Probabilistic priority assessment of nurse calls.

Current nurse call systems are very static. Call buttons are fixed to the wall, and systems do not account for various factors specific to a situation. We have developed a software platform, the ontology-based Nurse Call System (oNCS), which supports the transition to mobile and wireless nurse call buttons and uses an intelligent algorithm to address nurse calls. This algorithm dynamically adapts to the situation at hand by taking the profile information of staff and patients into account by using an ontology. This article describes a probabilistic extension of the oNCS that supports a more sophisticated nurse call algorithm by dynamically assigning priorities to calls based on the risk factors of the patient and the kind of call. The probabilistic oNCS is evaluated through implementation of a prototype and simulations, based on a detailed dataset obtained from 3 nursing departments of Ghent University Hospital. The arrival times of nurses at the location of a call, the workload distribution of calls among nurses, and the assignment of priorities to calls are compared for the oNCS and the current nurse call system. Additionally, the performance of the system and the parameters of the priority assignment algorithm are explored. The execution time of the nurse call algorithm is on average 50.333 ms. Moreover, the probabilistic oNCS significantly improves the assignment of nurses to calls. Calls generally result in a nurse being present more quickly, the workload distribution among the nurses improves, and the priorities and kinds of calls are taken into account.

Concurrent incidence of adverse events in hospitals and nursing homes.

PURPOSE: To describe the concurrent incidence of pressure ulcers, urinary tract infections, and falls in hospitals and nursing homes, and the preventive care given. Additionally, the correlation between the occurrence of these adverse events and preventive care was explored. DESIGN AND SETTINGS: A prospective, 3-month, cohort study at 10 hospitals and 10 nursing homes in the Netherlands. PARTICIPANTS: 687 hospital patients and 241 nursing home patients. MAIN OUTCOME MEASURES: The incidence of three adverse events and preventive care given to patients at risk. During weekly visits, the patients and their files were assessed. Additionally, observations were performed. RESULTS: Seventy-seven hospital patients (11%) and 111 nursing home patients (46%) developed one or more adverse events. The incidence rate for both types of patients, and for the three adverse events combined, was 9% adverse events per patient week. In hospitals, 34% of the patients received adequate pressure ulcer preventive care, while 47% of the patients received adequate urinary tract infection preventive care, and none of the patients received adequate falls preventive care. In nursing homes, 18% of the patients received adequate pressure ulcer preventive care, 42% of the patients received adequate urinary tract infection preventive care, and less than 1% of the patients received adequate falls prevention care. Negative or no correlations were found between the incidence rates for the three adverse events. In nursing homes the incidence of pressure ulcers and preventive care were positively correlated. CONCLUSIONS: There is a high incidence of adverse events in hospitals and nursing homes. Many patients at risk do not receive adequate preventive care.

Patient risk factors for pressure ulcer development: systematic review.

OBJECTIVE: To identify risk factors independently predictive of pressure ulcer development in adult patient populations? DESIGN: A systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies. DATA SOURCES: Fourteen electronic databases were searched, each from inception until March 2010, with hand searching of specialist journals and conference proceedings; contact with experts and a citation search. There was no language restriction. REVIEW METHODS: Abstracts were screened, reviewed against the eligibility criteria, data extracted and quality appraised by at least one reviewer and checked by a second. Where necessary, statistical review was undertaken. We developed an assessment framework and quality classification based upon guidelines for assessing quality and methodological considerations in the analysis, meta-analysis and publication of observational studies. Studies were classified as high, moderate, low and very low quality. Risk factors were categorised into risk factor domains and sub-domains. Evidence tables were generated and a summary narrative synthesis by sub-domain and domain was undertaken. RESULTS: Of 5462 abstracts retrieved, 365 were identified as potentially eligible and 54 fulfilled the eligibility criteria. The 54 studies included 34,449 patients and acute and community patient populations. Seventeen studies were classified as high or moderate quality, whilst 37 studies (68.5%) had inadequate numbers of pressure ulcers and other methodological limitations. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status. Skin moisture, age, haematological measures, nutrition and general health status are also important, but did not emerge as frequently as the three main domains. Body temperature and immunity may be important but require further confirmatory research. There is limited evidence that either race or gender is important. CONCLUSIONS: Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. The review highlights the limitations of over-interpretation of results from individual studies and the benefits of reviewing results from a number of studies to develop a more reliable overall assessment of factors which are important in affecting patient susceptibility.

Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes.

AIMS: To gain insight into the knowledge and attitudes of nurses and nursing assistants and to study the correlation between knowledge, attitudes and the compliance with the pressure ulcer prevention guidelines provided to residents at risk of pressure ulcers in nursing homes. BACKGROUND: There is a lack of evidence on knowledge and attitudes of nurses and nursing assistants towards pressure ulcer prevention in nursing homes. DESIGN: A cross-sectional multi-centre study. METHODS: A convenience sample of nine Belgian nursing homes, representing 18 wards was chosen in the study. In total, 145 nurses and nursing assistants were included. The compliance with the guidelines was evaluated in 615 residents, and data were collected using validated instruments. RESULTS: Fully compliant prevention was found in only 6·9% of the residents at risk. The mean knowledge score of the nurses was 29·3 vs. 28·7% for the nursing assistants. The overall attitude score was 74·5%, and attitude scores were significantly different between nurses and nursing assistants. Nurses showed to have a more positive attitude towards pressure ulcer prevention than nursing assistants, respectively 78·3 and 72·3%. A more positive attitude was a significant predictor of pressure ulcer prevention compliance with the guidelines provided to residents at risk of pressure ulcers in nursing homes. CONCLUSIONS: Knowledge about pressure ulcer prevention of both nurses and nursing assistants in nursing homes was low. Attitudes were a significant predictor of the application of fully compliant prevention in residents at risk. RELEVANCE TO CLINICAL PRACTICE: Pressure ulcer prevention is an important aspect in daily care for residents at risk in nursing homes. These insights will contribute to evidence-based practice in this area of care and will form the basis for the development of an education strategy for pressure ulcer prevention and management in nursing homes.

Determining a set of measurable and relevant factors affecting nursing workload in the acute care hospital setting: a cross-sectional study.

BACKGROUND: While there has been great interest in the effect of nurse staffing levels have on the quality of care in hospitals, less attention has been given to determining the factors that affect the nursing workload. There are no existing studies that help define measurable factors that have a clear relation to nursing workload. OBJECTIVES: The aim of this study was to determine the most important and measurable factors, other than patient acuity, that influence nursing workload. DESIGN: A cross-sectional design. SETTINGS: Hospitals within the acute hospital care setting. PARTICIPANTS: Persons with a nursing educational background, working in Belgian acute care hospitals. METHODS: A self-administered questionnaire was developed based on the results of an integrative review, the use of focus groups and a survey on measurability and relevance of the included factors. The questionnaire listed relevant and measurable factors related to nursing workload. Weight and frequency of each factor was assessed. RESULTS: The initial list consisted of 94 factors. These factors were regrouped and organised into a questionnaire of 28 measurable and sufficiently relevant factors affecting the nursing workload. More than half of the initial factors seemed to be relevant, but hard to measure on a daily basis. Based on the impact of each factor, the number of work interruptions was the most important factor related to nursing workload. CONCLUSIONS: It is unlikely that a workload instrument will ever be able to take into account all possible factors affecting the nursing workload. Nevertheless, the number of work interruptions, the patient turnover rate and the number of mandatory registrations should be included in the development or revision of a workload measurement tool.

A 3-in-1 perineal care washcloth impregnated with dimethicone 3% versus water and pH neutral soap to prevent and treat incontinence-associated dermatitis: a randomized, controlled clinical trial.

