised studies (210,905 participants) is very uncertain. AUTHORS' CONCLUSIONS: Given the low-to-very low certainty evidence for all outcomes from non-randomised studies, we have drawn our conclusions from the randomised evidence. This evidence provides low-certainty evidence that EWS and RRS may lead to little or no difference in hospital mortality, unplanned ICU admissions, length of hospital stay or adverse events; and moderate-certainty evidence of little to no difference on composite outcome. The evidence from this review update highlights the diversity in outcome selection and poor methodological quality of most studies investigating EWS and RRS. As a result, no strong recommendations can be made regarding the effectiveness of EWS and RRS based on the evidence currently available. There is a need for development of a patient-informed core outcome set comprising clear and consistent definitions and recommendations for measurement as well as EWS and RRS interventions conforming to a standard to facilitate meaningful comparison and future meta-analyses.

Leadership in Nursing Excellence: The Magnet Recognition® Journey Experiences in Europe.

Improving work conditions and the provision of high-quality care and patient safety is an issue in European hospitals. Inspired by a US program for nursing excellence, Magnet Recognition, a Belgian hospital shared their experiences by organizing a summer school in 2019 with nurses of 21 hospitals from 9 countries. This article explains the hospital's research program, the link between the journey and the content of the summer school, lessons learned, and the extent to which participants of European hospitals were interested in nursing excellence and Magnet designation.

The optimal threshold for prompt clinical review: An external validation study of the national early warning score.

AIMS AND OBJECTIVES: The aim of this study was to determine the optimal threshold for national early warning score in clinical practice. BACKGROUND: The national early warning score is an aggregate early warning score aiming to predict patient mortality. Studies validating national early warning score did not use standardised patient outcomes or did not always include clinical workload in their results. Since all patients with a positive national early warning score require a clinical workup, it is crucial to determine the optimal threshold to limit false-positive alerts. DESIGN: An external validation study using retrospectively collected data of patient admissions in six Belgian hospitals. METHODS: We adhered to the STARD guideline for reporting. Two sample groups were selected: the cross-sectional sample (admitted patients, 1 day every 4 months) and the serious adverse event sample (all patients with unexpected death, cardiac arrest and unplanned admission to the intensive care unit). The maximum registered national early warning score value was collected in both groups. Predictive values were used as estimates for clinical workload. RESULTS: We collected 1,523 in the cross-sectional sample and 390 patients in the serious adverse event sample. A national early warning score ≥5 had a predictive value of 6.8% and a negative predictive value of 99.5% to predict unexpected death, cardiac arrest with cardiopulmonary resuscitation or unplanned admission to intensive care (AUROC 0.841). The performance of national early warning score differed between outcome measures. Considering the predictive value, the optimal threshold for national early warning score is ≥5. CONCLUSIONS: We validated national early warning score to be applied in general hospital wards and confirmed the optimal threshold (≥5). RELEVANCE TO CLINICAL PRACTICE: When a patient has a national early warning score <5, we may assume that in the next 24 hr this patient is less likely to die unexpectedly, receive cardiopulmonary resuscitation or be transferred to the ICU. Because of the significant number of false positives when national early warning score is ≥5, hospitals should create workable guidelines for clinical practice.

Integration of nurses in general practice: A thematic synthesis of the perspectives of general practitioners, practice nurses and patients living with chronic illness.

AIMS AND OBJECTIVES: To explore the views of general practitioners, practice nurses and patients on interprofessional collaboration in general practice and to understand to what extent the nurse-doctor relationship meets their needs and expectations. BACKGROUND: To address future challenges of primary health care, there is a need for integrated interprofessional collaboration care systems with a patient-centred focus. Worldwide, there is an integration of nurses in general practice. However, in a transitioning Belgian context little is known about the perspectives of three key stakeholder groups. DESIGN: The results of four qualitative descriptive primary studies were triangulated and a secondary analysis resulted in a thematic synthesis within a pragmatic research paradigm. METHODS: Primary data were collected through individual, semi-structured interviews with 7 general practitioners, 19 practice nurses and 21 patients living with chronic illness in 26 primary care centres with different nurse integration levels. We conducted a secondary analysis for the thematic synthesis of the different stakeholders' perspectives. This study was reported in accordance with the COREQ checklist. RESULTS: Four overarching themes were found as follows: vision and mission at general practice level, patient-centred care, practice nurse role development and interprofessional collaboration. Interprofessional collaboration within general practice ensures better response to patient needs. Evolution of the practice nurse role to autonomous decision-making can be facilitated by clear vision and mission, team communication, complementarity of responsibilities and trust-based professional relationships. CONCLUSIONS: The key for patient-centred care in a well-organised practice is a clear vision and mission and well-defined task description for interprofessional collaboration. General practice is urging for systematic guidance for the sustainable integration of a practice nurse. RELEVANCE TO CLINICAL PRACTICE: Our study highlights opportunities and challenges to nurse integration in general practice from key stakeholders' perspectives, which can inform other transitioning contexts.

