Were the unfinished nursing care occurrence, reasons, and consequences different between COVID-19 and non-COVID-19 patients? A systematic review.

BACKGROUND: Unfinished Nursing Care (UNC) has been documented also during the Coronavirus (COVID-19) pandemic; however, while several secondary studies were conducted before this period to summarise occurrences, reasons, and consequences of UNC and provide a global picture of the phenomenon, no synthesis of the evidence produced during the pandemic has been documented to date. Therefore, the aim of this review is to identify differences, if any, in the UNC occurrence, reasons, and consequences perceived by nurses caring for COVID-19 and non-COVID-19 patients. METHODS: This study is a systematic review (PROSPERO CRD42023410602). According to the Population, Exposure, Comparator, and Outcomes framework, primary comparative cross-sectional, longitudinal, and cohort studies, randomised/non-randomised controlled trials were included from Medline, CINAHL, and Scopus, collecting perceptions of nurses with tools measuring UNC between COVID-19 and non-COVID-19 patients and published in English, Italian, or Turkish. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and Johanna Briggs Quality Appraisal Tool were used, and findings were summarised narratively. RESULTS: Five hospital-based cross-sectional studies using the self-administered MISSCARE and UNC Survey comparing data collected (a) before the pandemic vs. in the first wave; (b) before, in the second and in the third wave; and (c) simultaneously among COVID-19 and non-COVID-19 patients in the second wave. Three main patterns emerged suggesting a higher UNC occurrence among COVID-19 patients in the first wave, less occurrence among them compared to non-COVID-19 patients in the second wave, and contrasting findings with some in favour and others in contrast to COVID-19 patients. Similar patterns emerged regarding UNC reasons while no studies investigated the UNC consequences. CONCLUSIONS: In the first wave, COVID-19 patients were likely to be at increased risk of UNC, while in later waves non-COVID-19 patients were at increased risk of UNC. Reasons also were different across waves. Findings documented during the COVID-19 pandemic may help to prevent UNC in future disasters.

The first COVID-19 new graduate nurses generation: findings from an Italian cross-sectional study.

BACKGROUND: Nursing education has been disrupted by the onset of the COronaVIrus Disease 19 (COVID-19) pandemic, potentially impacting learning experiences and perceived competencies at the time of graduation. However, the learning experiences of students since the onset of COVID-19, their perceived competences achieved and the employment status one month after graduation, have not been traced to date. METHODS: A cross sectional online survey measured the individual profile, the learning experience in the last academic year and the perceived competences of the first COVID-19 new nursing graduates in two Italian universities. Details relating to employment status and place of employment (Covid-19 versus non-COVID-19 units) one month after graduation were also collected and the data compared with those reported by a similar cohort of new graduates pre-pandemic in 2018-2019. All those who graduated in November 2020 and attended their third year after the onset of the COVID-19 pandemic were eligible. The online survey included individual, nursing programme and first working experience variables alongside the Nurse Competence Scale (NCS). Descriptive and inferential statistical analyses were performed. RESULTS: A total of 323 new graduates participated. In their last academic year, they experienced a single, long clinical placement in non-COVID-19 units. One month after graduation, 54.5% (n = 176) were working in COVID-19 units, 22.9% (n = 74) in non-COVID-19 units and 22.6 (n = 73) were unemployed. There was no statistical difference among groups regarding individual variables and the competences perceived. Fewer new graduates working in COVID-19 units experienced a transition programme compared to those working in non-COVID-19 units (p = 0.053). At the NCS, the first COVID-19 new graduate generation perceived significantly lower competences than the pre-COVID-19 generation in the 'Helping role' factor and a significant higher in 'Ensuring quality' and 'Therapeutic interventions' factors. CONCLUSIONS: The majority of the first COVID-19 new graduate generation had been employed in COVID-19 units without clinical experience and transition programmes, imposing an ethical debate regarding (a) the role of education in graduating nurses in challenging times with limited clinical placements; and (b) that of nurse managers and directors in ensuring safe transitions for new graduates. Despite the profound clinical placement revision, the first COVID-19 new graduate generation reported competences similar to those of the pre-COVID-19 generation, suggesting that the pandemic may have helped them to optimise the clinical learning process.

Occurrence and reasons for unfinished nursing care between COVID-19 and non-COVID-19 patients.

