Exploring the Range of Lifestyle Interventions Used in Dutch Health Care Practice: A Qualitative Description.

BACKGROUND: The application of evidence-based lifestyle interventions is suboptimal, but little is known what interventions are actually used. This study aimed to explore the range of lifestyle interventions used in Dutch ambulatory health care settings. METHOD: We conducted interviews (n = 67) in purposefully selected hospitals, general practices, and community care organizations. Interviews focused on identifying activities to help patients stop smoking, reduce alcohol consumption, increase physical activity, eat a healthy diet, and lose weight. We also asked who developed the interventions. All reported activities were registered and analyzed. RESULTS: Four categories of health promotion activities emerged: giving advice, making referrals, offering counseling, and providing lifestyle interventions organized separately from the care process. In total, 102 lifestyle interventions were reported. Forty-five interventions were developed by researchers, of which 30 were developed by the Dutch Expert Center on Tobacco Control. Providers did not know the source of 31 interventions. Eighteen interventions were developed by the providers themselves, and eight were based on evidence-based guidelines. CONCLUSIONS: Health promotion activities seemed to be widely present in Dutch health care, in particular smoking cessation interventions. Although health care providers use many different interventions, replacing nontested for evidence-based interventions is required.

Goal setting and lifestyle changes in a nurse-led counselling programme for leg ulcer patients: an explorative analysis of nursing records.

AIMS AND OBJECTIVES: To describe goals set in individual nurse-led lifestyle counselling sessions in leg ulcer patients, and to explore patient and goal characteristics in relation to health behaviour change. BACKGROUND: Goal setting is increasingly used in nurse-led counselling programmes, but the delivery is often unknown, especially in patient groups for which only recently programmes have been developed, such as patients with venous leg ulcers. DESIGN: A secondary analysis of data collected in the intervention arm of a randomised clinical trial of counselling sessions in venous leg ulcer patients. METHODS: Nursing records (n = 71) were explored for the number of goals set, topic, quality and course of goals during the trajectory. Furthermore, goals and patient characteristics were compared in relation to health behaviour change. RESULTS: Forty-one patients (58%) succeeded in changing their behaviour after setting a goal. Setting goals for conducting leg exercises was chosen by most patients in this study, goals for adherence with compression therapy were chosen the least. Sixty-eight per cent of the goals met criteria for being Specific, Measurable and Time-bound. Patients who achieved behaviour change were significantly younger compared to the patients who did not. Except for age, there were no differences in characteristics between the group that did and did not achieve behaviour change. CONCLUSIONS: Goal setting could be improved by setting goals more Specific, Measurable and Time-bound, and by setting goals on an essential topic for behaviour change. This explorative study did not show that goal characteristics, including the quality of goals, were related to patients' behaviour change. RELEVANCE TO CLINICAL PRACTICE: The delivery of goal setting in this programme, and most likely in similar programmes, could be improved. Regular quality checks in daily goal setting practice should be considered. More research is needed into how to best provide health promotion to frail and elderly people.

First experiences with a two-step method for discussing goals with community-dwelling frail older people.

BACKGROUND: Although frail older people can be more reluctant to become involved in clinical decision making, they do want professionals to take their concerns and wishes into account. Discussing goals can help professionals to achieve this. OBJECTIVE: To describe the development of a two-step method for discussing goals with frail older people in primary care and professionals' first experiences with it. METHODS: The method consisted of (i) an open-ended question: If there is one thing we can do for you to improve your situation, what would you like? if necessary, followed by (ii) a bubble diagram with goal subject categories. We reviewed the goals elaborated with the method and surveyed professionals' (primary care nurses and social workers) experiences, using questions concerning time investment, reasons for not formulating goals, and perceived value of the method. RESULTS: One hundred and thirty-seven community-dwelling frail older people described 173 goals. These most frequently concerned mobility (n = 43; 24.9%), well-being (n = 52; 30.1%) and social context (n = 57; 32.9%). Professionals (n = 18) were generally positive about the method, as it improved their knowledge about what the frail older person valued. Not all frail older people formulated goals; reasons for this included being perfectly comfortable, not being used to discussing goals or cognitive problems limiting their ability to formulate goals. CONCLUSIONS: This two-step method for discussing goals can assist professionals in gaining insight into what a frail older person values. This can guide professionals and frail older people in choosing the most appropriate treatment option, thus increasing frail older people's involvement in decision making.

Evaluation of an eHealth intervention in chronic care for frail older people: why adherence is the first target.

