Experiences of healthcare professionals, patients and families with video calls to stimulate patient- and family-centred care during hospitalization: A scoping review.

AIM: To synthesize the literature on the experiences of patients, families and healthcare professionals with video calls during hospital admission. Second, to investigate facilitators and barriers of implementation of video calls in hospital wards. DESIGN: Scoping review. METHODS: PubMed, CINAHL and Google Scholar were searched for relevant publications in the period between 2011 and 2023. Publications were selected if they focused on experiences of patients, families or healthcare professionals with video calls between patients and their families; or between families of hospitalized patients and healthcare professionals. Quantitative and qualitative data were summarized in data charting forms. RESULTS: Forty-three studies were included. Patients and families were satisfied with video calls as it facilitated daily communication. Family members felt more engaged and felt they could provide support to their loved ones during admission. Healthcare professionals experienced video calls as an effective way to communicate when in-person visits were not allowed. However, they felt that video calls were emotionally difficult as it was hard to provide support at distance and to use communication skills effectively. Assigning local champions and training of healthcare professionals were identified as facilitators for implementation. Technical issues and increased workload were mentioned as main barriers. CONCLUSION: Patients, families and healthcare professionals consider video calls as a good alternative when in-person visits are not allowed. Healthcare professionals experience more hesitation towards video calls during admission, as it increases perceived workload. In addition, they are uncertain whether video calls are as effective as in-person conservations. IMPLICATIONS FOR THE CLINICAL PRACTICE: When implementing video calls in hospital wards, policymakers and healthcare professionals should select strategies that address the positive aspects of family involvement at distance and the use of digital communication skills. PATIENT CONTRIBUTION: No patient or public contribution.

The combined application of hand hygiene and non-sterile gloves by nurses in a tertiary hospital: a multi methods study.

BACKGROUND: The application of hand hygiene (HH) and the use of non-sterile gloves (NSG) in daily care is highly intertwined. We aimed (1) to assess the combined application of HH and NSG among nurses and (2) to explore determinants that influence their ability to combine both measures in their care. METHODS: In a multi-methods study, we combined direct observations of care episodes with semi-structured interviews with nurses in two affiliated university hospitals. Topics were based on Flottorp's checklist of determinants of practice. RESULTS: In total, we observed 205 care episodes and interviewed 10 nurses. Observations revealed that the combination of NSG and HH was correctly applied in 19% of care episodes in which a single procedure was executed, and in 2% of care episodes in which multiple procedures were performed. From the interviews, we found determinants that influenced compliance, covered mainly by three out of seven of Flottorp's checklist domains. Nurses indicated that their knowledge of protocols was limited to HH and protocols were hardly ever actively consulted; visual reminders within their workplace were used as sources of information. Nurses' behavior was primarily influenced by their ability to operationalize this information and their ability to integrate both infection prevention measures into their care. The intention to apply and combine HH and NSG use was influenced by their risk assessment of cross-contamination, by the urge to self-protect and gut feeling. The feasibility to execute HH and NSG protocols is influenced by the urgency and the complexity of the care episode. CONCLUSIONS: The combined correct application with HH and NSG measures by nurses is low. Nurses are instructed in a fragmented way while in the day to day care HH and NSG use are highly intertwined. Operationalization and simplification of infection prevention protocols, in which instructions on both infection prevention measures are fused, should be considered. Strategies to improve practice should consider the power of habit and nurses urge to self-protect.

Feasibility and effectiveness of communication tools for addressing intimacy and sexuality in patients with cancer: a systematic review.

