[Interrater reliability and concurrent validity of 4AT for the detection of postoperative delirium: A prospective cohort study]. / Interrater Reliabilität und Übereinstimmungsvalidität des 4AT zur Erfassung des postoperativen Delirs.

Interrater reliability and concurrent validity of 4AT for the detection of postoperative delirium: A prospective cohort study Abstract. Background: Numerous tools for detecting postoperative delirium are available. Guidelines recommend the 4 A's Test (4AT). However, there is little evidence on the validity and reliability of the German version of 4AT. Aim: To assess the interrater reliability of the German version of 4AT test for the detection of postoperative delirium in general surgical and orthopedic-traumatological patients, and the concurrent validity with the Delirium Observation Screening Scale (DOS). Methods: The present work is part of a prospective cohort study with a sample of 202 inpatients (≥ 65 years) who underwent surgery. The interrater reliability of the 4AT (intraclass coefficients) was determined with a subsample of 33 subjects who were rated by two nurses. Concurrent validity between the DOS scale and the 4AT was calculated using Pearson's correlation coefficient. Results: Interrater reliability for the 4AT total score and dichotomized total score were 0.92 (95% CI 0.84-0.96) and 0.98 (95% CI 0.95-0.98), respectively. The correlation between DOS and 4AT (Pearson) was 0.54 (p < 0.001). Conclusions: The 4A test can be used by nurses as a screening instrument for the detection of postoperative delirium in older patients on general surgery and orthopedic traumatology wards. In case of positive 4AT results further assessment by nurse experts or physicians is required.

Delirium in elderly postoperative patients: A prospective cohort study.

AIM: To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients. DESIGN: Prospective cohort study. METHODS: Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM-V. We performed descriptive and logistic regression analyses. RESULTS: From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho-geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.

"It's about how we do it, not if we do it". Nurses' experiences with implicit rationing of nursing care in acute care hospitals: A descriptive qualitative study.

BACKGROUND: The phenomenon of unfinished nursing care is gaining increasing interest among nursing researchers. While survey studies on the underlying concepts, e.g., implicit rationing of nursing care, revealed frequencies, antecedents and consequences, little is known about how nurses experience care rationing in clinical practice. OBJECTIVES: The aim of this study was to explore nurses' experiences with implicit rationing of nursing care in acute-care hospitals. DESIGN: We conducted a qualitative study using interpretive description methodology. METHODS: Using a convenience sample of 31 frontline nurses (i.e., registered nurses, nurse assistants) and 19 ward nurse managers from acute care units in seven hospitals in [Blinded], eight semi-structured focus group interviews were conducted, transcribed verbatim and analyzed via thematic analysis. RESULTS: Our findings indicate three interconnected themes: (a) maintaining stability within complexity; (b) applying strategies to limit rationing; and (c) nursing care between ideal and reality. According to study participants, implicit rationing of nursing care results when nurses cannot otherwise maintain stability for their patients and their units. Nurses reported several strategies, including postponing tasks or reducing quality, to prevent or limit rationing. Rationing accentuates the gap between ideal nursing care and day-to-day practice. CONCLUSIONS: In absence of guidelines on implicit rationing of nursing care nurses rely on intuitive and situational processes of decision-making and priority setting. Technical activities addressing patients' instability receive higher priority than relational ones. As quality may be an earlier casualty of implicit rationing than quantity, it challenges us to broaden the current focus of how care rationing manifests. In addition to encouraging open discourse on implicit and non-transparent rationing at all organizational levels, this qualitative study provides new insights that will inform the development and implementation of interventions to support nurses' priority setting and ultimately to limit rationing of nursing care.

[Extent and type of implicit rationing of nursing care in seven South Tyrolean hospitals: a descriptive study]. / Estensione e tipologia del razionamento implicitodell'assistenza infermieristica nei sette ospedalidell'Azienda Sanitaria dell'Alto Adige: studio descrittivo.

. Extent and type of implicit rationing of nursing care in seven South Tyrolean hospitals: a descriptive study. INTRODUCTION: Implicit rationing of nursing care is an international phenomenon, defined as withholding of or failure to carry out necessary nursing interventions due to a lack of nursing resources. AIMS: To describe the extent and type of nursing care implicitly rationed in South Tyrolean hospitals, and to explore differences across clinical areas and between registered nurses (RNs) and support staff. METHODS: The Basel Extent of Rationing of Nursing Care (BERNCA) questionnaire was completed between September and November 2015, by 934 RNs and support staff of the seven hospitals, involved in direct adult patient care (24 medical, 13 surgical, 5 rehabilitation, 4 intensive care units). Descriptive and explorative analyses were performed. RESULTS: The most rationed activities concerned "nursing care planning" (37.3%), "surveillance of confused patient" (30.7%), "providing emotional support" (30.1%) and "talking with patients and family" (28.4%). Of the ten most rationed activities, seven were common to RN and support staff, and across clinical areas, although with different frequencies. Significant differences between clinical areas were observed for: "nursing care planning", "rehabilitation care", and "comfort/talking with patients and family". DISCUSSION: Implicit rationing of nursing care occurs in South Tyrolean hospitals, mainly related to care planning and documentation. Higher priority is given to activities related to direct patient care. Further investigations on priority setting to increase the awareness among frontline nurses of what is rationed, and to guarantee the safety and quality of care is warranted.