BACKGROUND: Older people suffering from frailty often receive fragmented chronic care from multiple professionals. According to the literature, there is an urgent need for coordination of care. OBJECTIVE: The objective of this study was to investigate the effectiveness of an online health community (OHC) intervention for older people with frailty aimed at facilitating multidisciplinary communication. METHODS: The design was a controlled before-after study with 12 months follow-up in 11 family practices in the eastern part of the Netherlands. Participants consisted of frail older people living in the community requiring multidisciplinary (long-term) care. The intervention used was the health and welfare portal (ZWIP): an OHC for frail elderly patients, their informal caregivers and professionals. ZWIP contains a secure messaging system supplemented by a shared electronic health record. Primary outcomes were scores on the Instrumental Activities of Daily Living scale (IADL), mental health, and social activity limitations. RESULTS: There were 290 patients in the intervention group and 392 in the control group. Of these, 76/290 (26.2%) in the intervention group actively used ZWIP. After 12 months follow-up, we observed no significant improvement on primary patient outcomes. ADL improved in the intervention group with a standardized score of 0.21 (P=.27); IADL improved with 0.50 points, P=.64. CONCLUSIONS: Only a small percentage of frail elderly people in the study intensively used ZWIP, our newly developed and innovative eHealth tool. The use of this OHC did not significantly improve patient outcomes. This was most likely due to the limited use of the OHC, and a relatively short follow-up time. Increasing actual use of eHealth intervention seems a precondition for large-scale evaluation, and earlier adoption before frailty develops may improve later use and effectiveness of ZWIP.

Nurses' intention to leave their profession: a cross sectional observational study in 10 European countries.

BACKGROUND: As the European population ages, the demand for nursing care increases. Yet, a shortage of nurses at the labour market exists or is predicted for most European countries. There are no adequate solutions for this shortage yet, and recruitment of future nurses is difficult. Therefore, retaining nurses for the profession is urgent. OBJECTIVE: To determine factors associated with nurses' intention to leave the profession across European countries. DESIGN: A multi-country, multi-centre, cross-sectional analysis of survey data. SETTING: 2025 surgical and medical units from 385 hospitals in ten European countries that participated in the RN4Cast study. Hospital selection was based on a stratified randomised selection procedure. PARTICIPANTS: All nurses from the participating medical and surgical hospital wards received a survey. 23,159 nurses (64%) returned the survey. METHODS: The nurse survey included questions about intention to leave the profession, nurse characteristics, factors related to work environment, patient-to-nurse staffing ratio, burnout and perceived quality and safety of care. Multilevel regression analyses with 'intention to leave the profession' as dependent variable were conducted for all 10 countries combined as well as per country. RESULTS: Overall, 9% of the nurses intended to leave their profession. This varied from 5 to 17% between countries. Seven factors were associated with intention to leave the profession at European level: nurse-physician relationship (OR 0.86; 95%CI 0.79-0.93), leadership (OR 0.78; 95% CI 0.70-0.86), participation in hospital affairs (0.68; 95%CI 0.61-0.76), older age (OR 1.13; 95%CI 1.07-1.20), female gender (OR 0.67; 95%CI 0.55-0.80), working fulltime (OR 0.76; 95%CI 0.66-0.86) and burnout (OR 2.02; 95%CI 1.91-2.14). The relevance of these factors differed for the individual countries. Nurse perceived staffing adequacy, patient-to-nurse staffing ratio, perceived quality and safety of care and hospital size were not associated with intention to leave at a European level. CONCLUSION: Burnout is consistently associated with nurses' intention to leave their profession across the 10 European countries. Elements of work environment are associated with intention to leave the nursing profession but differ between countries, indicating the importance of national contexts in explaining and preventing nurses' intention to leave their profession.

Factors influencing the implementation of a lifestyle counseling program in patients with venous leg ulcers: a multiple case study.