AIM: To compare the occurrence and the reasons for unfinished care among coronavirus disease (COVID-19) and non-COVID-19 patients as perceived by nurses. BACKGROUND: The recent pandemic has imposed tremendous changes in hospitals in all countries. INTRODUCTION: Investigating the occurrence of and the reasons for unfinished care as perceived by nurses working in COVID-19 and non-COVID-19 units might help to gain insights and to address future pandemics. METHODS: A comparative cross-sectional study based on the STROBE guideline has been conducted during November 2020-January 2021. The Unfinished Nursing Care Survey, comprising part A (elements) and part B (reasons), was administered online to all 479 nurses working in medical and surgical units converted progressively into COVID-19 and non-COVID-19 units. A total of 90 and 200 nurses participated, respectively. RESULTS: No differences in the unfinished care occurrence have emerged at the overall level between nurses caring for COVID (2.10 out of 5; 95% confidence interval [CI], 1.94-2.27) and non-COVID-19 patients (2.16; 95% CI, 2.06-2.26). Reasons for unfinished care reported significant higher averages among nurses caring for COVID (2.21; 95% CI, 2.10-2.31) as compared with those caring for non-COVID-19 patients (2.07; 95% CI, 2.01-2.14; p = 0.030). DISCUSSION: The overall occurrence of unfinished care was slightly higher compared with pre-pandemic data in all patients. CONCLUSIONS: Reasons triggering unfinished care were slightly different and were due to priority setting and human resources issues, which were perceived at higher significance among nurses working in COVID-19 compared with non-COVID-19 units. IMPLICATION FOR NURSING AND HEALTH POLICIES: A clear map of action has emerged that might be valid in the post-COVID-19 era as well as in the case of future pandemics.

Assessing pain in children with autism spectrum disorders: findings from a preliminary validation study.

AIMS: Assessing pain in children with autism spectrum disorders (ASDs) can be extremely challenging, since many cannot self-report pain. This study aims to test the validity of the Non-Communicating Children's Pain Checklist - Revised (NCCPC-R) in identifying pain in children and adolescents affected by ASDs. MATERIALS AND METHODS: A two-phase validation study based on (a) the translation and cultural adaptation of the NCCPC-R to Italian and to ASD-specific needs and context; and (b) the validation of a modified, 32-item version of the NCCPC-R. In all, 141 carers of children aged 6-16 years with ASDs were asked to recall an in-pain episode and a not-in-pain episode of their child and to rate on a 3-point scale (0 = not at all, 3 = very often) each behaviour included in the tool. Internal consistency (Cronbach's α), explorative and confirmative factorial structure, as well as concurrent and discriminant validity, were all assessed. RESULTS: Confirmatory factor analysis established the revised version of the NCCPC-R for children with ASDs (named = NCCPC-RASD ), formed from 10 of the original 30 items categorised into three factors ('Changing in mood', 'Increasing in tension' and 'Alerting reaction') to have an acceptable level of reliability. The tool was internally consistent (α = 0.741 during in-pain episodes, α = 0.790 during not-in-pain episodes) and was able to discriminate between in-pain episodes (13.36 out of 40; CI 95% 12.34-14.39) and not-in-pain episodes (7.84 out of 40; CI 95% 6.86-8.82, p < 0.001). CONCLUSIONS: These results provide preliminary evidence that the 10-item version of the NCCPC-RASD is a reliable and valid tool for assessing pain in children with ASD.

Prevalence and reasons for non-nursing tasks as perceived by nurses: Findings from a large cross-sectional study.

