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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Protocols for pressure ulcer prevention: are they evidence-based?

AIM: This study is a report of a study to determine the quality of protocols for pressure ulcer prevention in home care in the Netherlands. BACKGROUND: If pressure ulcer prevention protocols are evidence-based and practitioners use them correctly in practice, this will result a reduction in pressure ulcers. Very little is known about the evidence-based content and quality of the pressure ulcer prevention protocols. METHOD: In 2008, current pressure ulcer prevention protocols from 24 home-care agencies in the Netherlands were evaluated. A checklist developed and validated by two pressure ulcer prevention experts was used to assess the quality of the protocols, and weighted and unweighted quality scores were computed and analysed using descriptive statistics. RESULTS: The 24 pressure ulcer prevention protocols had a mean weighted quality score of 63.38 points out of a maximum of 100 (sd 5). The importance of observing the skin at the pressure points at least once a day was emphasized in 75% of the protocols. Only 42% correctly warned against the use of materials that were 'less effective or that could potentially cause harm'. CONCLUSION: Pressure ulcer prevention commands a reasonable amount of attention in home care, but the incidence of pressure ulcers and lack of a consistent, standardized document for use in actual practice indicate a need for systematic implementation of national pressure ulcer prevention standards in the Netherlands to ensure adherence to the established protocols.

Determination of standard times of nursing activities based on a Nursing Minimum Dataset.

AIM: This paper is a report of a study conducted to determine the standard time per nursing activity and the proportion of nursing time covered by the nursing activities of the Belgian Nursing Minimum Dataset compared to the total time of a nurse shift, and to evaluate the correlation between hospital size and standard times of nursing activities. BACKGROUND: Because of a shrinking workforce and rising workload, nursing managers need tools that help them to allocate their staff to the wards. Such tools should be based on objective time measurements. METHODS: The study was performed in surgical, internal medicine and elder care wards in an acute hospital care setting. In the first phase, a two-round Delphi-procedure was used to operationalize the definitions of nursing activities. In the second phase, the standard time for each nursing activity was determined, based on data collected over a 6-month period during 2006-2007. A combination of 13,292 work sampling observations by external observers, 3000 recordings of direct time measurement by self-recording and subjective time assessments yielded times that were used to analyse the duration of the nursing activities. RESULTS: A standard time for 102 nursing activities was established. The coverage of the Belgian Nursing Minimum Dataset in the surgical, internal medicine and elder care wards was 47.5%, 46.4% and 51.0% respectively. The Belgian Nursing Minimum Dataset was found to cover almost 70% of direct and indirect nursing care. CONCLUSION: Further research is needed to assess the impact on the standard times of nursing activities of inefficient organizational structures and different cultural interpretations of the way an activity is conducted.

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.

The focus of family members' functioning in the acute phase of traumatic coma: part two: Protecting from suffering and protecting what remains to rebuild 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 the 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. 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 life. In this article (Part Two) we describe the phase of protecting from suffering and protecting what remains to rebuild 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.

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.

Prevention and treatment of incontinence-associated dermatitis: literature review.

AIM: This paper is a report of a review conducted to describe the current evidence about the prevention and treatment of incontinence-associated dermatitis and to formulate recommendations for clinical practice and research. BACKGROUND: Incontinence-associated dermatitis is a common problem in patients with incontinence. It is a daily challenge for healthcare professionals to maintain a healthy skin in patients with incontinence. DATA SOURCES: PubMed, Cochrane, Embase, the Cumulative Index to Nursing and Allied Health Literature, reference lists and conference proceedings were explored up to September 2008. REVIEW METHODS: Publications were included if they reported research on the prevention and treatment of incontinence-associated dermatitis. As little consensus about terminology was found, a very sensitive filter was developed. Study design was not used as a selection criterion due to the explorative character of the review and the scarce literature. RESULTS: Thirty-six publications, dealing with 25 different studies, were included. The implementation of a structured perineal skin care programme including skin cleansing and the use of a moisturizer is suggested. A skin protectant is recommended for patients considered at risk of incontinence-associated dermatitis development. Perineal skin cleansers are preferable to using water and soap. Skin care is suggested after each incontinence episode, particularly if faeces are present. The quality of methods in the included studies was low. CONCLUSIONS: Incontinence-associated dermatitis can be prevented and healed with timely and appropriate skin cleansing and skin protection. Prevention and treatment should also focus on a proper use of incontinence containment materials. Further research is required to evaluate the efficacy and effectiveness of various interventions.

How evidence-based is venous leg ulcer care? A survey in community settings.

