Low-value home-based nursing care: A national survey study

AIMS

To explore potential areas of low-value home-based nursing care practices, their prevalence and related influencing factors of nurses and nursing assistants working in home-based nursing care.

DESIGN

A quantitative, cross-sectional design.

METHODS

An online survey with questions containing scaled frequencies on five-point Likert scales and open questions on possible related influencing factors of low-value nursing care. The data collection took place from February to April 2022. Descriptive statistics and linear regression were used to summarize and analyse the results.

RESULTS

A nationwide sample of 776 certified nursing assistants, registered nurses and nurse practitioners responded to the survey. The top five most delivered low-value care practices reported were: (1) 'washing the client with water and soap by default', (2) 'application of zinc cream, powders or pastes when treating intertrigo', (3) 'washing the client from head to toe daily', (4) 're-use of a urinary catheter bag after removal/disconnection' and (5) 'bladder irrigation to prevent clogging of urinary tract catheter'. The top five related influencing factors reported were: (1) 'a (general) practitioner advices/prescribes it', (2) 'written in the client's care plan', (3) 'client asks for it', (4) 'wanting to offer the client something' and (5) 'it is always done like this in the team'. Higher educational levels and an age above 40 years were associated with a lower provision of low-value care.

CONCLUSION

According to registered nurses and certified nursing assistants, a number of low-value nursing practices occurred frequently in home-based nursing care and they experienced multiple factors that influence the provision of low-value care such as (lack of) clinical autonomy and handling clients' requests, preferences and demands. The results can be used to serve as a starting point for a multifaceted de-implementation strategy.

REPORTING METHOD

STROBE checklist for cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nursing care is increasingly shifting towards the home environment. Not all nursing care that is provided is effective or efficient and this type of care can therefore be considered of low-value. Reducing low-value care and increasing appropriate care will free up time, improve quality of care, work satisfaction, patient safety and contribute to a more sustainable healthcare system.

What can nurses learn from patient's needs and wishes when developing an evidence-based quality improvement learning culture? A qualitative study

BACKGROUND

Patient participation is fundamental in nursing care and has yielded benefits for patient outcomes. However, despite their compassionate care approach, nurses do not always incorporate patients' needs and wish into evidence-based practice, quality improvement or learning activities. Therefore, a shift to continuous quality improvement based on evidence-based practice is necessary to enhance the quality of care. The patient's opinion is an essential part of this process. To establish a more sustainable learning culture for evidence-based quality improvement, it is crucial that nurses learn alongside their patients. However, to promote this, nurses require a deeper understanding of patients' care preferences.

OBJECTIVE

To explore patients' needs and wishes towards being involved in care processes that nurses can use in developing an evidence-based quality improvement learning culture.

METHODS

A qualitative study was conducted in two hospital departments and one community care team. In total, 18 patients were purposefully selected for individual semi-structured interviews with an average of 15 min. A framework analysis based on the fundamental of care framework was utilised to analyse the data deductively. In addition, inductive codes were added to patients' experiences beyond the framework. For reporting this study, the SRQR guideline was used.

RESULTS

Participants needed a compassionate nurse who established and sustained a trusting relationship. They wanted nurses to be present and actively involved during the care delivery. Shared decision-making improved when nurses offered fair, clear and tailored information. Mistrust or a disrupted nurse-patient relationship was found to be time-consuming and challenging to restore.

CONCLUSIONS

Results confirmed the importance of a durable nurse-patient relationship and showed the consequences of nurses' communication on shared decision-making. Insights into patients' care preferences are essential to stimulate the development of an evidence-based quality improvement learning culture within nursing teams and for successful implementation processes.

The Dutch version of the Oral Health Assessment Tool: Translation and inter-rater reliability among community nurses

OBJECTIVES

Translating the Oral Health Assessment Tool (OHAT) into Dutch and assessing the inter-rater reliability among community nurses.

