Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study.

BACKGROUND: comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce. OBJECTIVE: to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls. DESIGN: complementary mixed-methods pre-post study, based on an embedded quasi-experimental model. SETTING: geriatric fracture centre. METHODS: qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12 weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing. RESULTS: thirty community-dwelling patients aged ≥65 years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge. CONCLUSION: as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.

What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland.

PURPOSE: Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries. DESIGN/METHODOLOGY/APPROACH: This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries. FINDINGS: The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries. ORIGINALITY/VALUE: Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

Barriers for Adult Patients to Access Palliative Care in Hospitals: A Mixed Methods Systematic Review.

BACKGROUND: Access to palliative care services is variable, and many inpatients do not receive palliative care. An overview of potential barriers could facilitate the development of strategies to overcome factors that impede access for patients with palliative care needs. AIM: To review the current evidence on barriers that impair, delay, or prohibit access to palliative care for adult hospital inpatients. DESIGN: A mixed methods systematic review was conducted using an integrated convergent approach and thematic synthesis (PROSPERO ID: CRD42021279477). DATA SOURCES: The Cochrane Library, MEDLINE, CINAHL, and PsycINFO were searched from 10/2003 to 12/2020. Studies with evidence of barriers for inpatients to access existing palliative care services were eligible and reviewed. RESULTS: After an initial screening of 3,359 records and 555 full-texts, 79 studies were included. Thematic synthesis yielded 149 access-related phenomena in 6 main categories: 1) Sociodemographic characteristics, 2) Health-related characteristics, 3) Individual beliefs and attitudes, 4) Interindividual cooperation and support, 5) Availability and allocation of resources, and 6) Emotional and prognostic challenges. While evidence was inconclusive for most socio-demographic factors, the following barriers emerged: having a noncancer condition or a low symptom burden, the focus on cure in hospitals, nonacceptance of terminal prognosis, negative perceptions of palliative care, misleading communication and conflicting care preferences, lack of resources, poor coordination, insufficient expertise, and clinicians' emotional discomfort and difficult prognostication. CONCLUSION: Hospital inpatients face multiple barriers to accessing palliative care. Strategies to address these barriers need to take into account their multidimensionality and long-standing persistence.

Avatar and virtual agent-assisted telecare for patients in their homes: A scoping review.

INTRODUCTION: Telecare can be an effective way to deliver healthcare to patients' homes. Avatar or virtual agent-equipped technologies have the potential to increase user engagement and adherence to telecare. This study aimed to identify telecare interventions assisted by avatars/virtual agents, reflect the concepts of telecare and give an overview on its outcomes. METHODS: A scoping review guided by the PRISMA-ScR checklist was conducted. MEDLINE, CINAHL, PsycINFO and grey literature were searched through 12 July 2022. Studies were included if patients were remotely cared for by healthcare professionals and received telecare interventions assisted by avatars/virtual agents in their homes. Studies underwent quality appraisal, and were synthesized along the dimensions 'study characteristics', 'intervention' and 'outcomes'. RESULTS: Out of 535 records screened, 14 studies were included, reporting the effects of avatar/virtual agent-assisted telecare interventions, tailored to specific patient groups. Telecare interventions mainly focused on teletherapy and telemonitoring. Telecare services were rehabilitative, preventive, palliative, promotive and curative. Modes of communication were asynchronous, synchronous or a mix of both. Tasks of the implemented avatars/virtual agents comprised delivering health interventions, monitoring, assessment, guidance and strengthening agency. Telecare interventions led to improved clinical outcomes and higher adherence. Most studies reported sufficient system usability and high satisfaction among participants. CONCLUSIONS: Telecare interventions were overall target group related and integrated in a service model. This combined with the use of avatars and virtual agents leads to improved adherence to telecare in the home setting. Further studies could account for relatives' experiences with telecare.

Patient perspectives on, and effects of, medication management in geriatric fallers (the EMMA study): protocol for a mixed-methods pre-post study.

