Nurses' perception of feedback on quality measurements: Development and validation of a measure

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Development of the Nurses' Observation Scale for Cognitive Abilities (NOSCA)

Background. To assess a patient's cognitive functioning is an important issue because nurses tailor their nursing interventions to the patient's cognitive abilities. Although some observation scales exist concerning one or more cognitive domains, so far, no scale has been available which assesses cognitive functioning in a comprehensive way. Objectives. To develop an observation scale with an accepted level of content validity and which assesses elderly patients' cognitive functioning in a comprehensive way. Methods. Delphi technique, a multidisciplinary panel developed the scale by consensus through four Delphi rounds (>70% agreement). The International Classification of Functioning/ICF was used as theoretical framework. Results. After the first two Delphi rounds, the panel reached consensus about 8 cognitive domains and 17 sub domains. After two other rounds, 39 items were selected, divided over 8 domains and 17 sub domains. Discussion. The Nurses' Observation Scale Cognitive Abilities (NOSCA) was successfully designed. The content validity of the scale is high because the scale sufficiently represents the concept of cognitive functioning: the experts reached a consensus of 70% or higher on all domains and items included; and no domains or items were lacking. As a next step, the psychometric qualities of the NOSCA will have to be tested

Biomarkers associated with delirium in critically ill patients and their relation with long-term subjective cognitive dysfunction; indications for different pathways governing delirium in inflamed and noninflamed patients

Introduction: Delirium occurs frequently in critically ill patients and is associated with disease severity and infection. Although several pathways for delirium have been described, biomarkers associated with delirium in intensive care unit (ICU) patients is not well studied. We examined plasma biomarkers in delirious and nondelirious patients and the role of these biomarkers on long-term cognitive function.Methods: In an exploratory observational study, we included 100 ICU patients with or without delirium and with ("inflamed”) and without ("noninflamed”) infection/systemic inflammatory response syndrome (SIRS). Delirium was diagnosed by using the confusion-assessment method-ICU (CAM-ICU). Within 24 hours after the onset of delirium, blood was obtained for biomarker analysis. No differences in patient characteristics were found between deliriousand nondelirious patients. To determine associations between biomarkers and delirium, univariate and multivariatelogistic regression analyses were performed. Eighteen months after ICU discharge, a cognitive-failure questionnaire was distributed to the ICU survivors.Results: In total, 50 delirious and 50 nondelirious patients were included. We found that IL-8, MCP-1, procalcitonin (PCT), cortisol, and S100-b were significantly associated with delirium in inflamed patients (n = 46). In the noninflamed group of patients (n = 54), IL-8, IL-1ra, IL-10 ratio Ab1-42/40, and ratio AbN-42/40 were significantly associated with delirium. In multivariate regression analysis, IL-8 was independently associated (odds ratio, 9.0; 95% confidence interval (CI), 1.8 to 44.0) with delirium in inflamed patients and IL-10 (OR 2.6; 95% CI 1.1 to 5.9), and Ab1-42/40 (OR, 0.03; 95% CI, 0.002 to 0.50) with delirium in noninflamed patients. Furthermore, levels of several amyloid-b forms, but not human Tau or S100-b, were significantly correlated with self-reported cognitive impairment 18 months after ICU discharge, whereas inflammatory markers were not correlated to impaired longterm cognitive function.Conclusions: In inflamed patients, the proinflammatory cytokine IL-8 was associated with delirium, whereas in noninflamed patients, antiinflammatory cytokine IL-10 and Ab1-42/40 were associated with delirium. This suggests that the underlying mechanism governing the development of delirium in inflamed patients differs from that in noninflamed patients. Finally, elevated levels of amyloid-b correlated with long-term subjective cognitive-impairment delirium may represent the first sign of a (subclinical) dementia process. Future studies must confirm these results

Using the Nursing Interventions Classification to identify nursing interventions in free-text nursing documentation in adult psychiatric outpatient care setting

