[Nursing homes versus assisted living facilities: Outcome quality regarding pressure ulcers, falls and malnutrition]. / Vollstationäre Pflegeeinrichtungen vs. "betreutes Wohnen mit ambulanter Versorgung": Ergebnisqualität bezogen auf Dekubitus, Sturz und Mangelernährung.

BACKGROUND: Assisted living has become more popular among individuals who are care-dependent or are threatened with care dependency as an attractive alternative to a standard nursing home. As differences regarding nursing care quality in both settings are so far unknown, the aim of the study was to compare the quality indicators occurrence of pressure ulcers, falls and malnutrition in both settings. MATERIAL AND METHODS: In spring 2010 a multicentre cross-sectional study on the prevalence of care problems was conducted including 3610 individuals in 31 nursing homes (NH) and 21 assisted living facilities (ALF) following a standardized study protocol. Comparative analyses of raw and adjusted prevalence of the care problems occurrence of pressure ulcers, falls and malnutrition were conducted. RESULTS: Individuals in the ALFs were on average older than those in the NHs (89.5 years vs. 83.2 years) but were more mobile and less care-dependent. The prevalence of care problems in the NHs compared to those in the ALFs showed the following results: pressure ulcers (NH = 3.9%, ALF = 2.3%), nosocomial pressure ulcer prevalence (NH = 2.3%, ALF = 0.2%), incidence of falls within 3 months (NH = 12.5%, ALF = 20.4%) and malnutrition according to a body mass index (BMI) ≤ 18.5 kg/m(2) (NH = 5.6%, ALF = 11.4%). CONCLUSION: Due to the population differences, no final conclusions about the quality of care according to the analysed indicators can be made. While the prevalence of pressure ulcers was remarkably lower, falls and malnutrition had a higher prevalence in ALFs. Ongoing and systematic outcome quality surveys in different long-term care facilities are recommended.

The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature.

BACKGROUND: Patient aggression is a longstanding problem in general hospital nursing. Staff training is recommended to tackle workplace aggression originating from patients or visitors, yet evidence on training effects is scarce. AIMS: To review and collate current research evidence on the effect of aggression management training for nurses and nursing students working in general hospitals, and to derive recommendations for further research. DESIGN: Systematic, narrative review. DATA SOURCES: Embase, MEDLINE, the Cochrane library, CINAHL, PsycINFO, pubmed, psycArticles, Psychology and Behavioural Sciences Collection were searched for articles evaluating training programs for staff and students in acute hospital adult nursing in a 'before/after' design. Studies published between January 2000 and September 2011 in English, French or German were eligible of inclusion. REVIEW METHODS: The methodological quality of included studies was assessed with the 'Quality Assessment Tool for Quantitative Studies'. Main outcomes i.e. attitudes, confidence, skills and knowledge were collated. RESULTS: Nine studies were included. Two had a weak, six a moderate, and one a strong study design. All studies reported increased confidence, improved attitude, skills, and knowledge about risk factors post training. There was no significant change in incidence of patient aggression. CONCLUSION: Our findings corroborate findings of reviews on training in mental health care, which point to a lack of high quality research. Training does not reduce the incidence of aggressive acts. Aggression needs to be tackled at an organizational level.

What patient characteristics guide nurses' clinical judgement on pressure ulcer risk? A mixed methods study.

