[Sounds in intensive care units: Perspectives of patients and parents. A qualitative study]. / Geräusche auf Intensivstationen: Perspektiven von Patient_innen und Eltern.

Sounds in intensive care units: Perspectives of patients and parents. A qualitative study Abstract: Background: Sound levels in intensive care units exceed internationally recommended limits. This can have negative effects on patients, relatives, and staff. There is a lack of evidence on noise-reducing measures. Aim: The aim of the study was the implementation and evaluation of ward-specific noise management in intensive care units. In the present article, the question of the noise and stress experience of intensive care patients and parents of neonatal intensive care patients was explored. Methods: 33 semi-structured interviews with intensive care patients and parents of neonatal intensive care patients in three intensive care units were conducted and analysed. Results: Sounds in intensive care units can be stressful (especially alarms) but also be interpreted as meaningful. This is not only related to the context of the ICU, but also to individual experiences and the social aspects of the sounds. In order to avoid or reduce stress, participants apply individual noise (stress) management. In contrast, ward-related noise management had no specific effect on the participants. Conclusions: The findings offer indications for suitable measures to reduce the noise exposure of intensive care patients and parents of neonatal intensive care patients. Research about measures such as concepts for supporting the attribution and differentiation of sounds could follow.

Potential for reducing immobility times of a mobility monitor in-bed sensor system - a stepped-wedge cluster-randomised trial.

BACKGROUND: Pressure ulcer prophylaxis is a central topic in clinical care. Pressure-relieving repositioning is strongly recommended for all pressure-sensitive patients. The Mobility Monitor (MoMo) is a technical device that records a patient's movements and transmits the data to a monitor. This study investigated the extent to which the MoMo sensor system, which records and visualises patients' movements in bed, supports nurses in performing pressure-relieving repositioning in neurological and neurosurgical intensive care units (ICU). METHODS: This stepped-wedge cluster-randomised trial involved two clusters: one neurological and one neurosurgical ICU. The study was carried out in two steps over three periods between November 2018 and May 2019, with a two-month interval between each step. At the beginning of the study, we equipped 33 beds across the two ICUs with a MoMo system. Our primary endpoint was the immobility rate, which is defined as the patient's inactive time in bed exceeding two hours without pressure-relieving movements divided by the time the MoMo was in the bed. The immobility rate ranges from 0 to below 1, with higher values indicating lower mobility. Secondary endpoints were the rate of new pressure ulcers and the rate of relevant pressure-relieving repositionings. Relevant repositionings are defined as the number of repositionings identified by the MoMo as a pressure-relieving repositioning divided by the total number of repositionings, RESULTS: 808 patients were included in the study, of whom 403 were in the control group and 405 were in the intervention group. The mean immobility rate was 0.171 during the control phase and 0.144 during the intervention phase. The estimated intervention effect was -0.0018 (95% confidence interval [-0.0471, 0.0436], p=0.94). The number of new pressure ulcers was 5/405 in the intervention phase and 15/403 in the control phase. We noted a small difference in the mean rate of relevant repositioningswith an estimated intervention effect of 0.046 (95% confidence interval [-0.018, 0.110], p=0.16). CONCLUSION: Our results are insufficient to recommend the standardised use of mobility monitors in neurological or neurosurgical ICUs. CLINICAL TRIAL REGISTRATION: The primary analysis was prespecified and the trial was registered in the German Clinical Trials Register (DRKS) under the reference number DRKS00015492 (31/10/2018).

Competencies and needs of nurse educators and clinical mentors for teaching in the digital age - a multi-institutional, cross-sectional study.