PURPOSE: We compared the effectiveness of a 3-in-1 perineal care washcloth versus standard of care (water and pH neutral soap) to prevent and treat incontinence-associated dermatitis (IAD). The product under study was a soft, premoistened washcloth, including a 3% dimethicone formula, with cleansing, moisturizing, and barrier protection properties. DESIGN: Randomized, controlled clinical trial. SUBJECTS AND SETTING: The study sample comprised a random sample of 11 nursing home wards (6 experimental and 5 control) in a convenience sample of 4 nursing homes in Belgium. The sample included nursing home residents at risk for and/or affected by IAD defined as incontinent of urine, feces, urine/feces, and/or having erythema of the perineal skin (not caused by pressure/shear), and/or having an edematous skin in the genital area. METHODS: Participants in the experimental group were treated according to a standardized protocol, including the use of a 3-in-1 perineal care washcloth impregnated with a 3% dimethicone skin protectant. Participants in the control group received perineal skin care with water and pH neutral soap, the standard of care in Belgian nursing homes. The study period was 120 days. Data were collected between February and May 2010. Incontinence-associated dermatitis prevalence and severity were assessed using the IAD Skin Condition Assessment Tool. The surface (cm), redness, and depth of the perineal lesion were assessed daily by the nurses. This tool generates a cumulative severity score (maximum score = 10) based on area of skin affected, degree of redness, and depth of erosion. RESULTS: Four hundred sixty-four nursing home residents were assessed and 32.9% (n = 141) met the criteria for inclusion, including 73 subjects in the experimental group and 68 in the control group. Baseline IAD prevalence was comparable in both groups (experimental: 22.3% vs control: 22.8%, P = .76). Baseline IAD severity was 6.9/10 in the experimental group and 7.3/10 in the control group. A significant intervention effect on IAD prevalence was found (experimental: 8.1% vs control: 27.1%, F = 3.1, P = .003). A nonsignificant effect on IAD severity could be determined (experimental: 3.8/10 vs control: 6.9/10, F = 0.8, P = .06). CONCLUSION: The use of a 3-in-1 washcloth, impregnated with a 3% dimethicone formula, resulted in a significantly reduced prevalence of IAD and a trend toward less severe lesions. These findings provide indicative evidence for the use of 3-in-1 perineal care washcloth as an effective intervention against the use of water and a pH neutral soap to prevent and/or treat IAD.

Non-direct patient care factors influencing nursing workload: a review of the literature.

AIMS: The aim of this paper was to detect which non-direct patient care factors are related to nursing workload in acute hospital nursing care and to develop a conceptual model to describe the relationship between the non-direct patient care factors and nursing workload. BACKGROUND: Since the 1930s, efforts to measure nursing workload have been undertaken. Still, it remains unclear which of the non-direct patient care elements are essential to the nursing workload. DATA SOURCES: PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, Engineering Village 2, Elin and the British Nursing Index were searched from 1970 up to July 2009. REVIEW METHODS: Studies were included in this integrative review if they described factors that are related to nursing workload or if they presented models that explored the association between potential factors, excluding the factors related to direct patient care. RESULTS: Thirty publications were included. The influencing variables were classified in five categories based on their level of impact: the hospital and ward, nursing team, individual nurse, patient and family and meta-characteristics. The variables were also classified, based on their cause-effect relationship. Some factors have a direct impact on the patient-nurse relationship, while others have an effect on the work fluency or on the subjective perception of the nursing workload. A conceptual model was built, based on the interaction between both classifications and derived from the systems theory. CONCLUSIONS: Nursing workload has a multi-causal aetiology. The influencing factors from this review can be integrated in a workload measurement tool.

Development and psychometric evaluation of an instrument to assess venous leg ulcer lifestyle knowledge among nurses.