BACKGROUND: Nurses' clinical judgement plays a vital role in pressure ulcer risk assessment, but evidence is lacking which patient characteristics are important for nurses' perception of patients' risk exposure. OBJECTIVES: To explore which patient characteristics nurses employ when assessing pressure ulcer risk without use of a risk assessment scale. DESIGN: Mixed methods design triangulating observational data from the control group of a quasi-experimental trial and data from semi-structured interviews with nurses. SETTING: Two traumatological wards at a university hospital. PARTICIPANTS: Quantitative data: A consecutive sample of 106 patients matching the eligibility criteria (age ≥ 18 years, no pressure ulcers category ≥ 2 at admission and ≥ 5 days expected length of stay). Qualitative data: A purposive sample of 16 nurses. METHODS: Quantitative data: Predictor variables for pressure ulcer risk were measured by study assistants at the bedside each second day. Concurrently, nurses documented their clinical judgement on patients' pressure ulcer risk by means of a 4-step global judgement scale. Bivariate correlations between predictor variables and nurses' risk estimates were established. Qualitative data: In interviews, nurses were asked to assess fictitious patients' pressure ulcer risk and to justify their risk estimates. Patient characteristics perceived as relevant for nurses' judements were thematically clustered. Triangulation: Firstly, predictors of nurses' risk estimates identified in bivariate analysis were cross-mapped with interview findings. Secondly, three models to predict nurses' risk estimates underwent multiple linear regression analysis. RESULTS: Nurses consider multiple patient characteristics for pressure ulcer risk assessment, but regard some conditions more important than others. Triangulation showed that these are measures reflecting patients' exposure to pressure or overall care dependency. Qualitative data furthermore indicate that nurses are likely to trade off risk-enhancing conditions against conditions perceived to be protective. Here, patients' mental capabilities like willingness to engage in one owns care seem to be particularly important. Due to missing information on these variables in the quantitative data, they could not be incorporated into triangulation. CONCLUSIONS: Nurses' clinical judgement draws on well-known aetiological factors, and tends to expand conditions covered by risk assessment scales. Patients' care dependency and self-care abilities seem to be core concepts for nurses' risk assessment.

[Patient education of elderly with mobility impairments : Conception and evaluation of needs during and after release from a geriatric clinic setting]. / Patientenedukation bei älteren Menschen mit Mobilitätseinschränkungen : Konzeption und Evaluation von Bedarfen während und nach der Entlassung aus dem klinisch-geriatrischen Setting.

BACKGROUND: Patient education can contribute to obtaining and maintaining mobility in elderly with mobility impairments. The aim of this study was to evaluate counseling, training, and information needs in elderly patients with mobility impairments before, during, and after a hospital stay in a geriatric clinic. METHODS: A prospective longitudinal study was conducted. Needs were assessed at admission (t1), after 2 weeks (t2), at discharge (t3), after 3 months (t4), and after 6 months (t5). Data were analyzed using descriptive statistics. RESULTS: At almost all time points, there was a need of counseling and information. Counseling needs mainly comprised the themes assistive advices, fall prevention, professional nursing care, other services, nutrition, and pain management. Information needs comprised the themes fall prevention, professional nursing care, other services, assistive devices, nutrition, and modification of living space. There was a need of training mainly at admission and at discharge. Training needs comprised approach to assistive devices and mobility facilitation. CONCLUSION: Training should include activities related to mobility, while counseling and information should comprise all areas of life.

[Frequency of pressure ulcers in german hospitals]. / Die Häufigkeit von Dekubitus in deutschen Krankenhäusern.

The prevalence and incidence of pressure ulcers are increasingly used to assess the quality of care delivered by health systems and facilities and the effectiveness of the pressure ulcer prevention initiatives in place. Available results about pressure ulcer prevalence and incidence in German hospitals are contradictory. The comparison of 3 multicentre nationwide studies is proposed to provide a more accurate estimation of the pressure ulcer frequency. Pressure ulcer prevalence was compared by data provided by the Charité with data of the software-based data collection packet "Kinexus". Additionally, data on pressure ulcer incidence of Kinexus were compared with the results of the incidence data of the "Generalindikator Dekubitusprophylaxe" of the German Society of Quality Assurance (BQS, now AQUA Institute). Data from 2007 and 2008 and patients 75 years and older were considered. For the calculation of the outcome "pressure ulcer" recommendations of the EPUAP and the NPUAP were followed. As category I (non-bleaching erythema) pressure ulcers are difficult to diagnose, all proportions were calculated including and excluding category I. All 3 samples were comparable regarding the mean age of 81 years. Pressure ulcer prevalence categories I-IV (II-IV) of the Kinexus study was 11.8% (6.1%) and of the Charité study it was 11.0% (5.5%). Regarding pressure ulcer incidence, the rate that was calculated by the BQS categories I-IV (II-IV) was 1.3% (0.8%), in comparison to the incidence rate of Kinexus which was 6.7% (3.9%). There were no statistically significant differences between the 2 prevalence measurements but the odds-ratio of the Kinexus incidence in comparison to the BQS incidence was more than 4 times higher (p<0.001). Results of the Kinexus study are more comparable to incidence figures of international studies on pressure ulcer incidence. The results of this secondary data analysis indicate that published incidence figures by the BQS (now AQUA Institute) might be underestimated. Since this measurement is expensive and burdensome, this mandatory procedure is questionable.