Development and psychometric testing of the toxic leadership behaviors of nurse managers (ToxBH-NM) scale.

AIM: This paper describes the development and testing of the psychometric property of the Toxic Leadership Behaviors of Nurse Managers (ToxBH-NM) Scale. BACKGROUND: Toxic leadership is growing increasingly pervasive in the field of nursing. However, the current literature lacks comprehensive attempts to explain how toxic leadership disrupts work processes in the field of nursing, a reality confounded in part by the absence of a reliable and a valid scale on which to examine toxic leadership behaviours in nurse managers. METHODS: An exploratory sequential research design was used to formulate and evaluate the psychometric property of ToxBH-NM Scale. The content validity was examined by experts in nursing administration. A sample of 313 nurses from selected hospitals was recruited to assess the scale's reliability and validity. The factor structure of the newly developed scale was determined by exploratory factor analysis (EFA). RESULTS: Exploratory factor analysis for ToxBH-NM Scale revealed 30 items loading on four factors. The overall Cronbach's α coefficient of the scale was 0.975, and Cronbach's α coefficient ranged from 0.895 to 0.965 for the four factors. Corrected item-to-total (0.310-0.69) and item-to-item correlations (0.47-0.66) were acceptable. The Scale-content Validity Index was 0.957, and the Item-content Validity Index ranged from 0.833 to 1.000. The test-retest reliability coefficient of ToxBH-NM Scale was 0.801, with a reliability coefficient that ranged from 0.745 to 0.911 for the four factors. The four factors explained 71.84% of the observed variance. CONCLUSIONS: ToxBH-NM Scale shows good psychometric properties and can be used to evaluate toxic leadership behaviours among nurse managers. IMPLICATIONS FOR NURSING MANAGEMENT: The use of ToxBH-NM Scale can aid nurse managers in better understanding and managing their own leadership behaviours within their organisations and in fostering desirable work outcomes among employees, a positive work climate and overall organisational success.

Appropriateness of transferring nursing home residents to emergency departments: a systematic review.

BACKGROUND: Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable. METHODS: Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract. RESULTS: Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital. CONCLUSIONS: The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient's autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

The impact of nurse staffing levels and nurse's education on patient mortality in medical and surgical wards: an observational multicentre study.

BACKGROUND: Growing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult. METHOD: In this observational study we analysed retrospectively the control group of a stepped wedge randomised controlled trial concerning 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. In all patients, we collected age, crude ward mortality, unexpected death, cardiac arrest with Cardiopulmonary Resuscitation (CPR), and unplanned admission to the Intensive Care Unit (ICU). A composite mortality measure was constructed including unexpected death and death up to 72 h after cardiac arrest with CPR or unplanned ICU admission. Every 4 months we obtained, from 30 consecutive patient admissions across all wards, the Charlson comorbidity index. The amount of nursing hours per patient days (NHPPD) were calculated every day for 15 days, once every 4 months. Data were aggregated to the ward level resulting in 68 estimates across wards and time. Linear mixed models were used since they are most appropriate in case of clustered and repeated measures data. RESULTS: The unexpected death rate was 1.80 per 1000 patients. Up to 0.76 per 1000 patients died after CPR and 0.62 per 1000 patients died after unplanned admission to the ICU. The mean composite mortality was 3.18 per 1000 patients. The mean NHPPD and proportion of nurse Bachelor hours were respectively 2.48 and 0.59. We found a negative association between the nursing hours per patient day and the composite mortality rate adjusted for possible confounders (B = - 2.771, p = 0.002). The proportion of nurse Bachelor hours was negatively correlated with the composite mortality rate in the same analysis (B = - 8.845, p = 0.023). Using the regression equation, we calculated theoretically optimal NHPPDs. CONCLUSIONS: This study confirms the association between higher nurse staffing levels and lower patient mortality controlled for relevant confounders.

An intervention including the national early warning score improves patient monitoring practice and reduces mortality: A cluster randomized controlled trial.