AIM: Development and psychometric testing of an instrument to assess venous leg ulcer lifestyle knowledge. BACKGROUND: Nurses often lack knowledge to provide adequate leg ulcer advice. No valid and reliable instruments are available to assess knowledge on venous leg ulcer advice among nurses. METHODS: The instrument was developed based on a literature review and patient cases. Content validity was evaluated in a Delphi procedure by nine leg ulcer experts. Item-analysis, construct validity and stability were assessed. A sample of 350 nurses and student nurses participated. Data collection took place between February and April 2009. RESULTS: The instrument included four topics: (1) Compression therapy, (2) Physical activity/leg exercises, (3) Leg elevation and (4) Pain management. Multiple-choice questions were developed to assess factual knowledge. Patient cases were developed to assess more complex cognitive skills. Content validity was established. The quality of the response alternatives varied between 0.01 and 0.68. The difficulty index for questions evaluating factual knowledge ranged from 0.12 to 0.78. Patient cases' questions had a difficulty index between 0.07 and 0.60. The score of participants with (theoretically expected) more expertise was significantly higher than the score of participants with (theoretically expected) less expertise. The intraclass correlation coefficients ranged between 0.71 and 0.77. Eleven questions had moderate kappa-values (0.41-0.60), and in eight questions, there was fair agreement (0.30-0.40). CONCLUSION: An instrument with an acceptable content validity and construct validity was developed. The instrument can be applied in nursing education, nursing practice and nursing research to evaluate venous leg ulcer advice knowledge.

Fewer adverse events as a result of the SAFE or SORRY? programme in hospitals and nursing homes. part i: primary outcome of a cluster randomised trial.

BACKGROUND: Patient care guidelines are usually implemented one at a time, yet patients are at risk for multiple, often preventable, adverse events simultaneously. OBJECTIVE: This study aimed to test the effect of the SAFE or SORRY? programme on the incidence of three adverse events (pressure ulcers, urinary tract infections and falls). This paper describes Part I of the study: the effect on the incidence of adverse events. DESIGN: A cluster randomised trial was conducted between September 2006 and November 2008. After a three-month baseline period the intervention was implemented followed by a nine-month follow-up period. SETTINGS: Ten wards from four hospitals and ten wards from six nursing homes were stratified for institute and ward type and then randomised to intervention or usual care group. PARTICIPANTS: During baseline and follow-up, patients (≥18 years) with an expected length of stay of at least five days, were asked to participate. METHODS: The SAFE or SORRY? programme consisted of the essential recommendations of guidelines for the three adverse events. A multifaceted implementation strategy was used for the implementation: education, patient involvement and feedback on process and outcome indicators. The usual care group continued care as usual. Data were collected on the incidence of adverse events and a Poisson regression model was used to estimate the rate ratio of the adverse events between the intervention and the usual care group at follow-up. RESULTS: At follow-up, 2201 hospital patients with 3358 patient weeks and 392 nursing home patients with 5799 patient weeks were observed. Poisson regression analyses showed a rate ratio for the development of an adverse event in favour of the intervention group of 0.57 (95% CI: 0.34-0.95) and 0.67 (95% CI: 0.48-0.99) for hospital patients and nursing home patients respectively. CONCLUSION: This study showed that implementing multiple guidelines simultaneously is possible, which is promising. Patients in the intervention groups developed 43% and 33% fewer adverse events compared to the usual care groups in hospitals and nursing homes respectively. Even so, more research is necessary to underline these results. TRIAL REGISTRATION: clinicaltrials.gov, number NCT00365430.

Knowledge and attitudes of nurses on pressure ulcer prevention: a cross-sectional multicenter study in Belgian hospitals.