[Pressure ulcers in German nursing homes: frequencies, grades, and origins]. / Dekubitus in deutschen Pflegeheimen: Häufigkeiten, Grade und Entstehungsorte.

BACKGROUND: The occurrence of pressure ulcers in long-term care facilities is regarded as a nursing-sensitive indicator of care. The aim of this study was to measure the frequency, categories, and points of origin of pressure ulcers in German nursing homes. METHODS AND SAMPLE: In spring 2010, a nationwide prevalence study was conducted in 52 nursing homes (n=3610 residents). According to a standardized study protocol, trained nurses collected data about pressure ulcer risk and pressure ulcers. RESULTS: The prevalence of pressure ulcers was 3.9% (95% CI 3.3-4.6). Excluding skin redness, the proportion of pressure ulcers of nursing home origin was 1.2% (95% CI 0.9-1.6). Risk-adjusted (adjusted for immobility) results showed no statistically significant differences between institutions. CONCLUSION: Compared to international figures, the prevalence of pressure ulcers in German nursing homes is very low.

[Funnel plots for comparing pressure ulcer and fall rates in 76 nursing homes]. / Funnel-Plots zum Vergleich von Dekubitus- und Sturzkennzahlen in 76 Pflegeheimen.

AIM OF THE STUDY: The aim of this study was to display the values of the quality indicators "falls in the institution" and "institutionally acquired pressure ulcers" of 76 German nursing homes in bar graphs and funnel plots and to discuss the advantages and disadvantages of both methods. METHODS: In 2009 a nationwide prevalence study has been conducted in 76 nursing homes (n= 5 521). Among others two trained data collectors assessed the fall and pressure ulcer risks, the presence of pressure ulcers and whether nursing home residents fell. Risk adjusted fall and pressure ulcer prevalence rates were calculated per institution and displayed in bar graphs and funnel plots. RESULTS: The proportions of residents with pressure ulcers grade 2, 3 or 4 varied between 0 and 11%. The average pressure ulcer prevalence was 2.5%. On average, 6% of residents at risk for falling fell during the last 2 weeks. The proportions of fallen residents varied between 0% and 100%. In bar graphs differences between institutions and rankings can be displayed. However, the precision of the point estimates is not taken into account. Furthermore, criteria for determining conspicuous institutions are arbitrary. In funnel plots values are plotted against their precision. Although there were differences between the investigated nursing homes, most of them could be explained by chance. CONCLUSION: Funnel plots should be used when comparing medical or nursing performance between health care institutions. They take the precision of estimates into account that is usually the size of the institution. Despite differences, there was no nursing home with a prevalence of institutionally acquired pressure ulcers that was significantly higher than those in all the other institutions. In 2 out of 75 nursing homes the proportions of fallers were higher than expected by chance. In terms of performance improvement the reasons for this should be further investigated. However, in spite of the advantages of funnel plots they do not provide guidance as to whether the measured results can be tolerated and are acceptable.

The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes.

OBJECTIVES: Pressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes. METHODS: A cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake. RESULTS: Two thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%-10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes. CONCLUSION: There is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU.