PURPOSE: Patients diagnosed with cancer might experience changes in intimacy and sexuality due to the illness itself, treatment, or psychological and social factors. Healthcare professionals (HCPs) often feel reluctant to discuss these changes. This study aimed to provide an overview of the feasibility and effectiveness of communication tools that support communication regarding changes in intimacy or sexuality among patients with cancer. METHODS: This is a systematic review. Databases are PubMed, Embase, CINAHL, PsycInfo, Web of Science and Cochrane Library from inception to June 2023. The Mixed Methods Appraisal Tool was used to assess included studies. Data were summarized in data charting forms. RESULTS: In total 35 studies were included, published between 2001 and 2023. Most had a quantitative design and moderate methodological quality. In 11 studies, the PLISSIT model (Permission, Limited Information, Specific Suggestions, Intensive Therapy) was used. Tools were integrated in counselling sessions or training programmes for individual patients, couples, groups of patients, or HCPs. All tools were considered feasible by patients or HCPs. Twenty studies reported significant improvement in sexual functioning, quality of life, quality of care or combined outcomes. CONCLUSION: Tools to support communication about changes in intimacy and sexuality among patients with cancer seem feasible and effective. The most commonly used tool, the PLISSIT model, proved to be feasible for HCPs and to have a positive effect on patients' and partners' sexual functioning and quality of life. Giving attention to changes in intimacy and sexuality seems to be important in itself, regardless of the communication tool or approach used.

Views of family members on using video calls during the hospital admission of a patient: A qualitative study.

BACKGROUND: Utilization of video calls on hospital wards to facilitate involvement of and communication with family members is still limited. A deeper understanding of the needs and expectations of family members regarding video calls on hospital wards is necessary, to identify potential barriers and facilitate video calls in practice. AIM: The aim of this study was to explore the views, expectations and needs of a patient's family members regarding the use of video calls between family members, patients and healthcare professionals, during the patient's hospital admission. METHODS: A qualitative study was carried out. Semi-structured interviews with family members of patients admitted to two hospitals were conducted between February and May 2022. Family members of patients admitted to the surgical, internal medicine and gynaecological wards were recruited. RESULTS: Twelve family members of patients participated. Family members stated that they perceive video calls as a supplemental option and prefer live visits during hospital admission. They expected video calls to initiate additional moments of contact with healthcare professionals, e.g. to join in medical rounds. When deploying video calls, family members mentioned that adequate instruction and technical support by nurses should be available. CONCLUSION: Family members considered video calls valuable when visiting is not possible or to participate in medical rounds or other contacts with healthcare professionals outside of visiting hours. IMPLICATIONS: Family members need to be supported in options and use of video calls on hospital wards. Additional knowledge about actual participation in care through video calls is needed as well as the effect on patient, family and healthcare professional outcomes. IMPACT: Using video calls on hospital wards can provide family members with flexible alternatives for contact and promote family involvement. REPORTING METHOD: COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: Family members of patients admitted to hospital have contributed by sharing their perspectives in interviews. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Family members perceive additional value from the use of video calls on hospital wards. For family, use of video calls needs to be facilitated with clear instruction materials and support. TRIAL AND PROTOCOL REGISTRATION: Amsterdam UMC Medical Ethics Review Committee (ref number W21_508 # 21.560).

How physicians see nurses' role in decision-making about life-prolonging treatments in patients with a short life expectancy: An interview study.

OBJECTIVE: Exploring physicians' views on hospital nurses' role in decision-making about potentially life-prolonging treatments in patients with a short life expectancy. METHODS: A qualitative study using semi-structured interviews with hospital physicians. Data were collected from May to September 2019 and analyzed following principles of thematic analysis. RESULTS: Fifteen physicians working in different hospitals and specialisms participated. Physicians stated that they are responsible for the final decision about potentially life-prolonging treatments. They considered nurses' role in decision-making to be complementary to the roles of both patients and the physicians themselves, especially when there are doubts or complex situations. Physicians varied in how important they found nurses' involvement in the decision-making process: some physicians saw the involvement of nurses as "situation-dependent", while others viewed nurses' involvement as standard practice. Furthermore, physicians mentioned practical obstacles to involving nurses, like the limited time available to both nurses and physicians themselves. CONCLUSION: Physicians recognize a complementary role for nurses in decision-making about potentially life-prolonging treatment, especially in cases with doubts or complex situations. PRACTICE IMPLICATIONS: Physicians and nurses should engage with each other to make nurses' involvement less situation-dependent. This inter-professional collaboration regarding decision-making about life-prolonging treatments should be stimulated, supported and maintained.