AIMS: To investigate the impact of the national early warning score on the frequency and the quality of vital sign registration and to study the association between protocol compliance and patient mortality. DESIGN: We conducted a post hoc data analysis of a stepped wedge cluster randomized controlled trial (RCT) in six hospitals. METHODS: All adult, non-pregnant patients admitted to 24 wards were included. The intervention comprised an observation protocol using the national early warning score combined with a pragmatic medical response strategy. Data collection lasted from October 2013-May 2015. Patient comorbidity scores and vital signs were sampled every 4 months on each ward. All vital signs in the 24 hr before a serious adverse event were collected. RESULTS: Patients (N = 60,956) were included of which 32,722 in the intervention group. Comorbidity scores were sampled in 3,600 patients and vital signs in 2,951 patients. In 668 patients, vital signs were collected before a serious adverse event. The mean number of vital signs per observation increased significantly in the intervention group. The observation frequency increased in patients with a serious adverse event and decreased in patients without a serious adverse event. Protocol compliance was negatively associated with patient mortality adjusted for comorbidity and age. CONCLUSION: Our intervention improved patient monitoring practice and reduced mortality. IMPACT: The impact of early warning scores on patient monitoring practice and patient outcomes remains unclear. Our intervention improved the observation of patients and reduced patient mortality. These results could support hospitals in their decision to implement rapid response systems. TRIAL REGISTRATION: We have registered this study in the clinicaltrials.gov database (identifier: NCT01949025).

Practice nurse support and task suitability in a general practice: a cross-sectional survey in Belgium.

Single-handed general practices and group practices are the two predominant modes of primary care provision across European countries. In Belgium, single-handed practices have been the main form of primary care provision for years, but recently a trend is emerging towards introducing more group practices where a number of primary care physicians collaborate with other health professionals such as primary care nurses. The aim of this study was to measure the current support in general practices, and to gain insight in the general practitioner attitudes towards being supported by a practice nurse. A cross-sectional study was conducted among general practitioners who were currently working in a general practice in Flanders (Belgium). 271 general practitioners filled out an online questionnaire. 30% declared to be supported by a practice nurse. The majority (>80%) of general practitioners showed positive attitudes towards collaboration with practice nurses, however the job profile and ethical framework of practice nurses remain insufficiently clear. Nurses are found most suitable to take on tasks concerning patient education and technical nursing skills. Despite the lack of governmental incentives in Belgium, general practitioners have taken the initiative to employ practice nurses - possibly - based upon an experienced necessity.

Stress and ways of coping among nurse managers: An integrative review.

AIMS AND OBJECTIVES: To appraise and synthesise empirical studies examining sources of occupational stress and ways of coping utilised by nurse managers when dealing with stress. BACKGROUND: The Nurse Manager's role is challenging yet draining and stressful and has adverse consequences on an individual's overall health and well-being, patients' outcomes and organisational productivity. Considerable research has been carried out; however, an updated and broader perspective on this critical organisational issue has not been performed. DESIGN: An integrative review. METHODS: Five databases (Cumulative Index to Nursing and Allied Health Literature, SCOPUS, PubMed, PsychINFO and MEDLINE) were searched to identify relevant articles. Search terms and MeSH terms included: "charge nurse," "coping," "coping strategy," "coping style," "psychological adaptation," "psychological stress," "stressors," "nurse manager" and "unit manager." Twenty-two articles were included in this review. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. RESULTS: Four themes were identified: moderate stress levels, common sources of stress, ways of coping and the impact of nurses' characteristics on stress. CONCLUSIONS: Nurse managers experienced moderate levels of stress mainly from heavy workloads, lack of resources and financial responsibilities. Enhancing social support and promoting job control were seen as important in reducing work stress and its related consequences. Additional studies using a more rigorous method and a larger sample size preferably in multicultural settings would shed more light on this topic. RELEVANCE TO CLINICAL PRACTICE: Hospital and nurse administrators play an important role in promoting supportive structures for daily professional practice for nurse managers through staffing, organisational resources, support services, leadership and stress management training.

Living in a nursing home: a phenomenological study exploring residents' loneliness and other feelings.

BACKGROUND: Loneliness is suggested to be one of the most prominent feelings nursing home residents are struggling with, and is related to various negative health outcomes and impaired quality of life. While there has been some research on social predictors and the impact of depression and loneliness on social relationships in nursing home residents, there has been very little qualitative research in investigating their own perception of such feelings. OBJECTIVE: To explore general feelings among nursing home residents, with a specific interest in loneliness in order to develop strategies for support and relief. METHOD: This phenomenological study used an interview guide with open-ended questions to ensure focused in-depth data collection. Data were obtained through face-to-face interviews (n = 11). Interpretative phenomenological analysis was used for data analyses. RESULTS: Loneliness is more than being alone among others. The residents' unfulfilled need for meaningful relationships plays a crucial role in feelings of loneliness. Losing their self-determination due to institutionalisation was strongly related to loneliness and caused strong emotions, such as grief. CONCLUSION: It is vital that healthcare professionals are aware of these feelings and pay much attention to resident preferences while developing (individualised) interventions to prevent loneliness.

An overview of systematic reviews on the collaboration between physicians and nurses and the impact on patient outcomes: what can we learn in primary care?