[Pressure ulcer prevalence in German nursing homes and hospitals: what role does the National Nursing Expert Standard Prevention of Pressure Ulcer play?]. / Dekubitusprävalenzen in deutschen Pflegeheimen und Kliniken--Welche Rolle spielt der Nationale Expertenstandard Dekubitusprophylaxe in der Pflege?

AIM OF THE STUDY: The aim of this study was to investigate the relationship between the use of the National Nursing Expert Standard Pressure Ulcer Prevention and the pressure ulcer prevalence in German nursing homes and hospitals. METHODS: Data were collected within two nationwide surveys conducted by the Department of Nursing Science of the Charité, Berlin, Germany. The surveys, designed as cross-sectional prevalence studies, serve as an investigation of the amount of clinically relevant nursing phenomena, i. e., pressure ulcers. Prevalence per facility in the at-risk group was explored by a ranking procedure of the 95 nursing homes and hospitals. The facilities were divided into two groups according to whether they used the German Expert Standard to develop the local protocol or not. RESULTS: The pressure ulcer prevalence of the at-risk group ranged from 0% to 24.6% in nursing homes and from 7% to 40% in hospitals. In about 40% of the hospitals and nursing homes the local protocol of pressure ulcer prevention was based on the German Expert Standard. The ranking figure indicates that there is no statistically significant relation between Expert Standard-based local protocols and the pressure ulcer prevalence in the at-risk group. CONCLUSION: A clear advantage to use the German Expert Standard compared with other sources cannot be shown with these data. However, a uniform pressure ulcer prevention is an essential quality feature of nursing care. The degree of implementation and the consequent transfer of the recommendations to daily practice should be evaluated regularly.

[Fall prevention in people with dementia - do experiences from long-term-care offer new methods of resolution?]. / Sturzprävention bei Menschen mit Demenzerkrankungen - Bieten die Erfahrungen der Altenpflegepraxis neue Lösungsansätze?

Elderly persons suffering dementia are at increased risk for falls. Because of this, an investigation of the state of the science and the state of the art in fall prevention in patients suffering dementia has been made. A systematic literature review showed lack of documentation of effective interventions in preventing falls in persons with cognitive impairment. This was the reason for studying which measures nurses undertake in the field of long-term-care. Focus-group interviews with experienced geriatric nurses were undertaken. Nurses assume that there are specific risk factors in this patient group which have to be taken into account. Cognitive deficits are causing an increased fall risk in a specific manner. Geriatric nurses have ideas about how to adapt interventions for persons with dementia. They also assume that interventions primarily addressing cognitive disorders may also reduce the risk of falling. The interventions mentioned by the interviewed experts have not yet been examined concerning their effectiveness, therefore, fall prevention for people with dementia has to be further differentiated and systemized on a scientific basis.

Pressure ulcer risk factors in cardiac surgery: a review of the research literature.

BACKGROUND: Pressure ulcer incidence in patients undergoing cardiac surgery is reported to be up to 29.5%. Common known risk factors for pressure ulcer development include compressive and shearing forces. However, knowledge about the specific risk factors in a defined population is helpful in the development of an effective prevention management. This literature review is part of a quality improvement project to reduce pressure ulcer incidence in the cardiac surgery population. OBJECTIVES: The objective is to determine "which specific risk factors for pressure ulcer development in the cardiac surgery population are identified in the literature." RESULTS: The results of this literature review indicate a high-risk potential in the tissue tolerance for oxygen as temperature manipulation, vasoactive drugs, hypotensive periods, and reduced hemoglobin and hematocrit levels. Time on the operating room table, frequency of repositioning, immobility time, older age, low albumin level, and corticosteroid are also found as significant risk factors in this population. CONCLUSION: Diseases that influence oxygen supply in older patients in combination with the special demands of temperature and circulation regulation during the cardiac surgical procedure place the patient at risk for pressure ulcer development. Prevention measures should be aimed at supporting tissue tolerance for pressure and tissue tolerance for oxygen. These measures should be additional to pressure-relieving devices on the operating room table and, postoperatively in bed, a defined minimum frequency of postoperative turning and early mobilization after the surgical procedure should be considered.