Evaluation of an infection control link nurse program: an analysis using the RE-AIM framework.

BACKGROUND: Important elements of programs that train and support infection control link nurses (ICLN) are the engagement of stakeholders, support from hospital and ward management and a structure for iterative improvement. The effects of programs, that combine all these elements, are unknown. We evaluated such a comprehensive program to explore its impact on link nurses and infection prevention practices and routines. METHODS: We used the RE-AIM framework, a robust, evidence-based framework within the field of Implementation Science, to evaluate the impact of our ICLN training and support program. We used a mixed methods approach and organized the outcomes along its five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance. RESULTS: Between 2014 and 2018, on average 91% of the inpatient wards and 58% of the outpatient clinics participated in the program (Reach) and impacted guideline adherence in inpatient wards. Link nurses felt engaged and empowered, and perceived their contribution to these results as pivotal. Ward managers confirmed the value of ICLN to help with implementing IPC practices (Effectiveness). The program was adopted both at the hospital and at the ward level (Adoption). Based on ongoing evaluations, the program was adapted by refining education, training and support strategies with emphasis on ward specific aspects (Implementation). The ICLN program was described as a key component of the infection prevention policy to sustain its effects (Maintenance). CONCLUSIONS: Our infection control link nurse program helped ICLN to improve infection prevention practices, especially in inpatient wards. The key to these improvements lay within the adaptability of our link nurse program. The adjustments to the program led to a shift of focus from hospital goals to goals tailored to the ward level. It allowed us to tailor activities to align them with the needs specific to each ward.

Nurses' Attitudes Regarding Family-Centered Care: Psychometric Properties and Survey Findings.

Background and Purpose: Measuring the attitude of nurses toward the importance of involving families in nursing care is essential to implement family-centered care. We aim to examine the reliability and factor structure of the Families' Importance in Nursing Care-Nurses' Attitudes questionnaire (FINC-NA-R). Methods: The psychometric properties of the FINC-NA-R were tested and the Dutch-revised version was used to assess the attitude of the nurses. Results: Principal component analysis confirmed a four-factor structure and the removal of four items achieved strong evidence of structural validity and internal consistency. Conclusions: The Dutch FINC-NA-R appeared to be a valid instrument to measure the attitude of nurses toward family-centered care.

Role perception of infection control link nurses; a multi-centre qualitative study.

Background: Infection control link nurses (ICLN) disseminate knowledge on infection prevention topics to their peers. Little is known about how they succeed and thereby contribute to infection prevention in daily practise. Aim: To explore the experiences of infection control link nurses regarding their role in acute care hospitals and identify perceived facilitators and best practices. Methods: We conducted a qualitative study with semi-structured individual and focus group interviews with ICLN. The effect of COVID-19 on the ICLN role was added as a topic in focus group interviews during the pandemic. Results: Twenty-six ICLN working in acute care hospitals were interviewed. ICLN perceived their role as to identify, monitor, facilitate and inform their colleagues on infection prevention topics related to their ward. Their experiences vary from feeling challenged and wonder how to get started, to feeling confident and taking initiatives that lead to ward-based improvements. When inspired by each other and supported by infection control practitioners or managers, ICLN feel empowered to initiate more activities to improve practice. During the COVID-19 pandemic, ICLN felt their responsibilities were magnified. When transferred to another ward, the focus on the ICLN role seemed dispersed. Discussion: Empowered ICLN adjust and operationalize infection prevention policies to fit the conditions of their specific wards and provide practical instructions and feedback to their peers which enable better compliance to infection prevention policies. Support and inspiration from other ICLN, infection control practitioners and management contribute to this empowerment and consequently to taking impactful initiatives to improve practice.