BACKGROUND: Primary care needs to be strengthened in order to address the many societal challenges. Group practices in primary care foster collaboration with other health care providers, which encourages care co-ordination and leads to a higher quality of primary care. Nursing roles and responsibilities expanded over time and nurses have been found to often provide equal high-quality chronic patient care compared to physicians, even with higher patient satisfaction. Inter-professional collaboration between primary care physicians and nurses is a possible strategy to achieve the desired quality outcomes in a strengthened primary care system. The objective of this research is to synthesize the evidence presented in literature on the impact of collaboration between physicians and nurses on patient outcomes in primary care or in comparable care settings. METHODS: A systematic review of peer-reviewed reviews was performed in four databases: COCHRANE, MEDLINE, EMBASE and CINAHL. All studies from 1970 until May 22 2016 were included in the search strategy. Titles, abstracts and full texts were respectively reviewed. At least two of the three authors independently reviewed each of the 277 abstracts and 58 full texts retrieved in the searches to identify those which contained all the inclusion criteria. Two authors independently appraised the methodological quality of the reviews, using the AMSTAR quality appraisal tool. RESULTS: A total of eleven systematic reviews met all the inclusion criteria and almost fifty different patient outcomes were described. In most reviews, it was concluded that nurses do have added value. Blood pressure, patient satisfaction and hospitalization are patient outcomes where three or more systematic reviews concluded better results when physicians and nurses collaborated, compared to usual care. Colorectal screening, hospital length of stay and health-related quality of life are outcomes where collaboration appeared not to be effective. CONCLUSIONS: Collaboration between physicians and nurses may have a positive impact on a number of patient outcomes and on a variety of pathologies. To address future challenges of primary care, there is a need for more integrated inter-professional collaboration care models with sufficiently educated nurses.

Autonomy and social functioning of recently admitted nursing home residents.

OBJECTIVES: This paper examines recently admitted nursing home residents' practical autonomy, their remaining social environment and their social functioning. METHOD: In a cross-sectional design, 391 newly admitted residents of 67 nursing homes participated. All respondents were ≥65 years old, had mini-mental state examination ≥18 and were living in the nursing home for at least 1 month. Data were collected using a structured questionnaire and validated measuring tools. RESULTS: The mean age was 84, 64% were female, 23% had a partner, 80% children, 75% grandchildren and 59% siblings. The mean social functioning score was 3/9 (or 33%) and the autonomy and importance of autonomy score 6/9 (or 67%). More autonomy was observed when residents could perform activities of daily living more independently, and cognitive functioning, quality of life and social functioning were high. Residents with depressive feelings scored lower on autonomy and social functioning compared to those without depressive feelings. Having siblings and the frequency of visits positively correlated with social functioning. In turn, social functioning correlated positively with quality of life. Moreover, a higher score on social functioning lowered the probability of depression. CONCLUSION: Autonomy or self-determination and maintaining remaining social relationships were considered to be important by the new residents. The remaining social environment, social functioning, quality of life, autonomy and depressive feelings influenced each other, but the cause--effect relation was not clear.

Vulnerability to burnout within the nursing workforce-The role of personality and interpersonal behaviour.

AIMS AND OBJECTIVES: To study the combination of personality and interpersonal behaviour of staff nurses in general hospitals in relation to burnout and its separate dimensions. BACKGROUND: More research on the individual factors contributing to the development of burnout is needed to improve the risk profile of nursing staff. Therefore, a combination of Leary's interpersonal circumplex model, which depicts the interpersonal behaviour trait domain, and the five-factor model was considered in the study at hand. DESIGN: A cross-sectional research method was applied using self-report questionnaires. METHODS: A total of 880 Belgian general hospital nurses were invited to participate in the study. Data were collected from November 2012-July 2013. The questionnaire consisted of three validated self-report instruments: the NEO five-factor inventory, the Dutch Interpersonal Behaviour Scale and the Maslach Burnout Inventory. RESULTS: Of the 880 nurses invited to participate, 587 (67%) returned the questionnaire. Sex, neuroticism, submissive-friendly behaviour, dominant-friendly behaviour and vector length were found to be predictive factors for emotional exhaustion. For depersonalisation, sex, neuroticism, conscientiousness, friendly behaviour, submissive-friendly behaviour, dominant-hostile behaviour and vector length were predictive factors. Finally, personal accomplishment was determined by neuroticism, openness, conscientiousness, and hostile behaviour. CONCLUSIONS: This study confirmed the influence of the Big Five personality factors on the separate dimensions of burnout. Interpersonal behaviour made a significant contribution to the predictive capacity of the regression models of all three dimensions of burnout. Additional longitudinal research is required to confirm the causal relationship between these individual factors and burnout. RELEVANCE TO CLINICAL PRACTICE: The results of this study can help to achieve a better understanding of which vulnerabilities an individual prevention programme for burnout should target. In addition, hospitals could use assessment instruments to identify nurses who are prone to burnout and thus would benefit from additional support or stress reduction programmes.