Quality in long term care facilities. An interventional trial using the Resident Assessment Instrument RAI 2,0

Hintergrund: Vor dem Hintergrund sich ändernder gesellschaftlicher Anforderungen, spätestens aber seit Inkrafttreten des Pflege-Qualitätssicherungsgesetzes interessiert die Anbieter und Kostenträger von Pflegeleistungen vermehrt, wie Pflegequalität erreicht und gemessen werden kann. Die bisherige Situation der Qualitätssicherung in der Praxis stellt sich aber insuffizient dar. Insbesondere werden Verfahren benötigt, die am unmittelbaren Prozess der Leistungserbringung ansetzen und die Mitarbei-ter/innen – als Hauptakteure der Pflege – in die Lage versetzen, professionelle Qualität zu erbringen, diese selbst zu überprüfen und so aktiv am Qualitätsprozess zu partizipieren. Zielstellung: In der vorliegenden Arbeit wurde untersucht, zu welchen Veränderungen ein strukturier-tes einheitliches und systematisches Dokumentationsverfahren führt. Lässt sich die Zustandsfeststel-lung – als Voraussetzung einer individuellen und zielgerichteten Pflege – verbessern, und wird die Pflegeplanung auf der Grundlage des Verfahrens systematischer und ursachenorientierter? Verfügen die Mitarbeiter/innen mit diesem Instrument über ein Handwerkszeug zur qualitätsorientierten Selbstkontrolle? Und können aus den im Pflegealltag erhobenen Informationen Hinweise für die gezielte Qualitätsverbesserung gewonnen werden? Methodisches Vorgehen: Gearbeitet wurde mit dem Resident Assessment Instrument RAI 2,0 (Morris et al.1991; deutsche Version: Garms-Homolová/Gilgen 2000). Das RAI ist ein Qualitätsin-strument, das auf einer strukturierten Beurteilung der Klient/innen mittels eines vollstandardisierten Datensatzes (MDS) basiert und durch ein schrittweises Vorgehen gekennzeichnet ist. Auf der Grundlage der Informationssammlung werden evidenzbasierte Alarmzeichen, die Probleme, Risiken und Ressourcen anzeigen, identifiziert. Diese werden mittels sog. Abklärungshilfen (Resident Assessment Protocols/RAPs) hinsichtlich ihrer Ursachen und in Bezug auf Interventionsmöglichkeiten untersucht, bevor die Aufnahme in den Pflegeplan erfolgt. Durchgeführt wurde eine Interventionsstudie in 4 Pflegeheimen mit 204 Zielpersonen. Gewählt wurde ein longitudenales Design; im Verlauf eines Jahres wurden zu drei Messzeitpunkten Assessments erhoben. Die Erfahrungen der Mitarbeiter/innen (25 Schulungsteilnehmer/innen, 37 Assessmentkoor-dinator/innen) wurden mittels teilstandardisiertem Fragebogen evaluiert. Ergebnisse: Die Befunde belegen, dass die Anwendung des RAI die Pflegequalität verbesserte: 1. Perspektive der Mitarbeiter/innen: Verbesserungen des Dokumentationsverhaltens wurden anhand der genaueren Kenntnis und Zustandsfeststellung der Klient/innen (u.a. Vollständigkeit der Dokumen-tation, Erlangen von Routine) gemessen. Für eine Verbesserung des Dokumentationsverhaltes spricht auch die Zunahme der Kommunikation zwischen den an der Pflege Beteiligten (u.a. mehr Mitwirken-de bei der Dokumentation). Die Verbesserung der Pflegeplanungspraxis wurde u.a. durch eine Zunahme der durchgeführten Abklärungshilfen (signifikante Verbesserungen in 4, tendenzielle Verbesserungen in 6 von insgesamt 18 planungsrelevanten Bereichen) und eine Zunahme der in die Planung aufgenommenen Probleme (signifikante Verbesserungen in 6, tendenzielle Verbesserungen in 4 der 18 Bereiche) angezeigt. Die tiefergehende Analyse der Bereiche Stürze und Dehydratation zeigte aber, dass die Verfahrensschritte des RAI von einem Teil der Mitarbeiter/innen nicht korrekt eingehal-ten wurden – speziell bei terminal Erkrankten wurde eine abweichende Planungspraxis beobachtet. 2. Perspektive der Bewohner/innen: Auf der Grundlage der erhobenen Daten konnten Hinweise zu Qualitätspotentiale in den Bereichen Stürze, Mobilität, Freiheitsbeschränkende Maßnahmen und Psychopharmaka gewonnen werden. Die Pflegekräfte erhalten Anhaltspunkte für die gezielte Qualitätsverbesserung und werden in die Lage versetzt, ihre Arbeit zu beurteilen. Voraussetzung für die Qualitätsmessung ist aber eine weitestgehend fehlerfreie Dokumentation, die in der vorliegenden Studie wahrscheinlich nicht immer erfolgte. Zusammenfassung: Die auch unter hiesigen Bedingungen nachgewiesenen positiven Effekte des RAI auf die Pflegequalität empfehlen es grundsätzlich als potentielles und vielversprechendes Verfahren. Die ausreichende Schulung der Mitarbeiter/innen und geeignete Rahmenbedingungen bei der Implementation erweisen sich aber als