Nurses' perspective on their involvement in decision-making about life-prolonging treatments: A quantitative survey study.

AIMS: In hospital settings, decisions about potentially life-prolonging treatments are often made in a dialogue between a patient and their physician, with a focus on active treatment. Nurses can have a valuable contribution in this process, but it seems they are not always involved. Our aim was to explore how hospital nurses perceive their current role and preferred role in shared decision-making about potentially life-prolonging treatment in patients in the last phase of life. DESIGN: Cross-sectional quantitative study conducted in the Netherlands in April and May 2019. METHODS: An online survey, using a questionnaire consisting of 12 statements on nurses' opinion about supporting patients in decisions about potentially life-prolonging treatments, and 13 statements on nurses' actual involvement in these decisions. RESULTS: In total 179 hospital nurses from multiple institutions who care for adult patients in the last phase of life responded. Nurses agreed that they should have a role in shared decision-making about potentially life-prolonging treatments, indicating greatest agreement with 'It is my task to speak up for my patient' and 'It is important that my role in supporting patients is clear'. However, nurses also said that in practice they were often not involved in shared decision-making, with least involvement in 'active participation in communication about treatment decisions' and 'supporting a patient with the decision'. CONCLUSION: There is a discrepancy between nurses' preferred role in decision-making about potentially life-prolonging treatment and their actual role. More effort is needed to increase nurses' involvement. IMPACT: Nurses' contribution to decision-making is increasingly considered to be valuable by the nurses themselves, physicians and patients, though involvement is still not common. Future research should focus on strategies, such as training programs, that empower nurses to take an active role in decision-making.

Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: A qualitative interview study.

OBJECTIVE: To explore whether nurses in hospital settings experience moral distress when involved in potentially life-prolonging treatments in adults with a short life expectancy. METHODS: A qualitative study using semi-structured interviews. RESULTS: 23 Registered nurses working in inpatient or outpatient hospital settings participated. The nurses stated they were often not involved in decisions regarding life-prolonging treatments. They reported signs of moral distress such as feeling powerless when they when they were not being listened to in the decision-making process and when confronted with negative treatment outcomes. Nurses felt frustrated when their own values were not reflected in the decision-making or when physicians created unrealistic expectations. CONCLUSIONS: Hospital nurses experience moral distress when they are involved in life-prolonging treatment because of the patient's advanced condition and their own lack of involvement in the decision-making process about the treatment. In these situations, moral distress is characterised by feelings of powerlessness and frustration. PRACTICE IMPLICATIONS: Nurses need to be empowered by training programmes that focus on an active role in the decision-making process. Further research is needed to evaluate effective tools and training programmes that help nurses in shared decision-making processes.

Feasibility and effectiveness of tools that support communication and decision making in life-prolonging treatments for patients in hospital: a systematic review.

OBJECTIVE: Patients with advanced diseases and frail older adults often face decisions regarding life-prolonging treatment. Our aim was to provide an overview of the feasibility and effectiveness of tools that support communication between healthcare professionals and patients regarding decisions on life-prolonging treatments in hospital settings. DESIGN: Systematic review: We searched PubMed, CINAHL, PsycINFO, Embase, Cochrane Library and Google Scholar (2009-2019) to identify studies that reported feasibility or effectiveness of tools that support communication about life-prolonging treatments in adult patients with advanced diseases or frail older adults in hospital settings. The Mixed Methods Appraisal Tool was used for quality appraisal of the included studies. RESULTS: Seven studies were included, all involving patients with advanced cancer. The overall methodological quality of the included studies was moderate to high. Five studies described question prompt lists (QPLs), either as a stand-alone tool or as part of a multifaceted programme; two studies described decision aids (DAs). All QPLs and one DA were considered feasible by both patients with advanced cancer and healthcare professionals. Two studies reported on the effectiveness of QPL use, revealing a decrease in patient anxiety and an increase in cues for discussing end-of-life care with physicians. The effectiveness of one DA was reported; it led to more understanding of the treatment in patients. CONCLUSIONS: Use of QPLs or DAs, as a single intervention or part of a programme, may help in communicating about treatment options with patients, which is an important precondition for making informed decisions.