INTRODUCTION: Pharmacotherapy is critical in geriatric fallers owing to the vulnerability of this population. Comprehensive medication management can be an important strategy to reduce the medication-related risk of falling in this patient group. Patient-specific approaches and patient-related barriers to this intervention have rarely been explored among geriatric fallers. This study will focus on establishing a comprehensive medication management process to provide better insights into patients' individual perceptions regarding their fall-related medication as well as identifying organisational and medical-psychosocial effects and challenges of this intervention. METHODS AND ANALYSIS: The study design is a complementary mixed-methods pre-post study which follows the approach of an embedded experimental model. Thirty fallers aged at least 65 years who were on five or more self-managed long-term drugs will be recruited from a geriatric fracture centre. The intervention consists of a five-step (recording, reviewing, discussion, communication, documentation) comprehensive medication management, which focuses on reducing the medication-related risk of falling. The intervention is framed using guided semi-structured pre-post interventional interviews, including a follow-up period of 12 weeks. These interviews will assess patients' perceptions of falls, medication-related risks and gauge the postdischarge acceptability and sustainability of the intervention. Outcomes of the intervention will be measured based on changes in the weighted and summated Medication Appropriateness Index score, number of fall-risk-increasing drugs and potentially inadequate medication according to the Fit fOR The Aged and PRISCUS lists. Qualitative and quantitative findings will be integrated to develop a comprehensive understanding of decision-making needs, the perspective of geriatric fallers and the effects of comprehensive medication management. ETHICS AND DISSEMINATION: The study protocol was approved by the local ethics committee of Salzburg County, Austria (ID: 1059/2021). Written informed consent will be obtained from all patients. Study findings will be disseminated through peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBER: DRKS00026739.

Piloting of the virtual telecare technology 'Addison Care' to promote self-management in persons with chronic diseases in a community setting: protocol for a mixed-methods user experience, user engagement and usability pilot study.

INTRODUCTION: Chronic diseases in older adults are one of the major epidemiological challenges of current times and leading cause of disability, poor quality of life, high healthcare costs and death. Self-management of chronic diseases is essential to improve health behaviours and health outcomes. Technology-assisted interventions have shown to improve self-management of chronic diseases. Virtual avatars can be a key factor for the acceptance of these technologies. Addison Care is a home-based telecare solution equipped with a virtual avatar named Addison, connecting older persons with their caregivers via an easy-to-use technology. A central advantage is that Addison Care provides access to self-management support for an up-to-now highly under-represented population-older persons with chronic disease(s), which enables them to profit from e-health in everyday life. METHODS AND ANALYSIS: A pragmatic, non-randomised, one-arm pilot study applying an embedded mixed-methods approach will be conducted to examine user experience, usability and user engagement of the virtual avatar Addison. Participants will be at least 65 years and will be recruited between September 2022 and November 2022 from hospitals during the discharge process to home care. Standardised instruments, such as the User Experience Questionnaire, System Usability Scale, Instrumental Activities of Daily Living scale, Short-Form-8-Questionnaire, UCLA Loneliness Scale, Geriatric Depression Scale, Stendal Adherence with Medication Score and Self-Efficacy for Managing Chronic Diseases Scale, as well as survey-based assessments, semistructured interviews and think-aloud protocols, will be used. The study seeks to enrol 20 patients that meet the criteria. ETHICS AND DISSEMINATION: The study protocol has been approved by the ethic committee of the German Society for Nursing Science (21-037). The results are intended to be published in peer-reviewed journals and disseminated through conference papers. TRIAL REGISTRATION NUMBER: DRKS00025992.

Ethical decision-making confidence scale for nurse leaders: Psychometric evaluation.

BACKGROUND: Ethical decision-making confidence develops from clinical expertise and is a core competency for nurse leaders. No tool exists to measure confidence levels in nurse leaders based upon an ethical decision-making framework. AIMS: The objective of this research was to compare ethical decision-making among nurse leaders in the U.S. and three German-speaking countries in Europe by developing and testing a newly constructed Ethical Decision-Making Confidence (EDMC) scale. METHODS: The cross-sectional survey included 18 theory-derived questions on ethical decision-making confidence which were used to develop the scale. PARTICIPANTS: A convenience sample of nurse leaders from the U.S. and three German-speaking countries in Europe who self-identified as holding a leadership position. ETHICAL CONSIDERATIONS: Ethical approval was given by the IRB Board of a U.S. university. Participation in the survey implied voluntary consent. RESULTS: The scale's item structure dimensionality and subscale's reliability were analyzed and compared between nurse leaders from all four countries. A principal component analysis (PCA) produced a 15-item bi-dimensional EDMC scale yielding a skill-related (9-item) and a behavior-related (6-item) confidence dimension. EDMC subscales showed good-to-excellent internal consistency. In both subscales, U.S. nurse leaders rated their mean EDMC score higher than their German-speaking counterparts in Europe. DISCUSSION: This exploratory study is the first of its kind to focus on nurse leaders' confidence regarding ethical decision-making in an international context. An overarching factor structure was identified, which is shared by the two samples of nurse leaders and to examine (sub)scales' psychometric properties. CONCLUSION: This newly developed scale is an effective tool for measuring ethical decision-making confidence in nurse leaders. The promising results of this study should be replicated to ensure validity and reliability of the EDMC scale measuring skill-related and behavior-related concepts and include nurse leaders from various cultural, social, and demographic groups.