BACKGROUND: Evidence-based guidelines for pressure ulcer prevention have been developed and promoted by authoritative organizations. However, nonadherence to these guidelines is frequently reported. Negative attitudes and lack of knowledge may act as barriers to using guidelines in clinical practice. AIMS: To study the knowledge and attitudes of nurses about pressure ulcer prevention in Belgian hospitals and to explore the correlation between knowledge, attitudes, and the application of adequate prevention. METHODS: A cross-sectional multicenter study was performed in a random sample of 14 Belgian hospitals, representing 207 wards. Out of that group, 94 wards were randomly selected (2105 patients). Clinical observations were performed to assess the adequacy of pressure ulcer prevention and pressure ulcer prevalence. From each participating ward, a random selection of at least five nurses completed an extensively validated knowledge and attitude instrument. In total, 553 nurses participated. A logistic regression analysis was performed to evaluate the correlation between knowledge, attitudes, and the application of adequate prevention. RESULTS: Pressure ulcer prevalence (Category I-IV) was 13.5% (284/2105). Approximately 30% (625/2105) of the patients were at risk (Bradenscore <17 and/or presence of pressure ulcer). Only 13.9% (87/625) of these patients received fully adequate prevention whilst in bed and when seated. The mean knowledge and attitude scores were 49.7% and 71.3%, respectively. The application of adequate prevention on a nursing ward was significantly correlated with the attitudes of the nurses (OR = 3.07, p = .05). No independent correlation was found between knowledge and the application of adequate prevention (OR = 0.75, p = .71). CONCLUSIONS: Knowledge of nurses in Belgian hospitals about the prevention of pressure ulcers is inadequate. The attitudes of nurses toward pressure ulcers are significantly correlated with the application of adequate prevention. No correlation was found between knowledge and the application of adequate prevention.

An ontology-based nurse call management system (oNCS) with probabilistic priority assessment.

BACKGROUND: The current, place-oriented nurse call systems are very static. A patient can only make calls with a button which is fixed to a wall of a room. Moreover, the system does not take into account various factors specific to a situation. In the future, there will be an evolution to a mobile button for each patient so that they can walk around freely and still make calls. The system would become person-oriented and the available context information should be taken into account to assign the correct nurse to a call.The aim of this research is (1) the design of a software platform that supports the transition to mobile and wireless nurse call buttons in hospitals and residential care and (2) the design of a sophisticated nurse call algorithm. This algorithm dynamically adapts to the situation at hand by taking the profile information of staff members and patients into account. Additionally, the priority of a call probabilistically depends on the risk factors, assigned to a patient. METHODS: The ontology-based Nurse Call System (oNCS) was developed as an extension of a Context-Aware Service Platform. An ontology is used to manage the profile information. Rules implement the novel nurse call algorithm that takes all this information into account. Probabilistic reasoning algorithms are designed to determine the priority of a call based on the risk factors of the patient. RESULTS: The oNCS system is evaluated through a prototype implementation and simulations, based on a detailed dataset obtained from Ghent University Hospital. The arrival times of nurses at the location of a call, the workload distribution of calls amongst nurses and the assignment of priorities to calls are compared for the oNCS system and the current, place-oriented nurse call system. Additionally, the performance of the system is discussed. CONCLUSIONS: The execution time of the nurse call algorithm is on average 50.333 ms. Moreover, the oNCS system significantly improves the assignment of nurses to calls. Calls generally have a nurse present faster and the workload-distribution amongst the nurses improves.

Systematic development and validation of a nursing intervention: the case of lifestyle adherence promotion in patients with leg ulcers.

AIMS: To describe and discuss of the added value of systematic development and validation of nursing interventions in nursing care. BACKGROUND: An adherence-promoting intervention for leg ulcer patients was developed in 2008, based on the model of van Meijel. This model requires a systematic development using an analysis of patients' (lived) experiences and professionals' views on (good) care. It employs a cyclical process of trying out, evaluating, revising and reassessing the adapted intervention in patients. The intervention consists of information and counselling sessions carried out by tissue viability nurses and focuses on wearing compression hosiery, practising leg elevation, physical activity and performing leg exercises. DISCUSSION: Exploring patients' and nurses' perspectives during the development of intervention increases the likelihood that the resultant intervention is both feasible and attuned to patients' needs. Various implementation issues were identified during the developmental process. Validation of the intervention through its use in nursing care aids in refining the intervention and in linking the techniques most successful in effecting behavioural change to theoretical constructs. It contributes to the refinement of concepts of behavioural theories by clarifying the processes underlying the intervention's effectiveness. Direct involvement of the researcher in the validation phase has great added value. IMPLICATIONS FOR NURSING: Patient involvement in intervention development is essential, as is the researcher's direct involvement in practical situations in which the intervention is tested. Qualitative (evaluation) approaches are recommended. CONCLUSION: Although the systematic development of nursing interventions is time-consuming, the contribution to the development of nursing practice and nursing science makes it worthwhile.

Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey.

INTRODUCTION: The development of a pressure ulcer is an adverse event and is often avoidable if adequate preventive measures are applied. No large-scale data, based on direct patient observations, are available regarding the pressure ulcer preventive interventions used in hospitals. PURPOSE: The aim of this study was to obtain insight into the adequacy of interventions used to prevent pressure ulcers in Belgian hospitals. METHODS: A cross-sectional, multi-centre pressure ulcer prevalence study was performed in Belgian hospitals. The methodology used to measure pressure ulcer prevalence was developed by the European Pressure Ulcer Advisory Panel. The data collection instrument includes five categories of data: general data, patient data, risk assessment, skin observation and prevention. RESULTS: The total sample consisted of 19,968 patients. The overall prevalence of pressure ulcers Category I-IV was 12.1%. Only 10.8% of the patients at risk received fully adequate prevention in bed and while sitting. More than 70% of the patients not at risk received some pressure ulcer prevention while lying or sitting. CONCLUSION: Generally, there is a limited use of adequate preventive interventions for pressure ulcers in hospitals, which reflects a rather low quality of preventive care. The implementation of pressure ulcer guidelines requires more attention. The pressure ulcer prevention used in practice should be re-evaluated on a regular basis.

Adherence to leg ulcer lifestyle advice: qualitative and quantitative outcomes associated with a nurse-led intervention.

AIM AND OBJECTIVES: Examining the (experienced) changes associated with a nursing intervention to enhance adherence to leg ulcer lifestyle advice. BACKGROUND: Few interventions to enhance adherence to leg ulcer treatment are developed and tested. DESIGN: Qualitative evaluation approach and pre-post-test design were used. METHOD: Twenty-six patients with venous ulcers in a community care setting participated. Data were collected by means of interviews and participant observation. Frequency and duration of wearing compression, leg exercising and leg elevation, activity level, pain and ulcer size were registered at baseline, after the end of the intervention and three months later. Inductive content analysis and Wilcoxon signed-rank test were used. RESULTS: Knowledge about leg ulcer advice increased. The education contributed to more consciously following of the advice. The rationale of the advice and its association with healing or recurrence remained often unclear. More patients performed exercises after the intervention and at follow-up. Patients often looked out onto a 'new' perspective where enhancement of quality of life and even healing might be attainable. Some patients regained independence after learning how to apply and remove compression garments themselves. The frequency of exercising and the duration of exercises increased significantly. Step counts had not altered significantly. Patients not elevating the legs at baseline elevated the legs more and for a longer period of time after the intervention. This effect on leg elevation decreased after three months. No significant changes were reported on hours wearing compression. CONCLUSIONS: The perceived changes suggest that the intervention holds a promise for current home care. Combining qualitative and quantitative research assisted to determine the possible effects of the intervention, increasing the potential for a meaningful randomised trial in the future. RELEVANCE TO CLINICAL PRACTICE: Education about leg ulcer advice should be incorporated in nursing practice. Further testing of the intervention is recommended.

Malnutrition and nutritional care practices in hospital wards for older people.

AIMS: This paper is a report of a study conducted to gain a better insight into the current nutritional care practices in Belgian hospital wards for older people, and to study the association between these practices and the prevalence of malnutrition. BACKGROUND: In 1999, the Council of Europe assessed nutritional care practices and support in 12 European countries and showed them to be sparse and inconsistent. At the time of research, no studies had described the association between nutritional care practices and malnutrition prevalence in Belgium. METHODS: In 2007, a cross-sectional survey was carried out in a representative sample of Belgian hospital wards for older people. In total, 2094 patients from 140 wards for older people were included. RESULTS: The overall prevalence rate of malnutrition in wards for older people was 31.9%. Nutritional care practices such as nutritional screening and assessment, use of a standardized screening instrument and a nutritional protocol were suboptimal. Multilevel analysis revealed that ward characteristics explained for 9.1% whether a patient was malnourished or not. None of the registered nutritional care practices could explain a patient's individual risk. CONCLUSION: Malnutrition is a frequently occurring problem on hospital wards for older people. Increased consciousness among healthcare professionals and hospital policy makers of the importance of nutritional care will contribute to further improvement in care quality.