METHODS

The original version of the OHAT was translated following the five stages of the 'Guidelines for the Process of Cross-Cultural Adaptation'. After a forward and backward translation, consensus on the pre-final version was obtained in an expert panel discussion. This version was pre-tested on its comprehensibility among 31 nurses and hereafter finalized. Then, inter-rater reliability of the OHAT-NL was determined by two trained nurses during oral assessments of 37 care-dependent community-dwelling older people. Intraclass correlation coefficient (ICC) and the Cohen's kappa statistic for individual items were estimated.

RESULTS

Feedback from nurses in the pre-test did lead to minor changes of the OHAT-NL. Inter-rater reliability was good (ICC 0.79; 95% CI 0.63-0.89) on the total score. Agreement on item level ranged from fair to very good, the kappa ranged from 0.36-0.89.

CONCLUSIONS

OHAT is now available in Dutch having good inter-rater reliability among trained community nurses. Future research can further validate the OHAT-NL and develop intervention according to total OHAT-NL scores.

Three Years of Continuous Vital Signs Monitoring on the General Surgical Ward: Is It Sustainable? A Qualitative Study

Continuous monitoring of vital signs using a wireless wearable device was implemented in 2018 at a surgical care unit of an academic hospital. This study aimed at gaining insight into nurses' and patients' perspectives regarding the use and innovation of a continuous vital signs monitoring system, three years after its introduction. This qualitative study was performed in a surgical, non-intensive care unit of an academic hospital in 2021. Key-user nurses (nurses with additional training and expertise with the device) and patients were selected for semi-structured interviews, and nurses from the ward were selected for a focus group interview using a topic list. Transcripts of the audio tapes were deductively analysed using four dimensions for adoptions of information and communication technologies (ICT) devices in healthcare. The device provided feelings of safety for nurses and patients. Nurses and patients had a few issues with the device, including the size and the battery life. Nurses gained knowledge and skills in using the system for measurement and interpretations. They perceived the system as a tool to improve the recognition of clinical decline. The use of the system could be further developed regarding the technical device's characteristics, nurses' interpretation of the data and the of type of alarms, the information needs of patients, and clarification of the definition and standardization of continuous monitoring. Three years after the introduction, wireless continuous vital signs monitoring is the new standard of care according to the end-users at the general surgical ward.

Low-value wound care: Are nurses and physicians choosing wisely? A mixed methods study

BACKGROUND

Choosing Wisely is an international movement that stimulates conversations about unnecessary care. The campaign created five recommendations including a statement that less wound care is sometimes better.

AIMS

The study aims to evaluate nurses' and physicians' adherence to the Choosing Wisely recommendations for acute wound care in the Netherlands and the barriers and facilitators to improve this.

DESIGN

This is a mixed methods study using a survey and interviews.

METHODS

The survey was completed by 171 nurses and 71 physicians from November 2017 to February 2018. A total of 17 nurses and 6 physicians were interviewed.

RESULTS

Awareness of the five recommendations ranged from 62% to 89% for nurses and 46% to 85% for physicians. However, up to 15% of the nurses and 28% of physicians were aware but did not adhere to the recommendations. Barriers to adhering were a lack of knowledge, the work environment and perceptions of patients' preferences. Repeated attention, cost-consciousness and an open culture facilitated the implementation.

CONCLUSION

Although most nurses and physicians were aware of the recommendations, not all adhered to them. Increasing awareness is not enough for successful implementation. A tailored approach that removes the barriers is necessary, such as increasing knowledge about wounds and changing the work environment.

Nurses' motivations to leave the nursing profession: A qualitative meta-aggregation

AIM

To systematically provide an overview of the qualitative evidence available on the motivations for nurses to leave the nursing profession.

DESIGN

A qualitative systematic review using the meta-aggregation design of the Joanna Briggs Institute.

DATA SOURCES

Qualitative studies in English, dating from 2010 until January 2023, were obtained from CINAHL, PsycINFO and PubMed.

REVIEW METHODS

Studies were selected using predetermined inclusion and exclusion criteria. Quality assessment was done using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The assessment of confidence in the review findings was done according to the ConQual approach.

RESULTS

Nine papers that investigated nurses' motivations to leave the profession were included. We developed four synthesized findings from 11 synthesized categories and 31 categories to reflect nurses' motivations to leave the profession, including (1) challenging work environment, (2) emotional distress, (3) disappointment about nursing reality, and (4) culture of hierarchy and discrimination.