BACKGROUND: The impact of technology and digitalization on health care systems will transform the nursing profession worldwide. Nurses need digital competencies to integrate new technology in their professional activities. Nurse educators play a crucial role in promoting the acquisition of digital competences and therefore need to be digitally competent themselves. Research on digital competencies of nursing educators is scarce but suggests lack of digital knowledge and skills and support needs. Although digitalization is to be seen as a global process, regional contexts need to be taken into account, such as pre-existing competencies, local conditions, and individual needs. Thus, it remains unclear which competencies nurse educators possess and which support needs they have. Aim of this study was to assess nurse educators' and clinical mentors' digital competencies and explore their needs and requirements concerning the digital aspects of their pedagogy and teaching activities in Germany. METHODS: A descriptive exploratory study with a cross-sectional design was conducted. Participants were identified using a convenience sampling approach. Data were collected during July and September 2020 using a standardized self-reported questionnaire that was developed specifically for this study. The questionnaire was provided in a paper and online format and participants could decide which format to use. It contained open- and closed-ended questions. Data were analyzed using descriptive and content analysis. Additionally, explorative subgroup analyses based on job designation, age, and gender were performed. Reporting of this study adhered to the STROBE checklist. RESULTS: A total of 169 educating nurses participated in the survey. The respondents considered themselves as digitally competent and showed a positive attitude towards the integration of digital technology in their teaching activities. Their perceived preparedness to integrate digital technology into teaching and training varied. Almost all respondents (98%) declared a need for further training and seemed motivated to participate in corresponding educational events. There were some indications for differences in competencies or needs between subgroups. CONCLUSIONS: Educating nurses appear to possess basic digital competencies but there is a need to support their professional development in terms of new technologies. Findings can be used as a basis for developing supportive interventions. Further qualitative investigations could inform the design and content of such interventions.

[Prevalence of dementia in university hospitals : Analysis of ICD-10 coding in 5 university hospitals in Germany over a 2-year period]. / Prävalenzen von Demenz in Universitätskliniken : Analyse von ICD-10-Kodierungen in fünf Universitätskliniken in Deutschland über zwei Geschäftsjahre.

BACKGROUND: Demographic changes result in a higher prevalence of patients suffering from dementia in hospital. In Germany, epidemiological data of this target group are scarce and prevalence rates from university hospitals (UH) are not available. The prevalence rates and distribution were analyzed on the basis of ICD-10-GM (German modification) routine data METHOD: A secondary analysis on ICD-10-GM main and secondary diagnoses of dementia from 2014 and 2015 from 5 UH was performed. All patients admitted to hospital for at least 24 h and ≥18 years old (2014 n = 187,168; 2015 n = 189,040) were included. A descriptive analysis for the >69-year-old group was carried out (2014, n = 67,111; 2015; n = 67,824). RESULTS: The 1­year prevalence (2014/2015) for all 5 UH for patients ≥18 years old was 1.3%/1.4% and for the >69-year-old group, 3.3%/3.5%. The prevalence rates between the five UH varied: for patients ≥18 years the range was 0.44-2.16% (2014) and 0.44-2.77% (2015) and for >69-year-olds 1.16-5.52% (2014) and 1.16-7.06% (2015). Most cases were correlated with major diagnostic categories of traumatology, cardiology, gastroenterology and neurology. CONCLUSION: Analysis of ICD-10-GM routine data can provide an indication of the prevalence of dementia in UH. Results of the >69-year-olds varied greatly between participating UH. The reasons for this might be different healthcare tasks, especially with respect to geriatric patients; however, it is also possible that assessment procedures are not standardized and unreliable and therefore the coding is invalid. A standardized procedure for the identification of people suffering from dementia is necessary.

Short-term intervention to reduce anxiety before coronary artery bypass surgery--a randomised controlled trial.

AIMS AND OBJECTIVES: The aim of this study was to evaluate an intervention with individualised information and emotional support before coronary artery bypass grafting in a controlled randomised trial. BACKGROUND: Anxiety is a typical phenomenon in patients who are to undergo cardiac surgery. Preoperative anxiety has been shown to correlate to adverse postoperative outcomes. Emotional support could be an effective measure to reduce preoperative anxiety. DESIGN AND METHODS: Patients with planned first coronary artery bypass grafting were randomised into an intervention group (n = 139) and a control group (n = 114). The patients of the control group were routinely informed as usual. The patients of the intervention group received a dialogue with individualised information and emotional support one day before surgery in addition to standard care. This intervention of ~30 minutes was based on a supportive psychotherapy model and was delivered by trained nurses. The primary outcome was the change in anxiety before operation. The secondary outcomes consisted of changes in postoperative anxiety, time on intensive care unit and in-hospital mortality. RESULTS: Significantly reduced anxiety was found in the intervention group patients compared to control patients before coronary artery bypass grafting (p < 0·001) and five days after surgery (p < 0·001). Both groups did not differ in in-hospital mortality and duration of stay in the intensive care unit. CONCLUSIONS: Our short-term psychosocial intervention in patients undergoing coronary artery bypass grafting had a beneficial effect on reducing pre- and postoperative anxiety that was better than routine information alone. RELEVANCE TO CLINICAL PRACTICE: These results advocate training for nurses and physicians to provide emotional support to patients before coronary artery bypass grafting.