AIM: The aim of this study is to describe the prevalence and reasons for non-nursing tasks as perceived by nurses. BACKGROUND: Four types of non-nursing tasks have been identified to date: (a) auxiliary; (b) administrative, (c) expected by allied health care professionals; and (d) medical. However, no studies on a large scale have been performed with the aim of identifying the prevalence of all of these non-nursing tasks, and factors promoting or hindering their occurrence, given that they represent a clear waste of nurses' time. METHODS: A cross-sectional study in 2017, following The Strengthening the Reporting of Observational studies. All active nurses registered in an Italian provincial Nursing Board (=1331) willing to participate were involved. A questionnaire survey exploring the nature of the nursing tasks performed in daily practice and the underlying reasons was administered via paper/pencil and e-mail. RESULTS: A total of 733 nurses participated of which 94.5% performed at least one type of non-nursing task, mainly administrative and auxiliary. Auxiliary tasks are less likely among nurses working in a community (odds ratio [OR] 0.43, 95% CI 0.29-0.63, p < .01) or in a residential (OR 0.41, 95% CI 0.23-0.72, p < .01) setting, in critical (OR 0.29, 95% CI 0.16-0.54, p < .01) or surgical (OR 0.37, 95% CI 0.19-0.75, p < .01) hospital settings, and when they deal with unexpected clinical events (OR 0.58, 95% CI 0.44-0.77, p < .01). Greater adequacy of nursing resources decreases the occurrence of auxiliary tasks (OR 0.98, 95% CI 0.97-0.99, p < .01), whereas the need to compensate for a lack of resources (OR 1.44, 95% CI 1.07-1.93, p < .01) increases it. CONCLUSIONS: Around one-third of shift time is devoted to non-nursing tasks; working in a hospital, in medical units, with lack of resources and with patients with predictable clinical conditions might increase the occurrence of auxiliary tasks. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies to increase the time available for nursing care should consider the type of tasks performed by nurses, their antecedents and the value added to care in terms of patient' benefits.

Does missed nursing care influence the use of physical restraint and its duration in acute medical patients? Secondary analysis of a longitudinal study.

Missed nursing care and physical restraint have been identified as indicators of patient safety, but no studies to date have explored their relation. To explore the relation between these two phenomena, a secondary analysis of a longitudinal study on 1464 in-hospital patients and 314 registered nurses was performed. The use of physical restraint was assessed at the bedside on a daily basis; missed care was assessed with the MISSCARE survey. Individual, nursing care, and hospital-level variables were measured. A total of 184 (12.6%) patients were restrained for 20.33% of their in-hospital stay. No significant differences emerged in the occurrence of missed care between restrained and unrestrained patients. However, some common antecedents of these two phenomena emerged: in units where there is a lack of personnel, both an increase in missed care and physical restraint duration should be expected. As a consequence, patients are threatened in their right to receive the required care and they are at risk of being restrained. Moreover, a higher skill mix is a preventive factor, which suggests that the increased numbers of registered nurses on the team, may prevent routine forms of physical restraint use by analyzing the physical restraint in place critically and removing them as soon as possible, thus reducing the duration of the restraints.

What nursing home environment can maximise eating independence among residents with cognitive impairment? Findings from a secondary analysis.

To explore the influence of the Nursing Home (NH) environment on eating independence while taking into account individual and nursing care factors, was the aim of the study. A secondary analysis was performed based on data collected in a multicentre prospective observational study involving 13 NHs. Residents aged >65 were included (n = 1,027). Dependence in eating was measured using the Edinburgh Feeding Evaluation in Dementia scale (EdFED, range 0-20). In addition to individual and nursing care variables, the NHs environments were assessed with the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH, range 0-149). The mean EdFED score was 2.48 (95% Confidence Interval [CI]=2.22-2.73) and the TESS-NH score was 122.19 (95% CI=115.89-128.49). A linear regression analysis explained 30.8% of the total variance in eating dependence. Alongside individual and nursing care factors, in poor NH unit environments, residents with severe cognitive impairment showed increased eating dependence; in contrast, in better environments, similar residents showed maximal eating performance.

Unfinished Nursing Care Survey: A development and validation study.

AIMS: To develop and validate a comprehensive tool based on those established in the field capable of reflecting the broader concept of Unfinished Nursing Care. BACKGROUND: Different tools have been established in the field of Missed Care, Rationing Care and Tasks Left Undone. However, despite them sharing similar items and all referring to the common concept of Unfinished Nursing Care, no attempts to collapse them in a single tool capable of reflecting current nursing practice, and its increased complexity, have been attempted to date. METHODS: A development and validation study was performed in 2017. After developing the instrument starting from the MISSCARE Survey and critically reviewing the other tools available in the field, the Unfinished Nursing Care Survey (UNCS) was subjected to validation. A total of 1977 nurses from 13 acute Italian hospitals were recruited. Acceptability, construct validity (Mokken Scaling, Explorative and Confirmative Factor Analysis), internal consistency, hypothesis testing and criterion validity were assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments guideline. RESULTS: 1,400 (70.8%) nurses participated. The UNCS is composed of part A (=elements of unfinished care) and part B (=reasons for unfinished care) with 21 and 18 items, respectively. The UNCS has showed high acceptability (>90%). Part A has reported a strong scalability (H = .52), thus suggesting a hierarchical structure among the items. The six factors in part B explained a total variance of 64.3% (internal consistency = .806) as confirmed by the Confirmative Factor Analysis. CONCLUSIONS: The comprehensive nature of the UNCS can contribute to the establishment of a common reference measure of the phenomenon worldwide although its psychometric properties require future investigation in different cultural contexts, languages and clinical settings. IMPLICATIONS FOR NURSING MANAGEMENT: Measuring Unfinished Nursing Care provides information on the processes implicated in the development of adverse events before these become visible; moreover, it can increase awareness on nurses' performance and inform appropriate interventions to improve it.