CONCLUSION

This review provides an in-depth and meaningful understanding of motivations for nurses to leave the profession. Among others, poor working conditions, a lack of opportunities for career development, a lack of support from managers, work-related stress, a discrepancy between nursing education and practice and bullying behaviour were motivations to leave the profession, which calls for targeted action to retain nurses in the profession.

IMPACT

Findings of this study shine a light on reasons why nurses leave the profession, providing evidence to support nurse managers and policymakers to develop retention strategies to move out of current crisis into recovery of sustainable global healthcare.

PATIENT OR PUBLIC CONTRIBUTION

There was no direct patient or caregiver contribution to this study because this study originated from the process of a Master study. However, two of the authors are still involved in clinical nursing practice and provided the necessary link between research and practice.

Bedside nurses' perspective on the Fundamentals of Care framework and its application in clinical practice: A multi-site focus group interview study

BACKGROUND

A changing nursing workforce and an increase in demands for care together with more complex care, raise arguments that leading and guiding nursing practice is more challenging than ever. Therefore, nurses need to have a shared agenda and a common language to show the importance of nursing care and the consequences of not addressing this in an appropriate way. In response to this the Fundamentals of Care framework was developed to also contribute to the delivery of person-centred care in an integrated way. However, to gain acceptance and applicability we need to ensure the framework's relevance to clinical practice from bedside nurses' perspectives.

OBJECTIVE

To describe bedside nurses' perspectives on the Fundamentals of Care framework and how it can be applied in clinical practice.

DESIGN

A descriptive qualitative design informed by the Fundamentals of Care framework.

SETTING(S)

The study was undertaken at seven hospitals in Sweden, Denmark and the Netherlands during 2019.

PARTICIPANTS

A total sample of 53 registered nurses working at the bedside participated. Participants had a wide variety of clinical experience and represented a range of different nursing practice areas.

METHODS

Twelve focus group interviews were used to collect data and analysed with a deductive content analysis approach.

RESULTS

Bedside nurses perceived that the Fundamentals of Care framework was adequate, easy to understand and recognised as representative for the core of nursing care. The definition for fundamental care covered many aspects of nursing care, but was also perceived as too general and too idealistic in relation to the registered nurses' work. The participants recognised the elements within the framework, but appeared not to be using this to articulate their practice. Three main categories emerged for implications for clinical practice; guiding reflection on one's work; ensuring person-centred fundamental care and reinforcing nursing leadership.

CONCLUSIONS

The Fundamentals of Care framework is perceived by bedside nurses as a modern framework describing the core of nursing. The framework was recognised as having clinical relevance and provides bedside nurses with a common language to articulate the complexity of nursing practice. This knowledge is crucial for bedside nurses both in clinical practice and in leadership roles to be able to speak up for the need to integrate all dimensions of care to achieve person-centred fundamental care. Various activities for reflection, person-centred care and leadership to apply the framework in clinical practice were presented, together with minor suggestions for development of the framework.

TWEETABLE ABSTRACT

Bedside nurses recognise their clinical practice within the Fundamentals of Care framework, showing the core of modern nursing.

Nursing leadership to facilitate patient participation in fundamental care: An ethnographic qualitative study

AIMS

To explore and describe hospital nurses' perceptions of leadership behaviours in facilitating patient participation in fundamental care.

DESIGN

An ethnographic interview study.

METHODS

Individual semi-structured interviews with 12 nurses with a bachelor's or master's degree working at a university medical centre were conducted between February and April 2021. The interview data were analysed using thematic analysis.

RESULTS

Six themes were derived from the data: (1) nursing leadership; (2) patient participation; (3) using patients' preferences; (4) building relationships; (5) task-focused nursing; (6) need for role modelling.

CONCLUSION

Nurses indicated leadership behaviour to facilitate patient participation in fundamental care as inviting patients to participate and eliciting and supporting patients' preferences. Although nurses also regarded leadership as motivating colleagues to act and enhancing evidence-based practice, they appeared not to practise this themselves about patient participation. Role modelling was indicated as a need for improvement.