Factors influencing hospitalized patients' perception of individualized nursing care: a cross-sectional study.

BACKGROUND: Individualized care is a cornerstone of patient-centered nursing care. To foster individualized care, influencing factors should be known. The aim of this study was to identify the individual and organizational factors influencing hospitalized patients' perception of individualized care. METHODS: A cross-sectional study was conducted of 606 patients from 20 wards from five hospitals across Germany. Individualized care and potential influencing factors were assessed via structured questionnaires. To identify influencing factors, we applied a hierarchical linear model with two levels. RESULTS: Self-rated health, length of ward stay, educational level and shared decision-making process about nursing care were perceived to influence individualized care. A higher rating of health and longer ward stay correlated with improved perceptions of individualized nursing care. In addition, an educational level of nine or fewer years and a perceived shared decision-making process about nursing care positively influenced the perception of nursing care as being tailored to individual needs. CONCLUSIONS: Several factors influence patients' perception of individualized care. However, only the decision-making process can be actively influenced by nurses. Therefore, nurses should be encouraged to promote shared decision-making regarding patients' nursing care. TRIAL NUMBER: DRKS00005174 (Date of registration: 2013/08/01).

Anxiety and fear in patients with short waiting times before coronary artery bypass surgery--a qualitative study.

AIMS AND OBJECTIVES: To obtain qualitative information on fears and anxieties of coronary artery bypass grafting patients with short waiting periods (up to a maximum of four weeks) before surgery. BACKGROUND: Coronary artery bypass grafting is a standard procedure in cardiac surgery. However, many patients suffer significant anxiety and fear before the operation. Preoperative anxiety and fear correlate with adverse outcomes, but there is a lack of data on the emotional stressors for patients with short waiting periods as applicable in Germany. This knowledge would be a prerequisite for the development of in-hospital interventions to reduce patients' anxieties and fears. DESIGN: An exploratory study was chosen to learn about patients' anxieties and fears. METHOD: The day before coronary artery bypass grafting, 24 patients were examined with respect to their emotional experience using semi-structured interviews. The results were categorised by inductive content analysis. RESULTS: The overall waiting time for coronary artery bypass grafting was 6 ± 6 days. According to the analysis, the patients' statements were grouped in 'fears', 'negation of fears' and 'other emotional and physical conditions'. The interviews could cover all categories simultaneously. Eighteen patients mentioned fears, and most of them referred to specific issues. However, 16 of the 18 patients also named nonspecific fears and uncertainties. Fifteen patients negated fear. Twenty-three patients described their emotions and/or somatic conditions. CONCLUSIONS: Patients with short waiting periods before coronary artery bypass grafting experience specific as well as nonspecific fears on the day before surgery. In contrast to patients with long waiting (longer than four weeks), uncertainty and frustration about waiting time and feelings of disability are no concerns. RELEVANCE TO CLINICAL PRACTICE: The detailed insight into the emotional experiences of patients with a short waiting time before coronary artery bypass grafting surgery is a basis for targeted anxiety-reducing interventions.

[Integrating academic nurses in German university hospitals: a follow-up survey]. / Einbindung von Pflegefachpersonen mit Hochschulabschlüssen an deutschen Universitätskliniken: ein Follow-up-Survey.