Depicting clinical nurses' priority perspectives leading to unfinished nursing care: A pilot Q methodology study.

AIMS: To highlight (a) trends common to all nurses on priorities attributed to interventions, and (b) whether there are profiles of nurses working in the same context who prioritize interventions in a similar way. BACKGROUND: The underlying prioritization of interventions leading to unfinished nursing care has been minimally investigated. METHODS: A 2017 pilot Q methodology study. Full-time nurses, with at least 6 months of experience in a surgical unit, were involved. Eleven nurses rated the priority given in daily practice (from -3 as the lowest to +3 as the highest) to 35 Q-sample statements representing nursing care, non-nursing and organisational interventions. RESULTS: Overall, the intervention receiving the lowest priority was 'Providing patient hygiene', while the highest was 'Answering phone calls'. In the by-person factor analysis (total variance = 60.79%), three profiles of nurses emerged, (a) 'Patient safety-oriented' (variance = 31.66%); (b) 'Nursing task-oriented' (=16.32%); and (c) 'Team process-oriented' (=12.81%). CONCLUSIONS: Three profiles of nurses emerged in the same setting with significant differences both in the statistical order of priorities and in their practical implications. IMPLICATIONS FOR NURSING MANAGEMENT: Understanding levels of prioritization, which are not only affected by the unit but also by sub-groups of nurses who rank priorities in a similar way, can support nurse managers in their role.

Clinical, demographical characteristics and hospitalisation of 3,010 patients with Covid-19 in Friuli Venezia Giulia Region (Northern Italy). A multivariate, population-based, statistical analysis.

OBJECTIVES: to describe the clinical and demographical characteristics of COVID-19 infected people in the Friuli Venezia Giulia Region (FVG, Northern Italy). DESIGN: retrospective cohort study with an individual level record linkage procedure of different administrative databases. SETTING AND PARTICIPANTS: the cohort included 3,010 patients residing in FVG who tested positive for COVID-19 between 1 March and 15 May 2020, 2020. Regional hospital admissions and deaths without hospital admissions up to June 1st, 2020 were analysed. Determinants of the probability of a highly severe illness were investigated in terms of hospitalisations or death without hospital admission. MAIN OUTCOME MEASURES: COVID-19 patients were identified from regional epidemiological data warehouse. Demographical and clinical variables such as gender, age, patient's comorbidities, vaccinations, ARBs/sartans prescriptions, and geographical residence variables were collected by linking different databases. Descriptive analyses were performed. Logistic multivariate regressions were used to estimate the probability of hospitalisation or death, whichever came first. Model coefficients and odds ratios (OR) were reported. RESULTS: COVID-19 population in FVG had a mean age of 60 years and 59% were females. The study found that 37% had hypertension while patients with cardiologic diseases, diabetes, and cancer were around 15%; 22% of the cases were residing in retirement homes. Approximately 30% received flu or pneumococcal vaccination and a similar proportion of patients had at least one prescription of ARBs /sartans in the previous 6 months. Statistical models showed a higher probability of a worst course of disease for males, elderly, highly complicated (in terms of resource use) subjects, in the presence of cardiologic diseases, diabetes, and pneumococcal vaccination. People living in retirement homes had a lower probability of hospitalisation/death without hospital admission. The cohort was divided into two groups: COVID-19 patients infected in the territory and infected in retirement homes. Among COVID-19 patients infected in the territory, the probability of hospitalisation/death was higher for males, for older individuals, and for those with comorbidities. Diabetes resulted to be a risk factor (OR 1.79; 95%CI 1.23-2.62), as well as pneumococcal vaccination (OR 1.64; 95%CI: 1.18-2.29), which is a likely proxy of fragile patients with pulmonary disease. The flu vaccination showed a potential protective effect with a 40% lower probability of hospitalisation or death (OR 0.62; 95%CI 0.44-0.85). Among the retirement homes cohort group, a higher probability of a bad course of disease emerged for males and for more complex patients. CONCLUSIONS: the greatest risk of hospitalisation/death as a measure of more severe illness was confirmed for males, elderly, and for individuals with comorbidities. Flu vaccination seemed to have had a protective effect while pneumococcal vaccination likely identified a group of high-risk patients to be actively monitored. For patients infected in the territory, different hospitalisation strategies were implemented by the regional health districts.