IMPACT

The findings established that not all leadership behaviours mentioned were used in practice about patient participation in fundamental care. Role modelling and the use of evidence-based practice are needed to increase patient participation. Further research will be necessary to develop and test leadership interventions to improve patient participation in fundamental care.

Factors influencing the delivery of nutritional care by nurses for hospitalised medical patients with malnutrition; a qualitative study

OBJECTIVES

To describe an insight into nursing nutritional care delivery in the hospital from the perspectives of observed nursing care and an exploration of multidisciplinary attitudes and experiences with patient participation in nutritional care.

BACKGROUND

The prevalence of malnutrition in hospitalised patients continues to be high. Nurses' essential role in the identification and treatment of malnutrition is an important aspect of the fundamentals of care. Nurses have a key role in providing optimal nutritional care in the hospital. A systematic nursing approach, combined with an active role for patients, is required to effectively counteract malnutrition.

DESIGN

A multicentre qualitative study using ethnographic observations and focus groups.

METHODS

Direct observation of nutritional care was conducted on two nursing wards; nurses and inpatients were observed; and data were thematically analysed based on the fundamentals of care framework. Subsequently, six focus groups were held on three nursing wards with nurses, dietitians and nutrition assistants (n = 34). Data were analysed using open, axial and selective coding. The COREQ guidelines were used for reporting the study.

RESULTS

During 54 days, representing 183 h, 39 nurses were observed in two medical wards. Three activities in nutritional care delivery were identified from observing nurses and patients: (1) screening and assessment/at-risk determination, (2) nutritional care plans and (3) monitoring and evaluating outcomes and transition-of-care planning. In addition, the focus groups identified barriers, facilitators, needs and expectations for optimal nursing nutritional care delivery.

CONCLUSIONS

This study provides an understanding of the difficulties in the delivery of nursing nutritional care. Patient participation in the nutritional care process is rare. Evidence-based strategies are required to improve the knowledge and skills of nurses and patients to participate in (mal)nutrition care.

RELEVANCE

The findings of this study are used for the development of a nursing nutrition intervention to optimise patient participation in (mal)nutrition care.

PATIENT OR PUBLIC CONTRIBUTION

During the study, patients were not involved with the observations of care and/or with the interviews; the researchers observed the nutritional care delivery at medical wards acting as passive participants. Nurses, nutrition assistants and dietitians were after the focus groups asked for feedback on the transcripts of the interviews.

Opportunities for Patient Participation in Perioperative Malnutrition Care: A Qualitative Study

Introduction

In the perioperative period of hospitalization, barriers to food intake are common due to special nutritional needs, compromised nutritional status, and metabolic stress. Good nutritional care call for an interdisciplinary approach. And patients themselves may also play an essential role in managing nutritional care.

Objective

This study aimed to explore how patients with malnutrition experience nutritional care, their perspectives on patient participation, and their own role in malnutrition care in the perioperative period of hospitalization.

Methods

A qualitative study was conducted using an interpretive phenomenological approach. To follow patients' experiences, in-depth longitudinal interviews were undertaken before, during, and after hospitalization. Interview transcripts were analyzed thematically using open, axial, and selective coding and interpreted in an iterative process.

Results

Fifty-six interviews were undertaken with 26 patients with malnutrition scheduled for surgery and during the perioperative period of hospitalization. Four themes were identified: (1) unawareness and stigmata about being malnourished, (2) feasibility of optimal nutritional care, (3) needs and expectations for self-management, and (4) barriers and facilitators of taking own responsibilities in nutritional care.

Conclusion

Awareness and responsiveness to patients' perspectives, motivation, and compliance are prerequisites for patient participation in malnutrition care. This requires good communication between healthcare professionals and patients in all phases of hospitalization.