BACKGROUND: Implementation of lifestyle interventions in patient care is a major challenge. Understanding factors that influence implementation is a first step in programs to enhance uptake of these interventions. A lifestyle-counseling intervention, Lively Legs, delivered by trained nurses, can effectively improve the lifestyle in patients with venous leg ulcers. The aim of this study was to identify factors that hindered or facilitated implementation of this intervention in outpatient dermatology clinics and in home care. METHODS: A mixed-methods multiple case study in five purposefully selected healthcare settings in the Netherlands was conducted. Measurements to identify influencing factors before and after implementation of Lively Legs included interviews, focus groups, questionnaires, and nurses' registration. Analyses focused on qualitative data as the main data source. All data were compared across multiple cases to draw conclusions from the study as a whole. RESULTS: A total of 53 patients enrolled in the Lively Legs program, which was delivered by 12 trained nurses. Barriers for implementation were mainly organizational. It was difficult to effectively organize reaching and recruiting patients for the program, especially in home care. Main barriers were a lack of a standardized healthcare delivery process, insufficient nursing time, and a lack of motivated nurses to deliver the program. Facilitating factors were nurse-driven coordination of care and a standardized care process to tie Lively Legs into, as this resulted in better patient recruitment and better program implementation. CONCLUSIONS: This study identified a range of factors influencing the implementation of a lifestyle-counseling program, mainly related to the organization of healthcare. Using a case study method proved valuable in obtaining insight into influencing factors for implementation. This study also shed light on a more general issue, which is that leg ulcer care is often fragmented, indicating that quality improvement is needed.

Implementation of an innovative web-based conference table for community-dwelling frail older people, their informal caregivers and professionals: a process evaluation.

BACKGROUND: Due to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved. METHODS: Mixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12). RESULTS: 290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people's exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP. CONCLUSIONS: This study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising.

Filling the Gaps in a Fragmented Health Care System: Development of the Health and Welfare Information Portal (ZWIP).

BACKGROUND: Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated. OBJECTIVE: To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR). METHODS: We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups. RESULTS: We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program. CONCLUSIONS: This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.

Physical activity and adherence to compression therapy in patients with venous leg ulcers.

OBJECTIVE: To assess levels of physical activity, particularly walking and leg exercises, among patients with venous leg ulcers and the extent to which patients adhere to compression therapy. DESIGN: Descriptive cross-sectional study. SETTING: Patients from 12 outpatient dermatology clinics were invited to participate in this study. When they agreed, they were asked to wear an accelerometer for a week and were then interviewed at the outpatient clinic. Patients A total of 150 patients with leg ulcers caused mainly by venous insufficiency. MAIN OUTCOME MEASURES: The amount of moderately strenuous physical activity, the amount of walking, and adherence to compression therapy. RESULTS: In this study, 39% of the patients interviewed displayed adherence to compression therapy. Self-reported data validated by the use of an accelerometer indicated that the amount of moderately strenuous activity in the study group was low compared with that of the general Dutch population; 35% of the patients did not have a 10-minute walk even once a week. CONCLUSIONS: Low levels of physical activity were established in a group of 150 patients with venous leg ulcers. Full adherence to compression therapy was reported in about 40% of the patients. Patients should be educated and encouraged to (1) enhance physical activity through walking and leg exercises and (2) increase adherence to compression therapy.

Ulcer-related problems and health care needs in patients with venous leg ulceration: a descriptive, cross-sectional study.

BACKGROUND: Patients with leg ulceration often have long lasting and recurrent wounds. The treatment exists mainly of wound-care and compression therapy. International literature shows several indications of problems in relation to leg ulceration, but no studies were performed to give a comprehensive overview of all problems identified and care received related to these problems. OBJECTIVES: The aim of the study was to describe leg ulcer-related problems in patients with leg ulcers based on venous insufficiency or a mixed aetiology. Furthermore, an inventory of current care and care deficits in the care for leg ulcer patients was made. METHODS: The study had a descriptive, cross-sectional design. A sample of 141 patients was taken from the population of outpatient clinics of seven hospitals in the Netherlands. Data were collected through patient interviews, questionnaires and wound-observations. Medical information was provided by the dermatologist or derived from the patients' medical file. RESULTS: The study identified a number of serious problems. Main problems were pain (85%), outdoor mobility (47%) and problems in finding appropriate footwear (60%). Statistical analysis showed no differences between patients with ulcers based on a venous aetiology and ulcers based on mixed aetiology. Fifty to seventy percent of the patients did not receive any care in relation to these problems. Only a rather small proportion of the patients, however, regarded the help as insufficient. CONCLUSION: Care at outpatient clinics is mainly focused on wound care and compression therapy. Pain treatment and care related to problems encountered by patients appears to be insufficient. This is not only affecting the patient's quality of life, but is likely to affect also the healing process and prevention of leg ulcers. Nurses and dermatologist should take their responsibilities in this matter.

Supporting adherence and healthy lifestyles in leg ulcer patients: systematic development of the Lively Legs program for dermatology outpatient clinics.