A path analysis on the direct and indirect effects of the unit environment on eating dependence among cognitively impaired nursing home residents.

BACKGROUND: This study aims to estimate the direct and indirect effects of the unit environment alongside individual and nursing care variables on eating dependence among residents who are cognitively impaired and living in a nursing home. METHOD: A multicentre observational study was carried out in 2017: 13 Italian nursing homes were involved in data collection. Included residents were aged > 65 at baseline, living in the considered facility for the last 6 months and during the entire study period and having received at least one comprehensive assessment. Data were collected (a) at the individual level: eating dependence using the Edinburgh Feeding Evaluation in Dementia Scale and other clinical variables; (b) at the nursing care level with daily interventions to maintain eating independence assessed with a checklist; and (c) at the nursing home level, using the Therapeutic Environment Screening Survey for Nursing Homes. RESULTS: One thousand twenty-seven residents were included with an average age of 85.32 years old (95% CI: 84.74-85.89), mainly female (781; 76%). The path analysis explained the 57.7% variance in eating dependence. Factors preventing eating dependence were: (a) at the individual level, increased functional dependence measured with the Barthel Index (ß - 2.374); eating in the dining room surrounded by residents (ß - 1.802) as compared to eating alone in bed; and having a close relationship with family relatives (ß - 0.854), (b) at the nursing care level, the increased number of interventions aimed at promoting independence (ß - 0.524); and (c) at the NH level, high scores in 'Space setting' (ß - 4.446), 'Safety' (ß - 3.053), 'Lighting' (ß - 2.848) and 'Outdoor access' (ß - 1.225). However, environmental factors at the unit level were found to have also indirect effects by influencing the degree of functional dependence, the occurrence of night restlessness and the number of daily interventions performed by the nursing staff. CONCLUSION: Eating dependence is a complex phenomenon requiring interventions targeting individual, nursing care, and environmental levels. The NH environment had the largest direct and indirect effect on residents' eating dependence, thus suggesting that at this level appropriate interventions should be designed and implemented.

Self-feeding dependence incidence and predictors among nursing home residents: Findings from a 5 year retrospective regional study.

The aim of this regionally-based, retrospective study was to describe the incidence of self-feeding dependence and predictors among elderly patients admitted from 2008 to 2013 to 105 Italian nursing homes. Data reported in a regional database collected at the time of nursing home admission and every 6 months up to the resident's death were accessed. The self-feeding degree of dependence was the dependent variable; at the individual and nursing home levels, explanatory variables were those collected at nursing home admission and every 6 months. The structural equation model and the ordinal polynomial logit regression analysis were performed. A total of 13 175 records of residents when admitted to the nursing home and their following 69 341 records, were included. At the time of nursing home admission, 6496 residents (49.3%) reported a certain degree of dependence in self-feeding and showed slight worsening in their dependence every 6 months. At the individual level, the increased functional dependence raised the proportional odds ratios of approximately 4.36 times of an increased dependence in self-feeding; the degree of cognitive impairment, the lack of social interactions, the occurrence of pressure sores, comorbidities, as well as the clinical instability and time all raised the risk of self-feeding dependence progression. At the nursing home level, an increased number of beds emerged as a factor also increasing the proportional odds of dependence in self-feeding. Factors affecting self-feeding dependence are multi-faceted at the individual and at the nursing home levels.

Opportunity to discuss ethical issues during clinical learning experience.