Patient Education Regarding Fasting Recommendations to Shorten Fasting Times in Patients Undergoing Esophagogastroduodenoscopy: A Controlled Pilot Study

This study evaluated the applicability and efficacy of patient education regarding fasting recommendations to shorten fasting times in patients undergoing esophagogastroduodenoscopy (EGD). A prospective nonrandomized controlled pilot study was performed. The intervention group (IG) was educated by nurses to eat until 6 hours and drink until 2 hours before EGD. The control group (CG) received usual care. Outcomes were applicability as perceived by patients, adherence to fasting recommendations, gastric visibility, and patients' comfort. A total of 109 patients were included of whom 42 were IG patients (37%). Patients' perspectives on fasting, their experienced discomfort, professional support, and circadian rhythm influenced application of fasting recommendations. Adherence to length of fasting from foods improved with 3:14 hours ( p < .001) and from liquids with 5:22 hours ( p < .001) in the IG compared with the CG. Gastric visibility during EGD was better in the IG than in the CG. The IG patients experienced significant less thirst, hunger, headache, and anxiety. To successfully reduce fasting times, fasting education should include positive, individual instructions, which help patients apply the fasting recommendations within their biorhythm. Positive, concrete instructions by nurses shortened fasting times before EGD, which improved gastric visibility and reduced patient discomfort.

Effect, economic and process-evaluation of a generic function focused care program for long-term care; study protocol of a multicenter cluster-randomized trial

BACKGROUND

Nurses are in a key position to stimulate older people to maximize their functional activity and independence. However, nurses still often work in a task-oriented manner and tend to take over tasks unnecessarily. It is evident to support nurses to focus on the capabilities of older people and provide care assistance only when required. Function-Focused Care (FFC) is a holistic care-philosophy aiming to support nurses to deliver care in which functioning and independence of older people is optimized. Dutch and internationally developed FFC-based interventions often lack effectiveness in changing nurses' and client's behavior. Process-evaluations have yielded lessons and implications resulting in the development of an advanced generic FFC-program: the 'SELF-program'. The SELF-program aims to improve activity stimulation behavior of nurses in long-term care services, and with that optimize levels of self-reliance in activities of daily living (ADL) in geriatric clients. The innovative character of the SELF-program lies for example in the application of extended behavior change theory, its interactive nature, and tailoring its components to setting-specific elements and needs of its participants. This paper describes the outline, content and theoretical background of the SELF-program. Subsequently, this paper describes a protocol for the assessment of the program's effect, economic and process-evaluation in a two-arm (SELF-program vs care as usual) multicenter cluster-randomized trial (CRT).

METHOD

The proposed CRT has three objectives, including getting insight into the program's: (1) effectiveness regarding activity stimulation behavior of nurses and self-reliance in ADL of geriatric clients, and (2) cost-effectiveness from a societal perspective including assessments of quality of life and health-care use. Measurements will take place prior to program implementation (baseline), directly after (T1), and in long-term (T2). Parallel to the CRT, a process evaluation will be conducted to provide insight into the program's: (3) feasibility regarding implementation, mechanisms of impact and contextual factors.

DISCUSSION

The SELF-program was developed following the Medical Research Council framework, which addresses the systematic development, feasibility testing, evaluation and implementation of complex interventions. The program has been subjected to a feasibility study before and results of studies described in this protocol are expected to be available from end 2022 onwards.

TRIAL-REGISTRATION

The study is registered in the Dutch Trial Register ( NL9189 ), as of December 22 2020.

Developing an Evidence-Based Nursing Culture in Nursing Homes: An Action Research Study

Background: Nursing homes face challenges caused by increasing numbers of older adults with multimorbidity and the demand for quality of care. Developing an evidence-based nursing (EBN) culture is a promising strategy to face these challenges. Therefore, the aim of this study was to develop an EBN culture in nursing homes and gain insight into the influencing factors. Methods: An action research study was conducted with 12 nursing teams in 4 Dutch nursing homes, using the Practice Development approach to develop an EBN culture. The teams (mostly certified nurse assistants) were coached by internal facilitators (bachelor’s or master’s degree nurses) and external facilitators (nursing teachers). Data were gathered at baseline and after 15 months using questionnaires and individual and focus group interviews. Results: With varying degrees, most nursing teams implemented elements (related to values, attitudes, and behaviors) of an EBN culture with appropriate leadership, advocacy, and training. The team members became open to new insights and asked critical questions. During the project, participants learned how EBN could be incorporated into daily practice, for example, by keeping it small, discussing information from professional journals, and using creative methods such as quizzes. Influencing factors of an EBN culture were: (a) support of managers, (b) inspiring facilitators close to the team, and (c) stable teams with driving forces and student nurses. Conclusions: Integrating EBN into daily practice in creative and motivating ways contributes to the development of an EBN culture in nursing homes. To facilitate this, managers should support teams in the process and content of EBN, and internal facilitators should collaborate with driving forces on the teams.