unabdingbar. Großflächige vertiefende Studien mit diesem Instrument wären auch vor dem Hintergrund der insuffizienten Forschungslage in Deutschland zur Pflegequalität im Heimbereich wünschenswert.Background: Against the background of changing social requests, but at the introduction of the "Act of quality assessment in care" Care Quality Control Law (PQsG) at the latest, the providers and cost units of care services are increasingly interested in how care quality can be achieved and measured. So far however, the quality control situation turns out to be inadequate. Particularly required are methods which tie in at the direct process of service provision and which enable members of staff - as the main providers of care – to provide professional quality, to control it by themselves and thereby actively take part in the quality process. Purpose: This thesis analysed which changes can be generated by a structured, standardised and systematic documentary practice. Is it possible to improve the determination of situations - as prerequisite for individual and purposeful care - and does care planning get more systematic and cause-oriented? Do members of staff possess with this instrument a tool for quality-oriented self-control? And finally, is it possible to extract clues for systematic quality improvement from information collected in daily care routine. Methods: For this study the 'Resident Assessment Instrument RAI 2,0' (Morris et al. 1991; German version: Garms-Homolová/Gilgen 2000) was used. The RAI is a quality instrument that is based upon a structured estimation of clients by using a fully standardised data set (MDS) and which is characterised by one-step operation. On the basis of this collection of information, evidence based alarm signals that indicate problems, risks and resources are identified. These are analysed with the use of so-called Resident Assessment Protocols/RAPs considering their causes and in relation to possibilities of intervention, before being put into the care plan. An intervention clinical trial was carried out in 4 nursing homes with 205 subjects. A longitudinal design was chosen; during one year assessments were taken at three measuring times. The experience of members of staff (25 training participants, 37 assessment coordinators) was evaluated using partially standardised questionnaires. Results: The results prove that the use of RAI improved the quality of care: 1. Members' of staff perspective: the improvements in documentation behaviour were measured on the basis of more exact knowledge and current state observation of the clients (among other things completeness of documentation, achieving routine). The increase of communication between all persons participating in care (among other things more people participating in the documentation) speaks in favour of the improvement of documentation behaviour. The improvement in care planning practice was, among other things, indicated by an increase in accomplished clarification aids (significant improvement in 4, trends indicating improvement in 6 out of a total of 18 fields that were relevant to planning) and an increase in the allowance made for problems in planning (significant improvement in 6, trends indicating improvement in 4 out of 18 fields). However, a more profound analysis in the areas of falls and dehydration indicated that the methodical steps of the RAI were not correctly followed by some of the members of staff - especially in the case of terminally ill people, a dissenting care planning practice could be observed. 2. Residents' perspective: on the basis of the collected data, indications for quality potentials in the areas of falls, mobility, constrictions in personal freedom and psychotropic drugs could be gained. Nurses get clues for specific quality improvement and are able to evaluate their work. However, a prerequisite for quality measuring is a documentation that is largely error-free, a condition that could not always be guaranteed in this study. Summary: The positive effects RAI has on the quality of care, proved under the described circumstances, recommend it as a promising method with potential. The sufficient training of staff members as well as adequate general conditions during the implementation prove to be indispensable. Extensive clinical trials using this instrument would be desirable, especially against the background of the insufficient research situation in Germany concerning quality of care in nursing homes