OBJECTIVES: The objective of our project was to develop a lifestyle program for leg ulcer patients at outpatient clinics for dermatology. METHODS: We used the intervention-mapping (IM) framework for systematically developing theory and evidence based health promotion programs. We started with a needs-assessment. A multidisciplinary project group of health care workers and patients was involved in all five IM steps; formulating proximal program objectives, selecting methods and strategies, producing program components, planning for adoption and implementation and planning for evaluation. Several systematic literature reviews and original studies were performed to support this process. RESULTS: Social Cognitive Theory was selected as the main theory behind the program 'Lively Legs' and was combined with elements of Goal-Setting Theory, the precaution adoption model and motivational interviewing. The program is conducted through health counseling by dermatology nurses and was successfully pre-tested. Also, an implementation and evaluation plan were made. CONCLUSION: Intervention mapping helped us to succeed in developing a lifestyle program with clear goals and methods, operational strategies and materials and clear procedures. PRACTICE IMPLICATIONS: Coaching leg ulcer patients towards adherence with compression therapy and healthy lifestyles should be taken on without delay. Systematic development of lifestyle programs for other patient groups should be encouraged.

Leg ulcers: a review of their impact on daily life.

BACKGROUND: Current nursing care for leg ulcer patients often focuses on wound care and providing compression therapy. Nurses perceive leg ulcer patients as 'under-served' with regard to problems patients experience in daily life. An overview of patient problems is a first and essential step in the development of comprehensive nursing care. AIMS AND OBJECTIVES: To gather information about the impact of leg ulcers on patient's daily life as described in quantitative and qualitative studies. DESIGN: Systematic literature review. METHODS: Medline and Cinahl databases were searched for venous leg ulcer studies, up to 2002; this was followed by the 'snowball method'. Studies were selected in accordance with preset criteria. RESULTS: A total of 37 studies was included. All studies report that leg ulcers pose a threat to physical functioning. Furthermore, a negative impact on psychological functioning is reported and, to a lesser degree, on social functioning. Major limitations are pain and immobility, followed by sleep disturbance, lack of energy, limitations in work and leisure activities, worries and frustrations and a lack of self-esteem. Patients have a significantly poorer quality of life compared with healthy people. Finally, patients report problems with regard to follow-up treatment. CONCLUSIONS: Having a leg ulcer has a major impact on a patient's life. There are indications of under-treatment of pain. RELEVANCE TO CLINICAL PRACTICE: Keeping in mind that leg ulceration is notorious for its chronic character, the negative impact on patient's life implies that many patients suffer over longer periods of time. This emphasizes the need to focus on quality of life aspects in patient care. There is much to gain, especially concerning pain and mobility. The development of comprehensive care programmes is essential.

Venous leg ulcer patients: a review of the literature on lifestyle and pain-related interventions.

BACKGROUND: Having a leg ulcer has a major impact on daily life. Lifestyle is mentioned in most leg ulcer guidelines but mostly without much emphasis on the subject. AIMS AND OBJECTIVES: Evidence for the effect of nutrition, leg elevation and exercise on the healing of leg ulcers was reconsidered. Furthermore, the evidence for effective pain-related interventions was investigated. DESIGN: Systematic literature review. METHODS: Medline, Cinahl, Psychinfo and Cochrane were searched for studies on pain related interventions, and the effectiveness of leg elevation, leg exercise and nutritional interventions in patients with venous leg ulceration. RESULTS: Some evidence was found to support a positive effect of leg exercises on the endurance and power of the calf muscle and on the haemodynamic status of the limb. There is also evidence for a positive effect of leg elevation during bed rest without compression. No hard evidence was found concerning the effect of enriched or altered nutrition on wound healing. However, there is some evidence of nutritional deficits in this patient group. The use of eutectic mixture of local anaesthetic cream is effective for reducing pain in wound debridement, but pain relief in daily life is insufficiently treated. CONCLUSION: There is no real evidence of effectiveness of the investigated lifestyle interventions but there are indications that lifestyle interventions might contribute to healing or prevention of venous leg ulceration. RELEVANCE TO CLINICAL PRACTICE: Although there is no hard evidence, it can be expected that interventions such as nutritional monitoring, guided exercise and leg elevation will have a substantial impact on wound healing in patients with venous leg ulceration. The use of eutectic mixture of local anaesthetic cream can be advised for pain relief with wound debridement. The current lack of effective pain treatment with venous leg ulceration emphasizes the need for effective pain treatment.