The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial.

Nurses' attitudes towards patient aggression may influence their behaviour towards patients. Thus, their enhanced capacity to cope with aggressive patients may nurture more positive attitudes and alleviate adverse feelings emanating from patient aggression. This cluster randomised controlled trial conducted on six psychiatric wards tested the hypotheses that a 5 day training course in aggression management would positively influence the following outcome measures: Nurses' perception and tolerance towards patient aggression and resultant adverse feelings. A repeated measures design was employed to monitor change. No effect was found. The short time frame between the training course and the follow up measurement or non-responsiveness of the measurement instruments may explain this finding.

Staff attitudes towards aggression in health care: a review of the literature.

The aim of this literature review was to explore the attitudes of health care workers towards inpatient aggression and to analyse the extent to which attitudes, as defined from a theoretical point of view, were addressed in the selected studies. Databases from 1980 up to the present were searched, and a content analysis was done on the items of the selected studies. The concepts 'cognition' and 'attitude' from the framework of 'The Theory of Reasoned Action' served as categories. The self-report questionnaire was the most common instrument used and three instruments specifically designed to measure attitudes were found. These instruments lacked profound validity testing. From a total of 74 items, two thirds focussed on cognitions and only a quarter really addressed attitudes towards aggression. Research was particularly concerned with the cognitions that nurses had about aggression, and attitudes were studied only to a limited extent. Researchers used different instruments, which makes it difficult to compare results across settings.

The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study.

Systematic risk assessment and training courses have been suggested as interventions to deal with patient violence in psychiatric institutions. A dual centre prospective feasibility study was conducted on two Swiss psychiatric admission wards to test the hypothesis that such interventions will reduce the frequency and severity of violent events and coercion. A systematic aggression risk assessment, in combination with a standardized training course in aggression management was administered and the frequency and severity of aggressive incidents and the frequency of coercive measures were registered. The incidence rates of aggressive incidents and attacks showed no significant reduction from the baseline through risk prediction and staff training, but the drop in coercive measures was highly significant. A 'ward effect' was detected with one ward showing a decline in attacks with unchanged incidence rates of coercion and the other ward showing the opposite. The severity of the incidents remained unchanged whilst the subjective severity declined after the training course. We conclude that a systematic risk assessment and a training course may assist in reducing the incidence rate of coercive measures on psychiatric acute admission wards. Further testing of the interventions is necessary to measure the effect of the training alone and to counteract 'ward effects'.

Predicting inpatient violence in acute psychiatric wards using the Brøset-Violence-Checklist: a multicentre prospective cohort study.

The Norwegian Brøset-Violence-Checklist (BVC) is one of the few instruments that is suitable for short-term prediction of violence of psychiatric inpatients by nursing staff in routine care. The instrument assesses the presence or absence of six behaviours or states frequently observed before a violent incident. We conducted a study to elucidate whether the predictive properties of the BVC are retained in other psychiatric settings than the original north-Norwegian validation dataset. During their admission period, 219 consecutive patients admitted to six acute psychiatric wards were assessed as to the risk for attack using a German version of the BVC (BVC-G). Data on preventive measures were concurrently collected. Aggressive incidents were registered using an instrument equivalent to the Staff Observation of Aggression Scale (SOAS-R). Fourteen attacks towards staff were observed with incident severity ranging from 5 to 18 of a possible 22 points. BVC-G sensitivity was 64.3%, the specificity 93.9%, the positive predictive value 11.1%, and the area under the receiver operating characteristic curve 0.88. In some false positive cases intense preventive measures had been implemented. The predictive accuracy of the BVC-G proved consistent with the Norwegian original.

The perception of aggression by nurses: psychometric scale testing and derivation of a short instrument.