Aims and objectives: To identify and describe nursing interventions in patient documentation in adult psychiatric outpatient setting and to explore the potential for using the Nursing Interventions Classification in documentation in this setting. Background: Documentation is an important part of nurses' work, and in the psychiatric outpatient care setting, it can be time-consuming. Only very few research reports are available on nursing documentation in this care setting. Methods: A qualitative analysis of secondary data consisting of nursing documentation for 79 patients in four outpatient units (years 2016-2017). The data consisted of 1,150 free-text entries describing a contact or an attempted contact with 79 patients, their family members or supporting networks and 17 nursing care summaries. Deductive and inductive content analysis was used. SRQR guideline was used for reporting. Results: We identified 71 different nursing interventions, 64 of which are described in the Nursing Interventions Classification. Surveillance and Care Coordination were the most common interventions. The analysis revealed two perspectives which challenge the use of the classification: the problem of overlapping interventions and the difficulty of naming group-based interventions. Conclusion: There is an urgent need to improve patient documentation in the adult psychiatric outpatient care setting, and standardised nursing terminologies such as the Nursing Interventions Classification could be a solution to this. However, the problems of overlapping interventions and naming group-based interventions suggest that the classification needs to be further developed before it can fully support the systematic documentation of nursing interventions in the psychiatric outpatient care setting. Relevance to clinical practice: This study describes possibilities of using a systematic nursing language to describe the interventions nurses use in the adult psychiatric outpatient setting. It also describes problems in the current free text-based documentation.</div

Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review

INTRODUCTION:Nurses often recognize deterioration in patients through intuition rather than through routine measurement of vital signs. Adding the 'worry or concern' sign to the Rapid Response System provides opportunities for nurses to act upon their intuitive feelings. Identifying what triggers nurses to be worried or concerned might help to put intuition into words, and potentially empower nurses to act upon their intuitive feelings and obtain medical assistance in an early stage of deterioration. The aim of this systematic review is to identify the signs and symptoms that trigger nurses' worry or concern about a patient's condition.METHODS:We searched the databases PubMed, CINAHL, Psychinfo and Cochrane Library (Clinical Trials) using synonyms related to the three concepts: 'nurses', 'worry/concern' and 'deterioration'. We included studies concerning adult patients on general wards in acute care hospitals. The search was performed from the start of the databases until 14 February 2014.RESULTS:The search resulted in 4,006 records, and 18 studies (five quantitative, nine qualitative and four mixed-methods designs) were included in the review. A total of 37 signs and symptoms reflecting the nature of the criterion worry or concern emerged from the data and were summarized in 10 general indicators. The results showed that worry or concern can be present with or without change in vital signs.CONCLUSIONS:The signs and symptoms we found in the literature reflect the nature of nurses' worry or concern, and nurses may incorporate these signs in their assessment of the patient and their decision to call for assistance. The fact that it is present before changes in vital signs suggests potential for improving care in an early stage of deterioration

The design of the Dutch EASYcare study: a randomised controlled trial on the effectiveness of a problem-based community intervention model for frail elderly people [NCT00105378]

BACKGROUND: Because of their complex clinical presentations and needs frail elderly people require another approach than people who age without many complications. Several inpatient geriatric health services have proven effectiveness in frail persons. However, the wish to live independently and policies that promote independent living as an answer to population aging call for community intervention models for frail elderly people. Maybe models such as preventive home visits, comprehensive geriatric assessment, and intermediate care qualify, but their efficacy is controversial, especially in frail elderly persons living in the community. With the Dutch EASYcare Study Geriatric Intervention Programme (DGIP) we developed a model to study effectiveness of problem based community intervention models in frail elderly people. METHODS/DESIGN: DGIP is a community intervention model for frail elderly persons where the GP refers elderly patients with a problem in cognition, mood, behaviour, mobility, and nutrition. A geriatric specialist nurse applies a guideline-based intervention with a limited number of follow up visits. The intervention starts with the application of the EASYcare instrument for geriatric screening. The EASYcare instrument assesses (instrumental) activities of daily life, cognition, mood, and includes a goal setting item. During the intervention the nurse regularly consults the referring GP and a geriatrician. Effects on functional performance (Groningen Activity Restriction Scale), health related quality of life (MOS-20), and carer burden (Zarit Burden Interview) are studied in an observer blinded randomised controlled trial. 151 participants were randomised over two treatment arms – DGIP and regular care – using pseudo cluster randomisation. We are currently performing the follow up visits. These visits are planned three and six months after inclusion. Process measures and cost measures will be recorded. Intention to treat analyses will focus on post intervention differences between treatment groups. DISCUSSION: The design of a trial evaluating the effects of a community intervention model for frail elderly people was presented. The problem-based participant selection procedure satisfied; few patients that the GP referred did not meet our eligibility criteria. The use of standard terminology makes detailed insight into the contents of our intervention possible using terminology others can understand well

Sample Size Considerations for GEE Analyses of Three-Level Cluster Randomized Trials