The role of hospital nurses in shared decision-making about life-prolonging treatment: A qualitative interview study.

AIMS: To examine hospital nurses' perception of their actual and potential contribution to shared decision-making about life-prolonging treatment and their perception of the pre-conditions for such a contribution. DESIGN: A qualitative interview study. METHODS: Semi-structured face-to-face interviews were conducted with 18 hospital nurses who were involved in care for patients with life-threatening illnesses. Data were collected from October 2018-January 2019. The interviews were recorded, transcribed verbatim and analysed using thematic analysis by two researchers. RESULTS: Nurses experienced varying degrees of influence on decision-making about life-prolonging treatment. Besides, we identified different points of contact in the treatment trajectory at which nurses could be involved in treatment decision-making. Nurses' descriptions of behaviours that potentially contribute to shared decision-making were classified into three roles as follows: checking the quality of a decision, complementing shared decision-making and facilitating shared decision-making. Pre-conditions for fulfilling the roles identified in this study were: (a) the transfer of information among nurses and between nurses and other healthcare professionals; (b) a culture where there is a positive attitude to nurses' involvement in decision-making; (c) a good relationship with physicians; (d) knowledge and skills; (e) sufficient time; and (f) a good relationship with patients. CONCLUSION: Nurses described behaviour that reflected a supporting role in shared decision-making about patients' life-prolonging treatment, although not all nurses experienced this involvement as such. Nurses can enhance the shared decision-making process by checking the decision quality and by complementing and facilitating shared decision-making. IMPACT: Nurses are increasingly considered instrumental in the shared decision-making process. To facilitate their contribution, future research should focus on the possible impact of nurses' involvement in treatment decision-making and on evidence-based training to raise awareness and offer guidance for nurses on how to adopt this role.

Nature of adverse events with opioids in hospitalised patients: a post-hoc analysis of three patient record review studies.

OBJECTIVE: Opioids are increasingly prescribed and frequently involved in adverse drug events (ADEs). The underlying nature of opioid-related ADEs (ORADEs) is however understudied. This hampers our understanding of risks related to opioid use during hospitalisation and when designing interventions. Therefore, we provided a description of the nature of ORADEs. DESIGN: A post-hoc analysis of data collected during three retrospective patient record review studies (in 2008, 2011/2012 and 2015/2016). SETTING: The three record review studies were conducted in 32 Dutch hospitals. PARTICIPANTS: A total of 10 917 patient records were assessed by trained nurses and physicians. OUTCOME MEASURES: Per identified ORADE, we described preventability, type of medication error, attributable factors and type of opioids involved. Moreover, the characteristics of preventable and non-preventable ORADEs were compared to identify risk factors. RESULTS: Out of 10 917 patient records, 357 ADEs were identified, of which 28 (8%) involved opioids. Eleven ORADEs were assessed as preventable. Of these, 10 were caused by dosing errors and 4 probably contributed to patients' death. Attributable factors identified were mainly on patient and organisational levels. Morphine and oxycodone were the most frequently involved opioids. The risk for ORADEs was higher in elderly patients. CONCLUSIONS: Only 8% of ADEs identified in our sample were related to opioids. Although the frequency is low, the risk of serious consequences is high. We recommend to use our findings to increase awareness among physicians and nurses. Future interventions should focus on safe dosing of opioids when prescribing and administering, especially in elderly patients.

Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.