Perspective-taking with affected others to promote climate change mitigation

Prior evidence suggests that perspective-taking may promote pro-environmental behavior, at least for low-cost behaviors or local environmental problems. Climate change, however, requires costly mitigation efforts and is a global problem. Thus, in this study, we examine whether perspective-taking in the context of climate change is effective in promoting mitigation behaviors, including actual and/or costly behaviors, the mechanisms through which perspective-taking works, and if the distance to the person adversely affected by climate change matters for the effect. We conducted an online experiment with a non-student sample from Germany (n = 557), utilizing a 2 × 2 factorial design, to investigate the impact of perspective-taking and distance on three outcome measures: a climate donation, signing a petition, and approval of mitigation policies. We find that perspective-taking does not promote these mitigation behaviors, yet it raises the degree perspective-takers value and – for close others – feel connected with the affected person. Exploratory analysis shows that dispositional perspective-taking and empathic concern are correlated with mitigation behaviors

Distance to climate change consequences reduces willingness to engage in low-cost mitigation actions-Results from an experimental online study from Germany

Adverse consequences of climate change often affect people and places far away from those that have the greatest capacity for mitigation. Several correlational and some experimental studies suggest that the willingness to take mitigation actions may diminish with increasing distance. However, the empirical findings are ambiguous. In order to investigate if and how socio-spatial distance to climate change effects plays a role for the willingness to engage in mitigation actions, we conducted an online experiment with a German population sample (n = 383). We find that the willingness to sign a petition for climate protection was significantly reduced when a person in India with a name of Indian origin was affected by flooding, as compared to a person in Germany with a name of German origin. Distance did not affect donating money to climate protection or approving of mitigation policies. Our results provide evidence for the existence of a negative effect of distance to climate change consequences on the willingness to engage in low-cost mitigation actions. Investigating explanations for such an effect, we find that it can be attributed to the spatial rather than the social dimension of distance. Moreover, we find some cautious evidence that people with strong racist attitudes react differently to the distance manipulations, suggesting a form of environmental racism that could also reduce mitigation action in the case of climate change

Fostering collective action through participation in natural resource and environmental management: An integrative and interpretative narrative review using the IAD, NAS and SES frameworks

Solving humanity's social-environmental challenges calls for collective action by relevant actors. Hence, involving these actors in the policy process has been deemed both necessary and promising. But how and to what extent can participatory policy interventions (PIs) foster collective action for sustainable environmental and natural resource management? Lab and lab-in-the-field experiments on co-operation in the context of collective action challenges (i.e. social dilemmas) and case study research on participatory processes both offer insights into this question but have hitherto mainly remained unconnected. This article reviews insights from these two streams of literature in tandem, synthesising and analysing them using the institutional analysis and development (IAD) framework in combination with the network of action situations (NAS) framework and the social-ecological systems (SES) framework. We thus perform an integrative and interpretative narrative review to draw a richer and more nuanced picture of PIs: their potential impacts, their (institutional and behavioural) mechanisms and challenges, and caveats and recommendations for their design and implementation. Our review shows that PIs can indeed foster collective action by (a) helping the relevant actors craft suitable and legitimate institutional arrangements and (b) addressing and/or influencing actors' attributes of relevance to collective action, namely their individual and shared understandings, beliefs and preferences. To fulfil this potential, the organisers and sponsors of PIs must address and link to the broader context through soundly designed and implemented processes. Complementary follow-up, enforcement and conflict resolution mechanisms are necessary to nurture, reassure and sustain understandings, beliefs and preferences that undergird trust-building and collective action. The conceptual framework developed for the review can help researchers and practitioners further assess these insights, disentangle PIs' mechanisms and impacts, and integrate the research and practice of participatory governance and collective action

Phase II trial of preoperative radiochemotherapy with concurrent bevacizumab, capecitabine and oxaliplatin in patients with locally advanced rectal cancer