Patient aggression is a serious problem in psychiatric nursing. Nurses' attitudes towards aggression have been identified as mediating the choice of nursing interventions. To date, investigations are lacking which elucidate the stability of one of the few scales for measuring the attitude of aggression. This study aimed to investigate the test-retest stability of the Perception of Aggression Scale and to derive a shortened version. In order to test the reliability of the Perception of Aggression Scale items, three groups of psychiatric nurses were requested to fill in the Perception of Aggression Scale twice (30 student nurses after 4 days, 32 qualified nurses after 14 days and 36 qualified nurses after 70 days). We derived the shortened version from an independent data set obtained from 729 psychiatry nurses using principal component analysis, aiming to maximize parsimony and Cronbach's alpha. Amongst competing short versions, we selected those with the highest reliability at 70 or 14 day retest. A scale using 12 of the original 32 items was derived yielding alphas of r = 0.69 and r = 0.67 for the two POAS factors with retest reliabilities of r = 0.76 and r = 0.77. The shortened scale offers a practical and viable alternative to the longer version.

[Care dependency in nursing homes--a psychometric study]. / Pflegeabhängigkeit im Pflegeheim--eine psychometrische Studie.

The Dutch Care Dependency Scale, an instrument for the assessment of a patient's care dependency, has been translated into German. The purpose of this study was to examine the reliability and validity of the German version of the scale. The 15-item scale has been developed for the use in nursing homes. Data were collected from 81 people living in nursing homes in Berlin, Germany. The sample was measured three times. Cronbach's alpha was 0.94. Interrater and intrarater reliability revealed moderate to substantial Kappa statistics. As the results of this study were satisfying, positive recommendations regarding the suitability of the German version of the Care Dependency Scale for use in nursing homes could be made. However, further psychometric testing of the scale is recommended.

Patients' autonomy in surgical care: a comparison of nurses' perceptions in five European countries.

BACKGROUND: This report forms part of the results of an international comparative study funded by the European Commission (1998-2001). AIM: To describe and compare the maintenance of patients' autonomy on surgical wards, from the point of view of nursing staff, in five European countries (Finland, Spain, Greece, Germany and Scotland). Autonomy is defined in terms of information received and decision making by patients. METHOD: The data were collected using a questionnaire specifically designed for use in this study. Responses (response rate 66%) were obtained from 1280 nurses working on surgical wards. Data analysis was based on descriptive statistics, t-tests, analysis of variance (ANOVA) with posthoc Tukey's HSD test and logistic regression. RESULTS: There were clear between-country differences in nurses' perceptions, especially on a north-south axis (Finland and Scotland vs. Greece and Spain), regarding the extent to which the autonomy of surgical patients is supported by nursing staff. Training and ethics education, in particular, were associated with nurses' perceptions of the maintenance of patient autonomy in Finland and Greece. CONCLUSION: Further research is needed to establish whether the results obtained are caused by differences in cultures, nursing practices or roles of health-care personnel or patients in different European countries.

Autonomy, privacy and informed consent 4: surgical perspective.

This is the fourth article in a four-part series that considers the issues of patient autonomy, privacy and informed consent. The article discusses these issues in the context of surgical patients and their nurses. There is an abundance of references to issues of autonomy and informed consent within the healthcare literature, although there are few empirical studies investigating these issues within practice. The issue of privacy has been somewhat less explored than that of autonomy or consent, particularly in the UK literature. This article reports the findings of a Scottish study that formed part of a multisite comparative study funded by the European Commission. A convenience sample of surgical patients (n = 282) and their nurses (n = 260) participated in the study. Data were collected by means of a self-completion questionnaire for both patients and nursing staff. Results indicated that there are significant differences in patient and staff perceptions on issues of patient autonomy, privacy and informed consent. However, the most marked difference in perceptions of patients and staff were found on the information-giving element of the autonomy subscale. Implications for nursing practice, education and research are highlighted.