Processes underlying adherence to leg ulcer treatment: a qualitative field study.

BACKGROUND: Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherent behaviour are not fully understood. Literature about processes underlying adherence in leg ulcer patients is scarce. OBJECTIVES: To explore the processes underlying adherent behaviour in patients with leg ulcers who received an intervention to enhance adherence to leg ulcer lifestyle advice. DESIGN: A qualitative field study was conducted among patients receiving an adherence-promoting intervention. SETTINGS: The study was carried out in a home care setting in Belgium. PARTICIPANTS: Twenty-six patients with venous leg ulcers were included and received the intervention from five tissue viability nurses in a community healthcare organisation. METHODS: Semi-structured interviews with open-ended questions were held with patients and nurses after the end of the intervention. Data were also collected by means of participant observation. Data collection and data analysis took place iteratively and analysis was validated by means of researcher triangulation. RESULTS: Trust in the nurse was central to leg ulcer treatment adherence. Patients who had a trusting relationship with their nurse showed better adherence to the recommended lifestyle modifications. Trust was facilitated by nurses spending meaningful time with the patient, which means they took time to talk with the patient. Trust was also established because nurses provided care beyond patients' expectations, taking time for wound care and being attentive to pain and other problems. A trusting relationship promoted 'compliance' even if patients were not convinced of the benefits of the leg ulcer lifestyle advice. Perceived physical improvement and diminished discomfort after following the lifestyle advice convinced patients of the importance and positive effect of the regimen, which they doubted at first. Self-efficacy for performing leg exercises was often much higher than self-efficacy for being physically active and elevating the legs. Physical impediments, co-morbidities and socio-structural impediments influenced the patient's ability to adhere to leg ulcer advice. CONCLUSIONS: A conceptual framework to understand adherence to leg ulcer treatment was developed. Nurses should be aware of how nurse-related factors can affect adherence. Aspects that foster trust could be incorporated into leg ulcer care.

Involvement of inpatient mental health clients in the practical training and assessment of mental health nursing students: Can it benefit clients and students?

Even though the central position of the client has been recognized in psychiatric nursing education, the client is seldom formally involved in the feedback provided to students during practical training. This research paper focuses on three questions: (1) What conditions support the gathering of meaningful client feedback to enhance the student's learning process and client's wellbeing? (2) Does the use of the practical model for client feedback lead to positive experiences, and if so, under what conditions? (3) To what extent is a client's feedback on the student's work performance, consistent with feedback from the mentor (nurse from the ward), the teacher and the student? Based on a literature review, participatory observation and contacts with experts, a practical model was developed to elicit client feedback. Using this model in two psychiatric inpatient services, clients were actively and formally involved in providing feedback to four, final year psychiatric nursing students. Clients, nurses, teachers and students were interviewed and data were analysed using a qualitative explorative research approach. Analyses revealed that client feedback becomes meaningful in a safe environment created by the psychiatric nurse. Client feedback generates a learning effect for the student and supports the student's recognition of the value and vulnerability of the psychiatric client.

Implementation of a guideline for pressure ulcer prevention in home care: pretest-post-test study.