INTRODUCTION: The effective integration of professional nursing staff with university training into care processes is associated internationally with better patient outcomes. In Germany, there is a current lack of reliable figures on graduates and their areas of responsibility. Therefore, the aim of this follow-up survey, designed as a repetition of a previous one, was to ascertain the number of nurses with a Bachelor's or Master's degree involved in direct patient care at university medical centers. METHOD: In a cross-sectional study, chief nursing officers in university medical centers were asked to quote the number of professional nurses with a university degree (Bachelor, Master, Doctorate). Additional questions focused on their tasks and responsibilities and the measures undertaken to facilitate their integration into the organization. The data were analyzed using descriptive statistics. RESULTS: In total, n=29 valid questionnaires from 35 university medical centers were included in the analysis, resulting in a response rate of 82.85%. For a total of 18 centers, the number of university-qualified nurses had increased by n=786 between 2015 (n=593) and 2018 (n=1,379). The overall percentage of nurses with a university degree working at a university medical center in the study was 3.16% (SD=1.66; min - max=1.09 - 6.69; Q1 - Q3=1.49 - 4.04; 95% CI 2.30 to 3.95). In direct patient care, the quota was 2.11% (SD=1.40; min - max=0.47 - 5.42; Q1 - Q3=0.87 - 3.16; 95% CI 1.36 to 2.76). The main focus of their duties was on standard care and patient education (graduates with a Bachelor's degree), evidence-based nursing practice development (Master's degree) and research activities (doctoral degree). DISCUSSION: Compared to 2015, the proportion of professional nursing staff with university training has increased but remains at a very low level. These nurses perform relevant clinical tasks and are involved in the development of good practice. However, there is a need for better competence-based differentiation.

[Instrument to assess nursing care delivery stystems "IzEP". Making nursing care systematically visible for practice, management and science]. / Instrument zur Erfassung von Pflegesystemen "IzEP". Pflegerische Organisation für Praxis, Management und Wissenschaft sichtbar machen.

Network activities and publications show a rising interest in nursing care delivery systems like primary nursing. There are aspects in quality and outcomes attributed to primary nursing to answer the changes in health care. To assign outcomes in nursing to different kinds of nursing care delivery systems and for systematic developing of primary nursing in a unit one needs a special assessment instrument. IzEP, the instrument to assess nursing care delivery systems, relates the nursing care delivery system of a unit to primary nursing. This article describes the development of the instrument, testing of reliability, validity and possibilities for using.

[Domains in the clinical practice of Clinical Nursing Experts in Germany and their correspondence with the internationally described "Advanced Nursing Practice"]. / Aufgabengebiete klinisch tätiger Pflegeexperten in Deutschland und deren Verortung in der internationalen Advanced Nursing Practice.

In spite of a growing trend toward academic education and increasing numbers of "nursing experts" functioning as change agents in Germany, actual nursing experts as in the internationally described Advanced Nursing Practice (ANP) are scarce. Drawing from a ten-year experience in implementing the international concept, the University Hospital Freiburg (UKF), Germany, constitutes a notable exception, as it presently employs ten clinically practicing nursing experts. Based on this background of educating nursing experts, this presentation aims at describing the implementation of the nursing expert's role and its fit and conformance with the international ANP. A 3-stage Delphi design was used for interviewing all the nursing experts at the hospital (n = 10) about their expert opinions; in addition, all nursing managers (n = 7) as well as unit and team leaders (n = 49) were asked about their opinion to relevant functions and domains of nursing experts. The following clinical practice domains of nursing experts were identified: Direct patient care, patient education, support and supervision of nurses, maintenance and expansion of professional skills and knowledge of the nursing staff, counselling of managers, quality assurance and organizational development, theory to practice transfer, nursing research, maintenance of own professional skills and knowledge and continuing education, and publicity work. Additionally, a three-year nursing education, a longer lasting professional experience, a degree in nursing science or nursing education, and specialist skills in the respective area of expertise were identified as credentials for nursing expert practice. The nursing expert concept at UKF shows elements of the international ANP with similarities to the role of a Clinical Nurse Specialist.

Pressure ulcer risk assessment immediately after cardiac surgery--does it make a difference? A comparison of three pressure ulcer risk assessment instruments within a cardiac surgery population.