Cluster randomized trials in health care may involve three instead of two levels, for instance, in trials where different interventions to improve quality of care are compared. In such trials, the intervention is implemented in health care units (“clusters”) and aims at changing the behavior of health care professionals working in this unit (“subjects”), while the effects are measured at the patient level (“evaluations”). Within the generalized estimating equations (GEE) approach, we derive a sample size formula that accounts for two levels of clustering: that of subjects within clusters and that of evaluations within subjects. The formula reveals that sample size is inflated, relative to a design with completely independent evaluations, by a multiplicative term that can be expressed as a product of two variance inflation factors, one that quantifies the impact of within-subject correlation of evaluations on the variance of subject-level means and the other that quantifies the impact of the correlation between subject level means on the variance of the cluster means. Power levels as predicted by the sample size formula agreed well with the simulated power for more than 10 clusters in total, when data was analyzed using bias-corrected estimating equations for the correlation parameters in combination with the model-based covariance estimator or the sandwich estimator with a finite sample correction

Using the Nursing Interventions Classification to identify nursing interventions in free-text nursing documentation in adult psychiatric outpatient care setting

Aims and objectives To identify and describe nursing interventions in patient documentation in adult psychiatric outpatient setting and to explore the potential for using the Nursing Interventions Classification in documentation in this setting. Background Documentation is an important part of nurses' work, and in the psychiatric outpatient care setting, it can be time-consuming. Only very few research reports are available on nursing documentation in this care setting. Methods A qualitative analysis of secondary data consisting of nursing documentation for 79 patients in four outpatient units (years 2016-2017). The data consisted of 1,150 free-text entries describing a contact or an attempted contact with 79 patients, their family members or supporting networks and 17 nursing care summaries. Deductive and inductive content analysis was used. SRQR guideline was used for reporting. Results We identified 71 different nursing interventions, 64 of which are described in the Nursing Interventions Classification. Surveillance and Care Coordination were the most common interventions. The analysis revealed two perspectives which challenge the use of the classification: the problem of overlapping interventions and the difficulty of naming group-based interventions. Conclusion There is an urgent need to improve patient documentation in the adult psychiatric outpatient care setting, and standardised nursing terminologies such as the Nursing Interventions Classification could be a solution to this. However, the problems of overlapping interventions and naming group-based interventions suggest that the classification needs to be further developed before it can fully support the systematic documentation of nursing interventions in the psychiatric outpatient care setting. Relevance to clinical practice This study describes possibilities of using a systematic nursing language to describe the interventions nurses use in the adult psychiatric outpatient setting. It also describes problems in the current free text-based documentation.Peer reviewe

The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: a cluster randomised trial

Background: patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy.Objectives: the aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses.Design: a cluster randomised trial was conducted between September 2006 and July 2008.Settings: ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward.Participants: all nurses from participating wards.Methods: a knowledge test measured nurses’ knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately.Results: after correction for baseline, the mean difference between the intervention and the control group on hospital nurses’ knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: ?0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10–0.81). For the other two topics there was no statistically significant effect. Nursing home nurses’ knowledge did neither improve (0 points, CI: ?0.35 to 0.35) overall, nor for the separate subjects.Conclusion: the educational intervention improved hospital nurses’ knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is neede

Prospective multicentre multifaceted before-after implementation study of ICU delirium guidelines: a process evaluation

Objective We aimed to explore: the exposure of healthcare workers to a delirium guidelines implementation programme; effects on guideline adherence at intensive care unit (ICU) level; impact on knowledge and barriers, and experiences with the implementation. Design A mixed-methods process evaluation of a prospective multicentre implementation study. Setting Six ICUs. Participants 4449 adult ICU patients and 500 ICU professionals approximately. Intervention A tailored implementation programme. Main outcome measure Adherence to delirium guidelines recommendations at ICU level before, during and after implementation; knowledge and perceived barriers; and experiences with the implementation. Results Five of six ICUs were exposed to all implementation strategies as planned. More than 85% followed the required e-learnings; 92% of the nurses attended the clinical classroom lessons; five ICUs used all available implementation strategies and perceived to have implemented all guideline recommendations (>90%). Adherence to predefined performance indicators (PIs) at ICU level was only above the preset target (>85%) for delirium screening. For all other PIs, the inter-ICU variability was between 34% and 72%. The implementation of delirium guidelines was feasible and successful in resolving the majority of barriers found before the implementation. The improvement was well sustained 6months after full guideline implementation. Knowledge about delirium was improved (from 61% to 65%). The implementation programme was experienced as very successful. Conclusions Multifaceted implementation can improve and sustain adherence to delirium guidelines, is feasible and can largely be performed as planned. However, variability in delirium guideline adherence at individual ICUs remains a challenge, indicating the need for more tailoring at centre level