BACKGROUND: Undergraduate nursing students have been documented to experience ethical distress during their clinical training and felt poorly supported in discussing the ethical issues they encountered. RESEARCH AIMS: This study was aimed at exploring nursing students' perceived opportunity to discuss ethical issues that emerged during their clinical learning experience and associated factors. RESEARCH DESIGN: An Italian national cross-sectional study design was performed in 2015-2016. Participants were invited to answer a questionnaire composed of four sections regarding: (1) socio-demographic data, (2) previous clinical learning experiences, (3) current clinical learning experience quality and outcomes, and (4) the opportunity to discuss ethical issues with nurses in the last clinical learning experience (from 0 - 'never' to 3 - 'very much'). PARTICIPANTS AND RESEARCH CONTEXT: Participants were 9607 undergraduate nursing students who were attending 95 different three-year Italian baccalaureate nursing programmes, located at 27 universities in 15 Italian regions. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after the research protocol was approved by an ethics committee. FINDINGS: Overall, 4707 (49%) perceived to have discussed ethical issues 'much' or 'very much'; among the remaining, 3683 (38.3%) and 1217 (12.7%) students reported the perception of having discussed, respectively, 'enough' or 'never' ethical issues emerged in the clinical practice. At the multivariate logistic regression analysis explaining 38.1% of the overall variance, the factors promoting ethical discussion were mainly set at the clinical learning environment levels (i.e. increased learning opportunities, self-directed learning, safety and nursing care quality, quality of the tutorial strategies, competences learned and supervision by a clinical nurse). In contrast, being male was associated with a perception of less opportunity to discuss ethical issues. CONCLUSION: Nursing faculties should assess the clinical environment prerequisites of the settings as a context of student experience before deciding on their accreditation. Moreover, the nursing faculty and nurse managers should also enhance competence with regard to discussing ethical issues with students among clinical nurses by identifying factors that hinder this learning opportunity in daily practice.

Multi-level analysis of national nursing students' disclosure of patient safety concerns.

CONTEXT: Error reporting is considered one of the most important mediating factors for patient safety (PS). However, reporting errors can be challenging for health care students. OBJECTIVES: The aims of the study were: (i) to describe nursing students' opportunity to report errors, near misses or PS issues that emerged during their clinical learning experience; and (ii) to explore associated factors of the process of reporting itself. METHODS: A national survey was conducted on 9607 (91.7%) undergraduate nursing students. The endpoint was to have reported PS issues in the last clinical learning experience (from 0 'never' to 3 'always'). Explanatory variables were set individual, nursing programme and regional levels. RESULTS: A total of 4004 (41.7%) nursing students reported PS issues from 'never/rarely' to 'sometimes'. In the multi-level analysis, factors increasing the likelihood of reporting events affecting PS have been mainly at the nursing programme level: specifically, higher learning opportunities (odds ratio [OR] = 3.040; 95% confidence interval [CI], 2.667-3.466), self-directed learning opportunities (OR = 1.491; 95% CI, 1.364-1.630), safety and nursing care quality (OR = 1.411; 95% CI, 1.250-1.594) and quality of tutorial strategies OR = 1.251; 95% CI, 1.113-1.406). By contrast, being supervised by a nurse teacher (OR = 0.523; 95% CI, 0.359-0.761) prevented the disclosure of PS issues compared with being supervised by a clinical nurse. Students attending their nursing programmes in some Italian regions showed a higher likelihood (OR from 1.346 to 2.938) of reporting PS issues compared with those undertaking their education in other regions. CONCLUSIONS: Nursing students continue to be reticent to report PS issues. Given that they represent the largest generation of future health care workers, their education regarding PS should be continuously monitored and improved; moreover, strategies aimed at developing a non-blaming culture should be designed and implemented both at the clinical learning setting and regional levels.

Multilevel National Analysis of Nursing Students' Perceived Opportunity to Access Evidence-Based Tools During Their Clinical Learning Experience.