The intensive care unit (ICU) population has a high risk of developing pressure ulcers. According to several national expert guidelines for pressure ulcer prevention, a risk assessment for every situation in which the patient's condition is changing should be performed using a standardized risk assessment instrument. The aims of this study were to (a) assess the number of patients who are 'at risk' for the development of pressure ulcer according to three commonly used risk assessment instruments in the intermediate period after cardiac surgery procedures, (b) assess which instrument best fits the situation of the ICU patients and c) decide if 'static' risk assessment with an instrument should be recommended. The modified Norton scale, the Braden scale and the 4-factor model were used in a convenience sample of 53 patients to assess the risk for development of pressure ulcer in the first 5 days (in ICU) after cardiac surgery procedures. The number of patients at risk were >60% by the 4-factor model, >70% by the modified Norton scale and >80% by the Braden scale. Sensitivity and specificity in all scales were not satisfactory. Forty-nine per cent (n= 26) of the patients developed a pressure ulcer in the operating room, 13% (n= 7) up to day 5 in the cardiac surgery ICU. Only 1.9% (n= 1) of the pressure ulcers were stage 2. The study concluded that the patients in the cardiac surgery ICU can be identified as at risk during the first 5 days after surgical procedure without continuously using a standardized risk assessment instrument in every changing condition. Individual risk assessment by a standardized risk assessment instrument is only recommended to enable initiation of preventive measures based on patient-specific risk factors.

[State of development of the role of academic nursing staff at German university hospitals in 2015]. / Survey zur Einbindung von Pflegefachpersonen mit Hochschulabschlüssen an deutschen Universitätskliniken - Stand 2015.

INTRODUCTION: In order to meet the requirements of the increasing complexity of patient care it is recommended to promote more differentiated nursing staff structures and to integrate academic nurses, which is international standard and recommended by the German Science Council. The implementation level is unclear. What is the percentage of nurses with an academic degree at German university hospitals, and what are their task profiles? METHOD: Standardised written survey by nursing directors of all 32 German university hospitals and medical universities in 2015. RESULTS: The response rate was 75 %. The ratio of nurses with an academic degree amounted to 1.7 % overall, and to 1.0 % in direct patient care. The activities of nurses with an academic degree correspond to international Advanced Nursing Practice approaches including conceptual development (76 %), support of evidence-based care (72 %), practice projects (64 %) and patient counselling (56 %). There were significant variations among hospitals nationwide concerning pay rates with a current lack of reliable pay structures. DISCUSSION: This is the first national survey to determine the quota of nurses with an academic degree in direct patient care. The ratio of 1 % is well below the 10 to 20 % recommended by the German Science Council - hence the need for immediate action and comprehensive reforms. A follow-up survey is planned for 2017.

The German version of the Individualized Care Scale - assessing validity and reliability.

AIM: To assess validity and reliability of the German version of the Individualized Care Scale (ICS). BACKGROUND: Individualized nursing care plays a pivotal role in establishing patient-centered care. To assess individualized nursing care and to compare it in different settings and countries, valid and reliable instruments are needed. No psychometric-tested instrument for comparing individualized nursing care with other countries is available in Germany. DESIGN: Cross-sectional study. METHODS: Data were collected between September 2013 and June 2014 from 606 patients in 20 wards in five hospitals across Germany. Unidimensionality of the ICS scales ICSA (patients' views on how individuality is supported through nursing interventions) and ICSB (patients' perceptions of individualized nursing care) was analyzed by confirmatory factor analysis. Internal consistency was assessed by calculating Cronbach's alpha. The Smoliner Scale (patients' perceptions of the decision-making process in nursing care) and results from participating hospitals' assessment of the nursing care delivery systems were used to assess known-groups validity and concurrent validity. RESULTS: Fit indices of confirmatory factor analysis indicate unidimensionality of the ICSA (Comparative Fit Index: 0.92; Tucker-Lewis Index: 0.902; root mean square error of approximation: 0.09; standardized root mean square residual: 0.05) and the ICSB (Comparative Fit Index: 0.91; Tucker-Lewis Index: 0.89; root mean square error of approximation: 0.09; standardized root mean square residual: 0.05). Internal consistency using Cronbach's alpha was 0.95 (95% confidence interval: 0.94-0.95) for ICSA and 0.93 (95% confidence interval: 0.92-0.94) for the ICSB. Concurrent validity was established by a significant relationship between the Smoliner Scale and ICSA (r=0.66; P<0.01) and ICSB (r=0.72; P<0.01). Known-groups validity was approved by ICSA/ICSB score differences related to nursing care delivery systems and patients' perceptions of decision-making style. CONCLUSION: The German version of the ICS is deemed a valid and reliable instrument for use in practice and research with hospitalized patients.