Hygiene management for long-term ventilated persons in the home health care setting: a scoping review.

BACKGROUND: Evidence and recommendations for hygiene management in home mechanical ventilation (HMV) are rare. In Germany, few regionally limited studies show poor hygiene management or a lack of its implementation. This scoping review of international literature identified the evidence in hygiene management for ventilated patients in the home care setting which has to be implemented for infection prevention and control. METHODS: A review of international literature was conducted in CINAHL, PubMed and Web of Science. The search focused on four key domains: HMV, hygiene management, home care setting, and methicillin-resistant Staphylococcus aureus (MRSA). Data of included studies were extracted using a data charting sheet. Extracted data were assigned to the categories (1) study description, (2) setting and participants, and (3) hygiene management. RESULTS: From 1,718 reviewed articles, n = 8 studies met inclusion criteria. All included studies had a quantitative study design. The approaches were heterogeneous due to different settings, study populations and types of ventilation performed. Regarding aspects of hygiene management, most evidence was found for infectious critical activities (n = 5), quality management for hygiene (n = 4), and training and education (n = 4). This review identified research gaps concerning kitchen hygiene, relatives and visitors of HMV patients, and waste management (n = 0). DISCUSSION: Overall evidence was rather scarce. Consequently, this review could not answer all underlying research questions. No evidence was found for measures in hygiene management relating to ventilated patients' relatives. Evidence for kitchen hygiene, waste management and interaction with relatives is available for inpatient care settings. However, this may not be transferable to outpatient care. Binding legal requirements and audits may help regulate the implementation of HMV hygiene measures. CONCLUSION: Infection control programmes included qualified personnel, hygiene plans, and standards for MRSA and multidrug-resistant organisms (MDRO). The appropriateness of hygiene management measures for outpatient care is the basis for their application in practice.

Interviewer effects in a survey examining pain intensity and pain interference in nursing home residents.

INTRODUCTION: Face-to-face surveys are applied frequently when conducting research in older populations. Interviewers play a decisive role in data quality, may affect measurement and influence results. This study uses survey data about pain in nursing home residents and analyses, whether affiliation-of-interviewer (internal vs. external to nursing home) and gender-of-interviewer affect residents' responses in terms of interviewer variance and systematically varying pain reports. METHODS: Overall, 258 nursing home residents with up to moderate cognitive impairment were examined by 61 interviewers about pain intensity and interference applying the Brief Pain Inventory. Interviewer variance was measured using intra-interviewer correlation coefficients (ρ). Two-factorial covariance analysis was applied to analyse whether pain intensity and interference scores differ by interviewer characteristics. RESULTS: Interviewer heterogeneity accounts for almost one quarter of total variance on average. Interviewer variance is higher for internal and male interviewers than for external and female interviewers. Covariance analyses show significant effects of interviewer characteristics on pain reports. Average pain intensity and interference scores vary considerably by interviewer gender and affiliation. Highest pain intensity was reported towards female internal and male external interviewers; highest pain interference was reported towards male external interviewers. CONCLUSION: Residents' answers substantially differ in relation to who is assessing pain. There is a risk of imprecise and biased survey estimates on sensitive topics like pain in nursing homes. Interviewer gender and affiliation seem to evoke gender-specific and status-related expectations and attributions which influence residents' response process. Interviewer effects pose a considerable threat to survey data quality in institutionalised older populations.

Safety climate in hospitals: A cross-sectional study on the perspectives of nurses and midwives.