BACKGROUND: Infection control link nurse programs show considerable variation. We report how Dutch link nurse programs are organized, how they progress, and how contextual factors may play a role in the execution of these programs. METHODS: This mixed-methods study combined a survey and semi-structured interviews with infection control practitioners, based on items of the Template for Intervention Description and Replication (TIDieR) checklist. RESULTS: The Netherlands has 74 hospitals; 72 infection control practitioners from 72 different hospitals participated in the survey. Four of these infection control practitioners participated in interviews. A link nurse program was present in 67% of the hospitals; responsibility for 76% of these programs lied solely with the infection prevention and control team. The core component of most programs (90%) was education. Programs that included education on infection prevention topics and training in implementation skills were perceived as more effective than programs without such education or programs where education included only infection prevention topics. The interviews illustrated that these programs were initiated by the infection prevention team with the intention to collaborate with other departments to improve practice. Content for these programs was created at the time of their implementation. Infection control practitioners varied in their ability to express program goals and to engage experts and key stakeholders. CONCLUSIONS: Infection control link nurse programs vary in content and in set up. Programs with a clear educational content are viewed as more successful by the infection control practitioners that implement these programs.

Infection control link nurses in acute care hospitals: a scoping review.

Background: Involving link nurses in infection prevention and control is a strategy to improve clinical practice that has been implemented in hospitals worldwide. However, little is known about the use, the range and benefits of this strategy. We aimed to identify key concepts of infection control link nurses (ICLN) and ICLN programs, to evaluate the effect of such programs, and to identify gaps in the evidence base. Methods: In a scoping review, we searched PubMed, CINAHL, Google and Google Scholar for manuscripts on ICLN in acute care hospitals. We included research- and opinion-based papers, abstracts, reports and guidelines. Results: We included 29 publications and identified three key concepts: the profile of ICLN, strategies to support ICLN, and the implementation of ICLN programs. The majority of included studies delineates the ICLN profile with accompanying roles, tasks and strategies to support ICLN, without a thorough evaluation of the implementation process or effects. Few studies report on the effect of ICLN programs in terms of patient outcomes or guideline adherence, with positive short term effects. Conclusion: This scoping review reveals a lack of robust evidence on the effectiveness of ICLN programs. Current best practice for an ICLN program includes a clear description of the ICLN profile, education on infection prevention topics as well as training in implementation skills, and support from the management at the ward and hospital level. Future research is needed to evaluate the effects of ICLN on clinical practice and to further develop ICLN programs for maximal impact.

Interruptions during intravenous medication administration: A multicentre observational study.

AIMS: The aim of this study was to determine the frequency and cause of interruptions during intravenous medication administration, which factors are associated with interruptions and to what extent interruptions influence protocol compliance. BACKGROUND: Hospital nurses are frequently interrupted during medication administration, which contributes to the occurrence of administration errors. Errors with intravenous medication are especially worrisome, given their immediate therapeutic effects. However, knowledge about the extent and type of interruptions during intravenous medication administration is limited. DESIGN: Multicentre observational study. METHODS: Data were collected during two national evaluation studies (2011 - 2012 & 2015 - 2016). Nurses were directly observed during intravenous medication administration. An interruption was defined as a situation where a break during the administration was needed or where a nurse was distracted but could process without a break. Interruptions were categorized according to source and cause. Multilevel logistic regression analyses were conducted to assess the associations between explanatory variables and interruptions or complete protocol compliance. RESULTS: In total, 2,526 intravenous medication administration processes were observed. During 291 (12%) observations, nurses were interrupted 321 times. Most interruptions were externally initiated by other nurses (19%) or patients (19%). Less interruptions occurred during the evening (odds ratio: 0.23 [95% confidence interval: 0.08-0.62]). Do-not-disturb vests were worn by 61 (2%) nurses. No significant association was found between being interrupted and complete protocol compliance. CONCLUSION: An interruption occurred in every eight observed intravenous medication administration, mainly caused by other nurses or patients. One needs to consider critically which strategies effectively improve safety during the high-risk nursing-task of intravenous medication administration.