Suicide prevention in neurology patients: evidence to guide practice.

OBJECTIVE: This article is an overview of the neurological diagnoses with highest attempt in suicide. The most common risk factors in suicidal ideation in neurology patients are identified, as well as the description of ways to assess and implement treatment of patients with suicidal ideation, including the recommendations for patients with specific neurological diagnosis. A guideline development is needed to address suicide concerns in these patients. METHODS: A literature search was conducted to find published studies and patient guidelines that were relevant to suicidal ideation, assessment, and treatment in neurology patients. RESULTS: Information found was not always exclusive for neurology patients. Findings often discussed psychiatric patients. The neurological diagnosis most associated with suicidal ideation includes multiple sclerosis, epilepsy, and Parkinson's disease. The most common risk factors for suicidal ideation are hopelessness, depression, and social isolation. As treatment factors, a therapeutic relationship, treatment for depression, assurance of patient safety, and specific interventions for suicidal prevention were identified to provide healthcare professionals in neurology ways to address suicidal issues for patients with neurological diagnoses. Three protocols highlighted staff prevention activities. DISCUSSION: Because patients with neurological disorders experience suicidal ideation with a greater risk of suicide, particularly in multiple sclerosis, epilepsy, and Parkinson's disease, the potential risk for suicide requires active assessment, monitoring, and intervention by nurses and health professionals to address this clinical issue. The assessments available require further psychometric testing for reliability and validity with patient use. There is a need for more research to develop a guideline/protocol exclusively for neurological patients.

[Nursing, patient safety and the acquisition of nursing-sensitive outcomes in German hospitals]. / Pflege, Patientensicherheit und die Erfassung pflegesensitiver Ergebnisse in deutschen Krankenhäusern.

As the largest occupational group in healthcare, nurses continuously work in very close contact to patients and nursing home residents. No other professionals in the healthcare sector are involved in or responsible for so many different processes. They play a key role in, on the one hand, identifying and potentially avoiding errors and, on the other hand, in causing them. Traditionally, error handling in Germany is still strongly influenced by pointing a finger to and tabooing problematic behaviour. Structured systems for detecting errors and error reports can help to improve risk management in nursing. There is a need to develop fundamental structures like national indicators of nursing quality for systematic and valid error measurements and the structured collection of nursing-sensitive outcomes at a national level.

A 4-cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery.

AIMS AND OBJECTIVES: In this experimental study, a 4-cm thermoactive viscoelastic foam overlay and a heating source on the operating room table was compared with the standard operating room table with a heating source for the effect on the postoperative pressure ulcer incidence in cardiac surgery patients. BACKGROUND: Pressure ulcer incidence in the cardiac surgery population is reported to be up to 29.5%. The prolonged compressive forces from lying on the operating room table are one source of pressure ulcer development in this population. Pressure-reducing devices on the operating room (OR)-table should reduce the patients' interface pressure and thus the hazard of skin breakdown. METHODS: A randomized controlled trial was performed to test the effect of a 4-cm thermoactive viscoelastic foam overlay with a water-filled warming mattress on the OR-table (test OR-table) compared with the standard OR-table (a water-filled warming mattress, no pressure-reducing device) on the postoperative pressure ulcer incidence in cardiac surgery patients. INSTRUMENTS: The pressure ulcer classification system of the European Pressure Ulcer Advisory Panel (EPUAP) was used for pressure ulcer grading. RESULTS: The results show that patients lying on the 4-cm thermoactive viscoelastic foam overlay suffer slightly more pressure ulcer (17.6%) than patients on the standard OR-table without the foam overlay (11.1%). Because of the clinical relevance of the results, the randomized controlled trial was terminated after 175 patients at the interim analysis although the power calculation stated 350 patients. CONCLUSIONS: The combination of a 4-cm viscoelastic foam overlay and a warming source cannot be recommended for pressure ulcer prevention on the operating room table. RELEVANCE TO CLINICAL PRACTICE: Foam overlays are used to prevent pressure ulcers in patients. It is necessary to use such devices according to patient safety and use of resources.