AIMS: To explore nurses' and midwives' perspectives of safety climate in Austrian hospitals as measurable elements of safety culture and to identify areas of quality improvement. BACKGROUND: Due to close contact with patients, nurses and midwives play a vital role in ensuring patient safety. METHOD: An online survey among 713 nurses and midwives was conducted, using the 19-item Safety Climate Survey (SCS). To answer the survey, a 5-point Likert scale was provided with higher ratings indicating a more positive safety climate. RESULTS: Results demonstrate a positive safety culture (MD 4.09, SD 0.53). Significant group differences in overall safety climate score could be found regarding nurses and midwives in managerial positions, between gender and participants age with low effect size. High item missing rates focus aspects on management/leadership, institutional concerns, leadership by physicians, and handling of adverse events. In addition, these items present the lowest ratings in safety climate. CONCLUSION: Results indicate potentials for optimization in the areas of leadership communication and feedback, the handling of safety concerns, and visibility or improvement of patient safety strategies. IMPLICATIONS FOR NURSING MANAGEMENT: A regular, standardized safety climate measurement can be a valuable tool for nurse managers and (political) decision-makers to manage patient safety initiatives.

Psychometric Properties of the Safety Climate Survey in Austrian Acute Care: Factor Structure, Reliability, and Usability.

BACKGROUND: Hospitals are complex organizations with a potential for medical errors that can be influenced by safety culture. Safety climate, as measurable element of safety culture, illustrates the perception of safety-relevant aspects of health care staff at a certain time. The Safety Climate Survey is applied internationally to measure safety climate. However, psychometrics for the German version of the survey have yet not been evaluated. The aim of this study is to explore the factor structure, reliability, and potential usefulness of the Safety Climate Survey in Austrian acute care. METHODS: Cross-sectional surveys of physicians, therapists, and nurses/midwives were implemented. An exploratory factor analysis was carried out, both in total sample and split by 2 selected professions. After deriving a factor structure for both professions, internal consistency and scale means were calculated for the subscales. Finally, mean subscale differences between physicians and nurses/midwives were tested. RESULTS: Of 5160 eligible staff, 933 respondents participated. A 6-factor solution explaining 59.1% of total variance was identified. Comparison by profession illustrated that the factor structures and item loading patterns differ between physicians and nurses/midwives. To achieve an overarching solution, 5 items were excluded from consecutive subscale measures because of cross-loadings and contradictory factor loadings. Subscales demonstrated good to low internal consistency (α = 0.794-0.535). Significant mean differences between subscales of professions were found relating to 3 factors. CONCLUSIONS: The German Safety Climate Survey measures safety climate multidimensionally rather than unidimensionally and demonstrated some limitations in factor structures and item loadings but overall had satisfactory reliability of the 6 subscales.

A case report of COVID-19 monitoring in the Austrian professional football league.

Since the beginning of the COVID -19 pandemic, many contact sport teams are facing major challenges to safely continue training and competition. We present the design and implementation of a structured monitoring concept for the Austrian national football league. 146 professional players from five clubs of the professional Austrian football league were monitored for a period of 12 weeks. Subjective health parameters, PCR- test results and data obtained from a geo-tracking app were collected. Simulations modelling the consequences of a COVID-19 case with increasing reproduction number were computed. No COVID -19 infection occurred during the observation period in the players. Infections in the nearer surroundings lead to increased perceived risk of infection. Geo tracking was particularly hindered due to technical problems and reluctance of users. Simulation models suggested a hypothetical shut-down of all training and competition activities. A structured monitoring concept can help to continue contact sports safely in times of a pandemic. Cooperation of all involved is essential. Trial registration: ID: DRKS00022166 15/6/2020 https://www.who.int/ictrp/search/en/ .

Effects of age and cognitive function on data quality of standardized surveys in nursing home populations.

BACKGROUND: Data quality is of special concern when it comes to survey research in nursing homes. Very little is known about specifics of cognitively impaired elderly in responding to survey questions. This study examines effects of cognitive impairment, age, gender, and interview duration on the data quality in a sample of 659 nursing home residents (NHR). METHODS: Within a cross-sectional design, survey methodology was used to evaluate the pain situation in 13 nursing homes. Residents were stratified into NHR with no/mild (Mini-Mental State Examination MMSE: 18-30) and NHR with moderate (MMSE: 10-17) cognitive impairment. Data quality is measured by item nonresponse (INR). Correlation analyses, ANCOVA, linear and logistic regression models are applied. RESULTS: Neither interview duration nor gender have effects on item nonresponse. Age accounts for higher INR (ß = 0.12, p < 0.001). Cognitive impairment strongly predicts INR (ß = - 0.40, p < 0.001). INR significantly differs between NHR with no/mild (3.98%) and moderate cognitive impairment (11.85%). The likelihood of INR > 5% for residents with moderate cognitive impairment is 3.8-times (p < 0.001) of that for those with no/mild impairment. CONCLUSIONS: Surveys are adequate for residents with no/mild cognitive impairment but data quality is threatened in residents with moderate impairments. Precision and validity of responses from NHR with progressed cognitive impairment are potentially limited and results may be biased. The results clearly do support the need for a multidisciplinary 'general theory' of the question-/answer-process which has to be also inclusive for cognitively impaired elderly persons.