BACKGROUND: Easy-to-access tools have been demonstrated to improve evidence-based practice (EBP) competences among nursing students. However, students' perception of access to EBP tools (e.g., clinical practice guidelines [CPGs], protocols) is unknown. AIMS: To explore: (1) nursing students' opportunity to access EBP tools during their education, and (2) associated factors. METHODS: A national cross-sectional study including all Italian nursing programs. Nursing students were deemed eligible according to the following inclusion criteria: Those who (1) were attending or just ended their practical rotation lasting at least 2 weeks at the time of the survey, and (2) expressed through written informed consent their willingness to take part in the study. Participants were asked about their perceived opportunity to access EBP tools during their most recent clinical learning experience (from 0 - not at all to 3 - always). A set of explanatory variables was collected at the individual, nursing program, and regional levels by using a questionnaire. RESULTS: Nine thousand six hundred and seven (91.6%) out of 10,480 nursing students took part in the study. Overall, 4,376 (45.6%) students perceived not at all or only a small opportunity to access EBP tools during their most recent clinical rotation. In the multilevel analysis, factors promoting access were mainly set at the clinical learning environment level (high safety and nursing care quality, high self-directed learning opportunities, high quality of the learning environment, and being supervised by a clinical nurse). In contrast, male gender and lower academic class were associated with a lower perception of accessibility to EBP tools. A consistent variability in the perceived opportunity to access EBP tools emerged across regions. LINKING EVIDENCE TO ACTION: Evidence-based decision-making is increasingly expected from nurses. Therefore, nursing faculties should safeguard and continuously improve students' competence regarding EBP, by implementing strategies mainly at the nursing program and regional levels.

Efficacy and safety of far infrared radiation in lymphedema treatment: clinical evaluation and laboratory analysis.

Swelling is the most common symptom of extremities lymphedema. Clinical evaluation and laboratory analysis were conducted after far infrared radiation (FIR) treatment on the main four components of lymphedema: fluid, fat, protein, and hyaluronan. Far infrared radiation is a kind of hyperthermia therapy with several and additional benefits as well as promoting microcirculation flow and improving collateral lymph circumfluence. Although FIR therapy has been applied for several years on thousands of lymphedema patients, there are still few studies that have reported the biological effects of FIR on lymphatic tissue. In this research, we investigate the effects of far infrared rays on the major components of lymphatic tissue. Then, we explore the effectiveness and safety of FIR as a promising treatment modality of lymphedema. A total of 32 patients affected by lymphedema in stage II and III were treated between January 2015 and January 2016 at our department. After therapy, a significant decrease of limb circumference measurements was noted and improving of quality of life was registered. Laboratory examination showed the treatment can also decrease the deposition of fluid, fat, hyaluronan, and protein, improving the swelling condition. We believe FIR treatment could be considered as both an alternative monotherapy and a useful adjunctive to the conservative or surgical lymphedema procedures. Furthermore, the real and significant biological effects of FIR represent possible future applications in wide range of the medical field.

Alteration of Skin Mechanical Properties in Patients Undergoing Botulinum Toxin Type A Injections of Forehead Rhytides.

BACKGROUND: Although application of botulinum toxin type A (BTX-A) for the treatment of forehead rhytides has become very popular, the effects of its intramuscular injections on the skin mechanical properties remain unclear. OBJECTIVES: We prospectively investigated the alterations in the mechanical properties of the skin of patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides and compared two injection doses. METHODS: Of the 42 enrolled patients, one randomly assigned half received intramuscular injections of two units (group I), and the other half received four units (group II) of BTX-A in each injection point. The baseline and post-treatment skin mechanical parameters, including gross elasticity (R2), net elasticity (R5), viscoelastic ratio (R6) and biological elasticity (R7), were measured using the Cutometer(®) and compared. RESULTS: Treatment with BTX-A resulted in significant overall alterations in the mechanical properties of skin at the injection sites of both treatment groups during the 16-week period, and no significant differences were observed between groups. Significant decreases in biological elasticity, net elasticity and viscoelasticity properties were observed at 2 weeks follow-up and began to recover at that time. All of the skin mechanical properties recovered to baseline levels by 16 weeks of follow-up in both dosage groups, which indicates that the higher dosage (4 units) did not delay relapse compared to the two-unit dosage. CONCLUSIONS: We concluded that intramuscular injections of BTX-A significantly regulated the gross elasticity, net elasticity, functional elasticity and viscoelastic elasticity at the injection point over a radius of 1.5 cm at 2, 4 and 8 weeks follow-up. The alteration in the skin measurements had completely diminished by the 16-week follow-up. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bipedicled Preexpanded Forehead Flaps for Simultaneous Reconstruction of Total Nasal and Upper Lip Subunits: A Novel Approach to Complex Facial Resurfacing.