AIMS AND OBJECTIVES: To investigate the effect of the implementation of a patient and family education programme for pressure ulcer prevention in an organisation for home care nursing on guideline adherence and on prevalence and severity of pressure ulcers and to examine the determining factors for the application of measures for pressure ulcer prevention. BACKGROUND: Quality improvement programmes in pressure ulcer prevention are not always successful. DESIGN: Implementation study using a pretest-post-test design. Data were collected in three probability samples. The first post-test data collection was held after six months, the second after 18 months. METHOD: Statistical analysis was used, comparing the pretest sample and the second post-test sample. RESULTS: After 18 months, the proportion of subjects with adherent measures had increased from 10·4-13·9%, the proportion of subjects with non-adherent measures decreased from 45·7-36·0%, the proportion of subjects without pressure ulcer prevention increased from 43·9-50·1% (p<0·0001, Chi-square test). Sub-analysis revealed that a positive change in guideline adherence was observed principally in the group at risk. Better process-of-care indicators were associated by lower pressure ulcer prevalence and less severe skin lesions. The nurses' judgement of a patient risk status was the most important factor for applying preventive measures. Furthermore, application of pressure ulcer prevention was determined by higher age (from the age category of 70-79 years), higher dependency for the activities of daily living, higher than baseline mobility score and the presence of a pressure ulcer. CONCLUSIONS: Guideline adherence in pressure ulcer prevention changed significantly after implementation of the education programme. There might have been inconsistencies in the nurses' risk judgement. RELEVANCE TO CLINICAL PRACTICE: Quality of pressure ulcer prevention improved, but several items for improvement remain. Adaptation of risk assessment procedures is needed.

Pressure ulcers and incontinence-associated dermatitis: effectiveness of the Pressure Ulcer Classification education tool on classification by nurses.

CONTEXT: Previous studies report that pressure ulcer classification and differentiation from incontinence associated dermatitis are difficult. Incorrect classification and differentiation result in incorrect prevention and treatment. Education is important to spread evidence-based insights about this topic and to improve classification skills. AIM: To assess the effectiveness of the Pressure Ulcer Classification (PUCLAS) education tool. PUCLAS was developed by the PUCLAS Workgroup of the European Pressure Ulcer Advisory Panel. DESIGN: Randomised controlled trial. SETTING AND PARTICIPANTS: A convenience sample of 1217 Belgian, Dutch, British and Portuguese nurses. OUTCOME MEASURE: Correct classification of pressure ulcer photographs and differentiation from photographs of incontinence-associated dermatitis. RESULTS: Baseline, 44.5% of the photographs were classified correctly. In the post-test, the results in the intervention group were significantly higher (63.2%) compared with the control group (53.1%; p<0.001). The percentage of correct assessments of incontinence associated dermatitis (IAD) was 70.7% in the intervention group and 35.6% in the control group (p<0.001). The skill to differentiate IAD from pressure ulcers was significantly associated with the experimental intervention (OR 4.07, 95% CI 3.21 to 5.15, p<0.001). CONCLUSION: The PUCLAS tool improved pressure ulcer classification and IAD differentiation significantly.

The focus of family members' functioning in the acute phase of traumatic coma: part one: The initial battle and protecting life.

AIMS: The identification and description of the basic psychological process linked with the focus of family members' functioning during the acute phase of traumatic coma. BACKGROUND: Earlier research learned that hope is a core category in coping with traumatic coma. Hope seems to be the drive to keep family members going and to enable them to fulfil their main task namely protecting. In two articles on the focus of family members functioning, this task is defined and the process linked with it is described. DESIGN: A qualitative approach according to the grounded theory method with constant comparison. METHOD: Twenty four in-depth interviews with 22 family members of 16 patients with traumatic coma. RESULTS: Family members describe the period after the confrontation with traumatic coma as a battle. During this battle, they feel the urge to protect their relative in coma, other family members and themselves. They go through three phases: protecting life, protecting from suffering, protecting what remains to rebuild live. In this article (Part One) we describe the initial battle and the phase of protecting life. CONCLUSIONS: All relatives go through the three phases. Family members who have already overcome previous set-backs get through the process slightly more quickly and experience less extreme emotions. RELEVANCE TO CLINICAL PRACTICE: Understanding the process of protecting in different phases may help health care professionals to do anything in their power to avoid unnecessary suffering, to ease the pain and to support family members in their task of protecting.