AIM: This paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses. BACKGROUND: Incongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice. METHOD: Two focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated (n = 789). The data were collected in 2006. FINDINGS: Compression was applied in 58.7% of patients with venous ulcers. Pain was present in 82.9%. A third of patients with pain received analgesics, but half of these patients (52.1%) took analgesics as prescribed. Half of the nurses (50.8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68.3%), promoting physical activity (39.8%) and optimizing nutrition (16.7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3.75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult. CONCLUSION: Patients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management.

A review of why patients with leg ulcers do not adhere to treatment.

AIM: To provide an overview of what is known thus far about reasons for and determinants of non-adherent behaviour. BACKGROUND: Compression, leg exercises and leg elevation are regarded as essential components in leg ulcer treatment and in the prevention of ulcer recurrence. Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherence are not fully understood. DESIGN: Systematic review. METHOD: Medline, CINAHL and the Cochrane database were explored from 1995 - December 2007. Reference lists of retrieved articles were searched. Studies were eligible if they included patients with venous or mixed leg ulcers, reported reasons or determinants of non-adherence and were published in English, Dutch, French or German. Thirty-one studies were included. RESULTS: Non-adherence is a multidimensional problem. Pain, discomfort and lack of valid lifestyle advice by healthcare professionals were primary reasons for non-adherence from patient's perspective. CONCLUSIONS: Healthcare professionals mainly focus on patient-related factors such as poor motivation, lack of knowledge and understanding and unwillingness. The beliefs that compression was unnecessary, uncomfortable, worthwhile and prevented recurrence significantly determined (non-)adherence. RELEVANCE TO NURSING AND NURSING SCIENCE: Interventions to promote adherence will require a multifaceted approach and a holistic comprehensive assessment. Therapeutic non-judgemental relationships are essential to enhance patient adherence. Effective pain management is recommended and social support by family or significant others could be encouraged. Healthcare professionals should give clear, unambiguous and tailored information. Research can best focus on the factors and processes affecting patient adherence to leg ulcer treatment. Comprehensive adherence-enhancing strategies could be developed and their effectiveness should be tested.

The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers.

AIMS AND OBJECTIVE: The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2-4) in nursing home patients with non-blanchable erythema. BACKGROUND: No studies could be found that identify risk factors for further development of pressure ulcer in patients with non-blanchable erythema. For some patients with non-blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. DESIGN: Secondary data analyses of a previously conducted randomised controlled trial were performed. METHODS: Eighty-four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non-blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. RESULTS: The cumulative pressure ulcer incidence was 18.7% (44/235). Hypotension (relative risk = 3.42, 95% CI = 1.56-7.49), a history of a cerebral vascular accident (relative risk = 1.94, 95% CI = 1.10-3.70) and contractures (relative risk = 2.02, 95% CI 1.03-3.95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. CONCLUSIONS: In nursing home residents with non-blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. RELEVANCE TO CLINICAL PRACTICE: Patients with non-blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.

Incidence and risk factors for pressure ulcers in the intensive care unit.

AIMS: To determine the incidence of pressure ulcers occurring at least 48 hours after admission and risk factors for pressure ulcers grade 2-4 in a long-stay surgical Intensive Care Unit (ICU) population. BACKGROUND: The incidence of pressure ulcers in intensive care units is larger than in non-intensive environments. DESIGN: Prospective descriptive research design. METHODS: Using pressure ulcers grade 2-4 as an outcome measure, a multivariate logistic regression analysis was used to identify the risk factors. Data were obtained on a daily basis in a surgical intensive care unit of the University Hospital Leuven between November 2003-March 2004. A total of 520 long-stay (>or= 24 hours) intensive care patients were included. RESULTS: Cumulative incidence of pressure ulcers grade 2-4 was 20.1%. The following variables were positively associated with pressure ulcers grade 2-4: history of vascular disease, treatment with Dopamine or Dobutamine, intermittent haemodialysis (IHD) or continuous veno-venous haemofiltration (CVVH), mechanical ventilation. Also preventive measures were statistically positively associated with pressure ulcers grade 2-4: turning, floating heels, alternating mattresses, adequate prevention. The use of sedatives, body temperature above 38.5 degrees C and sitting in chair where negatively associated with pressure ulcers. Pressure ulcers are statistically associated with different risk factors and preventive measures. CONCLUSION: The identified risk factors are eligible to be included in a new risk assessment scale for patients admitted to intensive care units. RELEVANCE TO CLINICAL PRACTICE: The novel insights have implications for risk assessment for patients in intensive care units. Patients admitted to intensive care units have other risk factors for pressure ulcers which are eligible to be included in a new risk assessment scale.