Background Reconstruction of the central facial subunits is a complex and challenging task. In cases in which both the nasal and upper lip subunits are involved, a technique that can reconstruct both aesthetic units with tissue of similar color and texture from a single donor site will be ideal. In this article we present our experience with the bipedicled preexpanded forehead flap for simultaneous nasal and upper lip resurfacing. Patients and Methods Between January 2012 and January 2015 we used this technique in the simultaneous reconstruction of total nasal and upper lip subunits in five patients. All cases were for burns scar resurfacing. Results Good aesthetic results were achieved in each of our five cases to date and no complications were encountered. All donor sites closed primarily with aesthetically pleasing well-concealed linear scars. In all cases small modifications such as philtral shaping and further flap thinning were performed under local anesthesia between 6 and 12 months postoperatively Conclusion The preexpanded forehead flap provides an unparalleled color and texture match when it comes to facial resurfacing. When both total nasal and upper lip resurfacings are required, it is possible to achieve this in a single sitting from a single donor site by using a bipedicled preexpanded forehead flap.

Revisit of the anatomy of the distal perforator of the descending genicular artery and clinical application of its perforator "propeller" flap in the reconstruction of soft tissue defects around the knee.

PURPOSE: In this article,we revisited the anatomy of the distal perforator of the descending genicular artery (DGA) and report the clinical application of its perforator propeller flap in the reconstruction of soft tissue defects around the knee. METHODS: Forty fresh human lower limbs were dissected to redefine the anatomy of the branches of the DGA and their perforators and the anatomical landmarks for clinical applications. Five patients underwent "propeller" distal anteromedial thigh (AMT) flaps based on DGA perforators for the reconstruction of post-traumatic (n = 4) and post-oncologic (n = 1) soft tissue defects occurring near the knee with a size ranging from 4.8 cm × 6.2 cm to 10.5 cm × 18.2 cm. RESULTS: A constant cutaneous perforator of the osteoarticular branch (OAB) of the DGA was found in the distal AMT fossa with a mean caliber of 1.2 ± 0.4 mm. It arose 9.4 ± 3.1 cm distally to the origin of the OAB and 4.0 ± 0.4 cm above the knee joint. The size of the harvested flaps ranged from 6.0 cm × 7.1 cm to 11.0 cm × 20.1 cm. All the flaps healed uneventfully at a mean period of 7.4 months. All the patients regained full range motion of the knee-joint. CONCLUSION: Our study provided evidence of the vascular supply and the clinical application of the distal AMT flap based on a constant perforator arising from the OAB of the DGA. This flap may be a versatile alternative for the reconstruction of the defects around the knee because of its consistent vascular pedicle, pliability and thinness, adequate retrograde perfusion, and the possible direct suture of the donor site.

Bipaddle radial forearm flap for head and neck reconstruction.

BACKGROUND: Although the radial forearm free flap has become a workhorse flap in head and neck reconstruction, the skin grafting of the donor is the main drawback resulting in an unacceptable contour deformity and an unsightly appearance. Several technical modifications have been therefore applied to the radial forearm (RF) flap marking, elevation, and inset to overcome this major shortcoming. In this article, we report our clinical series with the bipaddle RF flap. METHODS: The authors described their 11 cases of head and neck oncologic reconstruction with the bipaddle RF flap. The skin island is designed longer and narrower and split into 2 separate skin paddles each nourished by a proximal and a distal independent perforators raising from the radial artery so that the donor site could be closed directly. The narrow design of the skin paddle and the subsequent splitting in its 2 components applying the "perforator-pedicle propeller flap method" allow for the changing of the flap shape according to the shape of the recipient site defect. RESULTS: From 2007 to 2013, the bipaddle RF flap method was used in 11 patients to restore head and neck defects following cancer ablation. The mean age of the patients was 43 years, ranging from 31 to 50 years. The location of the defects was the tongue (n = 7) and the intraoral region (n = 4). The defect sizes varied from 4 × 5 cm to 5 × 6 cm, and the flap maximum width was 3 cm with mean area of 26.4 cm. The healing was uneventful in all patients with excellent cosmetic and functional results of both donor site and recipient site after 20 months of mean follow-up. CONCLUSIONS: The bipaddle RF free flap is a reliable and versatile option for the reconstruction of a wide range of soft tissue defects of head and neck region. This method allows for a customized resurfacing of the defect because of its large variability in shape and size. The harvesting site is closed primarily, and a second donor site for skin graft is avoided.Clinical Question, Level of Evidence: Therapeutic, IV.