Background: Preoperative radiochemotherapy (RCT) with 5-FU or capecitabine is the standard of care for patients with locally advanced rectal cancer (LARC). Preoperative RCT achieves pathological complete response rates (pCR) of 10-15%. We conducted a single arm phase II study to investigate the feasibility and efficacy of addition of bevacizumab and oxaliplatin to preoperative standard RCT with capecitabine. Methods: Eligible patients had LARC (cT3-4; N0/1/2, M0/1) and were treated with preoperative RCT prior to planned surgery. Patients received conventionally fractionated radiotherapy (50.4 Gy in 1.8 Gy fractions) and simultaneous chemotherapy with capecitabine 825 mg/m2 bid (d1-14, d22-35) and oxaliplatin 50 mg/m2 (d1, d8, d22, d29). Bevacizumab 5 mg/kg was added on days 1, 15, and 29. The primary study objective was the pCR rate. Results: 70 patients with LARC (cT3-4; N0/1, M0/1), ECOG < 2, were enrolled at 6 sites from 07/2008 through 02/2010 (median age 61 years [range 39–89], 68% male). At initial diagnosis, 84% of patients had clinical stage T3, 62% of patients had nodal involvement and 83% of patients were M0. Mean tumor distance from anal verge was 5.92 cm (± 3.68). 58 patients received the complete RCT (full dose RT and full dose of all chemotherapy). During preoperative treatment, grade 3 or 4 toxicities were experienced by 6 and 2 patients, respectively: grade 4 diarrhea and nausea in one patient (1.4%), respectively, grade 3 diarrhea in 2 patients (3%), grade 3 obstipation, anal abscess, anaphylactic reaction, leucopenia and neutropenia in one patient (1.4%), respectively. In total, 30 patients (46%) developed postoperative complications of any grade including one gastrointestinal perforation in one patient (2%), wound-healing problems in 7 patients (11%) and bleedings in 2 patients (3%). pCR was observed in 12/69 (17.4%) patients. Pathological downstaging (ypT < cT and ypN ≤ cN) was achieved in 31 of 69 patients (44.9%). All of the 66 operated patients had a R0 resection. 47 patients (68.1%) underwent sphincter preserving surgery. Conclusions: The addition of bevacizumab and oxaliplatin to RCT with capecitabine was well tolerated and did not increase perioperative morbidity or mortality. However, the pCR rate was not improved in comparison to other trials that used capecitabine or capecitabine/oxaliplatin in preoperative radiochemotherapy

Phospholipases and Reactive Oxygen Species Derived Lipid Biomarkers in Healthy and Diseased Humans and Animals – A Focus on Lysophosphatidylcholine

Phospholipids (PL) are converted into lipid biomarkers by the action of phospholipases and reactive oxygen species (ROS), which are activated or released under certain physiological and pathophysiological conditions. Therefore, the in vivo concentration of such lipid biomarkers [e.g., lysophospholipids (LPLs)] is altered in humans and animals under different conditions such as inflammation, stress, medication, and nutrition. LPLs are particularly interesting because they are known to possess proand anti-inflammatory properties and may be generated by two different pathways: either by the influence of phospholipase A2 or by different reactive oxygen species that are generated in significant amounts under inflammatory conditions. Both lead to the cleavage of unsaturated acyl residues. This review provides a short summary of the mechanisms by which lipid biomarkers are generated under in vitro and in vivo conditions. The focus will be on lysophosphatidylcholine (LPC) because usually, this is the LPL species which occurs in the highest concentration and is, thus, easily detectable by chromatographic and spectroscopic methods. Finally, the effects of lipid biomarkers as signaling molecules and their roles in different human and animal pathologies such as infertility, cancer, atherosclerosis, and aging will be shortly discussed

The Level of Awareness on the Green ICT Concept and Self Directed Learning among Malaysian Facebook Users

AbstractThe Green information and communication technology is introduced to support the implementation of the green environment. Recent initiatives of promoting green technology and green economy which include “green manufacturing hub “green infrastructure”, low carbon emission, efficient use of resources and a healthy, well- educated populace. For this study, the independent variable is the self directed learning readiness while the dependent variable is the level of awareness on Green ICT. The sample size is seventy seven student adult learners. Random sampling is the sampling method used for this study. The study is to highlight the level of awareness among Malaysian Facebook users

Ultracold chemical reactions of a single Rydberg atom in a dense gas

Within a dense environment ($\rho \approx 10^{14}\,$atoms/cm$^3$) at ultracold temperatures ($T < 1\,\mu{}\text{K}$), a single atom excited to a Rydberg state acts as a reaction center for surrounding neutral atoms. At these temperatures almost all neutral atoms within the Rydberg orbit are bound to the Rydberg core and interact with the Rydberg atom. We have studied the reaction rate and products for $nS$ $^{87}$Rb Rydberg states and we mainly observe a state change of the Rydberg electron to a high orbital angular momentum $l$, with the released energy being converted into kinetic energy of the Rydberg atom. Unexpectedly, the measurements show a threshold behavior at $n\approx 100$ for the inelastic collision time leading to increased lifetimes of the Rydberg state independent of the densities investigated. Even at very high densities ($\rho\approx4.8\times 10^{14}\,\text{cm}^{-3}$), the lifetime of a Rydberg atom exceeds $10\,\mu\text{s}$ at $n > 140$ compared to $1\,\mu\text{s}$ at $n=90$. In addition, a second observed reaction mechanism, namely Rb$_2^+$ molecule formation, was studied. Both reaction products are equally probable for $n=40$ but the fraction of Rb$_2^+$ created drops to below 10$\,$% for $n\ge90$.Comment: 13 pages, 13 figure