Self-Management Support in Patients With Incurable Cancer: How Confident Are Nurses?

OBJECTIVES: To explore how nurses perceive their self-efficacy and performance in supporting self-management among patients with incurable cancer, and whether these perceptions differ between community and hospital nurses. SAMPLE & SETTING: 222 hospital nurses (n = 94) and community nurses (n = 128) working with adult patients with incurable cancer. METHODS & VARIABLES: An online survey included the Self-Efficacy and Performance Into Self-Management Support instrument. Possible differences in age, gender, work setting, and additional training in oncology between groups were explored. RESULTS: Nurses felt confident about their self-efficacy, particularly in assessing patients' knowledge and beliefs and in advising about their disease and health status. Nurses felt less confident in their performance, particularly in the use of technology (arranging follow-up care), but also in agreeing on collaborative goals and assisting patients in achieving these goals. Compared to hospital nurses, community nurses reported significantly higher scores on self-efficacy and performance. IMPLICATIONS FOR NURSING: More effort is needed to increase nurses' confidence in providing self-management support, with a focus on arranging follow-up care with the use of technology and on collaborating with patients in setting and achieving goals.

Nurse compliance with a protocol for safe injectable medication administration: comparison of two multicentre observational studies.

OBJECTIVES: Medication administration errors with injectable medication have a high risk of causing patient harm. To reduce this risk, all Dutch hospitals implemented a protocol for safe injectable medication administration. Nurse compliance with this protocol was evaluated as low as 19% in 2012. The aim of this second evaluation study was to determine whether nurse compliance had changed over a 4-year period, what factors were associated over time with protocol compliance and which strategies have been implemented by hospitals to increase protocol compliance. METHODS: In this prospective observational study, conducted between November 2015 and September 2016, nurses from 16 Dutch hospitals were directly observed during intravenous medication administration. Protocol compliance was complete if nine protocol proceedings were conducted correctly. Protocol compliance was compared with results from the first evaluation. Multilevel logistic regression analyses were used to assess the associations over time between explanatory variables and complete protocol compliance. Implemented strategies were classified according to the five components of the Systems Engineering Initiative for Patient Safety (SEIPS) model. RESULTS: A total of 372 intravenous medication administrations were observed. In comparison with 2012, more proceedings per administration were conducted (mean 7.6, 95% CI 7.5 to 7.7 vs mean 7.3, 95% CI 7.3 to 7.4). No significant change was seen in complete protocol compliance (22% in 2016); compliance with the proceedings 'hand hygiene' and 'check by a second nurse' remained low. In contrast to 2012, the majority of the variance was caused by differences between wards rather than between hospitals. Most implemented improvement strategies targeted the organisation component of the SEIPS model. CONCLUSIONS: Compliance with 'hand hygiene' and 'check by a second nurse' needs to be further improved in order to increase complete protocol compliance. To do so, interventions focused on nurses and individually tailored to each ward are needed.

Nurses' Experience of Maintaining Their Therapeutic Relationship With Outpatients With Bipolar Disorder and Their Caregivers During Different Stages of a Manic Episode: A Qualitative Study.

PURPOSE: Caregivers often consult community mental health (CMH) nurses when they recognize prodromes of mania in the outpatient. The purpose of this study was to determine nurses' experiences of their therapeutic relationship and nursing interventions to outpatients and caregivers during different stages of mania. DESIGN AND METHODS: A qualitative study was conducted. Nine nurses were interviewed. FINDINGS: CMH nurses experienced dual loyalty when facing conflicting interests. They strived to stay connected to patients and caregivers with an open and nonjudgmental attitude. In euthymic episodes, nurses anticipated by developing good relationships with both and by making relapse prevention plan. PRACTICE IMPLICATIONS: Early involvement of caregivers in the treatment is recommended.