Does item overlap render measured relationships between pain and challenging behaviour trivial? Results from a multicentre cross-sectional study in 13 German nursing homes.

Several studies suggest that pain is a trigger for challenging behaviour in older adults with cognitive impairment. However, such measured relationships might be confounded due to item overlap as instruments share similar or identical items. The purpose of this study was to examine whether the frequently observed association between pain and challenging behaviour might be traced back to item overlap. This multicentre cross-sectional study was conducted in 13 nursing homes and examined pain (measure: Pain Assessment in Advanced Dementia Scale) and challenging behaviour (measure: Cohen-Mansfield Agitation Inventory) in 150 residents with severe cognitive impairment. The extent of item overlap was determined by juxtaposition of both measures' original items. As expected, comparison between these instruments revealed an extensive item overlap. The statistical relationship between the two phenomena can be traced back mainly to the contribution of the overlapping items, which renders the frequently stated relationship between pain and challenging behaviour trivial. The status quo of measuring such associations must be contested: constructs' discrimination and instruments' discrimination have to be discussed critically as item overlap may lead to biased conclusions and assumptions in research as well as to inadequate care measures in nursing practice.

A Prospective Multicentre Study to Improve Postoperative Pain: Identification of Potentialities and Problems.

Many studies still indicate insufficient pain management after surgery, e.g., in patients after small- or medium-size operations. Yet it is still uncertain if postoperative pain based on patient-related outcomes can be improved by implementing guideline-related programmes in a multicentre approach. Adult patients in six hospitals in one German city were included in this prospective study. Data collection took place twice in each hospital, once before and once after implementation of concepts and in-house training. Pain and pain-related aspects were assessed one day after surgery and compared between the pre- and post-test group including subgroup analysis of certain surgical procedures by using Student's t-tests, Mann-Whitney U tests and chi-square tests (alphatwo-tailed = 0.05). Overall, pain at rest and during movement was slightly lower after the intervention. Significant changes were observed after thoracic surgery, small joint surgery and other minor surgical procedures. The rather moderate decrease in pain likely relates to a reasonable pre-existing pain management and to detached improvements in certain patient subgroups. Interestingly, specific analyses revealed significantly lower post-test pain as compared to pre-test pain only in patients without pre-existing chronic pain. Side effects related to pain medication were significantly lower after intervention. Our data show, for the first time, benefits of a perioperative teaching programme in a multicentre approach. Pain ratings improved mainly in specific subgroups of patients, e.g., small surgical procedures and patients without preoperative pain. Thus, general improvement is possible but special attention should be paid to the group of patients with preoperative pain.

Adherence of pain assessment to the German national standard for pain management in 12 nursing homes.

BACKGROUND: Pain is very common among nursing home residents. The assessment of pain is a prerequisite for effective multiprofessional pain management. Within the framework of the German health services research project, 'Action Alliance Pain-Free City Muenster', the authors investigated pain assessment adherence according to the German national Expert Standard for Pain Management in Nursing, which is a general standard applicable to all chronic/acute pain-affected persons and highly recommended for practice. OBJECTIVES: To evaluate the state of pain assessment and to identify need for improvement in 12 nursing homes in a German city. METHODS: In the present study, the authors used an ex-post-facto design (survey methodology). Available written policies for routine pain assessment in residents ≥65 years of age were reviewed and a standardized online survey completed by 151 of 349 nurses in 12 nursing home facilities was conducted between September 2010 and April 2011. RESULTS: Most of the included nursing homes provided written policies for pain assessment, and the majority of nurses reported that they assess and regularly reassess pain. However, observational tools for residents with severe cognitive impairment and written reassessment schedules were lacking in many facilities or were inconsistent. CONCLUSIONS: Essentially, pain assessment appeared to be feasible in the majority of the German nursing homes studied. However, the absence or inconsistency of reassessment schedules indicate that pain management guidelines should include a detailed and explicit reassessment schedule for the heterogenic needs of nursing home residents. For residents with severe cognitive impairment, assessment tools are needed that are simple to use and clearly indicate the presence or absence of pain.