Exploring infection prevention practices in home-based nursing care: A qualitative observational study

BACKGROUND

Home-based nursing care continues to expand, delivering care to increasingly older clients with multiple, chronic and complex conditions that require the use of additional and more numerous invasive medical devices. Therefore, the prevention of infections poses a challenge for nurses, professional caregivers and clients.

OBJECTIVE

This article explores infection prevention practices and related behavioural factors in both nurses and clients to identify barriers and facilitators of infection prevention practices in home-based nursing care.

DESIGN

A qualitative, exploratory design.

SETTING

Four healthcare organisations providing home-based nursing care in the Netherlands.

METHODS

Participant observations were used as the main source of data collection complemented with focus group discussions and semi-structured interviews.

PARTICIPANTS

Participant observations: 16 nurses, three professional caregivers and 80 clients. Semi-structured interviews: 11 clients. Focus group discussions: 15 nurses and four professional caregivers.

RESULTS

A total of 87 unique care delivery situations were observed for 55 h, complemented with three focus group discussions and 11 individual semi-structured client interviews. Infection prevention practices in home-based nursing care appeared to be challenged by 1. The specific context or environment in which the care occurred, which is more autonomous, less structured, less controlled and less predictable than other care settings; 2. Suboptimal and considerable variation in professional performance concerning the application of hand hygiene and the proper use of personal protective equipment such as face masks, barrier gowns and disposable gloves; 3. Extensive use in and outside the client's surroundings of communication devices that are irregularly cleaned and tend to interrupt nursing procedures; and 4. Inadequate organisational support in the implementation and evaluation of new information or policy changes and fragmentation, variation and conflicting information regarding professional guidelines and protocols.

CONCLUSIONS

From a first-hand observational viewpoint, this study showed that the daily practice of infection prevention in home-based nursing care appears to be suboptimal. Furthermore, this research revealed considerable variation in the work environment, the application of hand hygiene, the proper use of personal protective equipment, the handling of communication devices and organisational policies, procedures and support. Finally, the study identified a number of important barriers and facilitators of infection prevention practices in the work environment, professional and team performance, clients and organisations.

Hospital and home care nurses' experiences and perceptions regarding nutritional care for older adults to prevent and treat malnutrition: A cross-sectional study

AIMS AND OBJECTIVES

To gain insight into the experiences and perceptions of hospital and home care nurses regarding nutritional care for older adults to prevent and treat malnutrition.

BACKGROUND

In-depth knowledge about hospital and home care nurses' experiences and perceptions can contribute to optimise nutritional care for older adults across the care continuum between hospital and home to prevent and treat malnutrition.

DESIGN

Multicentre cross-sectional descriptive study.

METHOD

A validated questionnaire addressing malnutrition was used. A total of 1,135 questionnaires were sent to hospital and home care nurses. The STROBE statement was followed for reporting.

RESULTS

The response rate was 49% (n = 556). Of all the nurses, 37% perceived the prevalence of malnutrition among their care recipients between 10% and 25%. Almost 22% of the nurses neither agreed nor disagreed or disagreed with the statement that prevention of malnutrition is possible. More than 28% of the nurses reported that malnutrition is a small or no problem. Over 95% of the hospital nurses and 52.5% of the home care nurses stated they screened routinely for malnutrition. The nurses considered several interventions for treating malnutrition important. Over 81% of the nurses indicated they wanted to follow further training.

CONCLUSION

Most hospital and home care nurses perceived that nutritional care for older adults to prevent and treat malnutrition was important. A fair group of nurses, however, had the opposite perception.

RELEVANCE TO CLINICAL PRACTICE

Raising the awareness of all hospital and home care nurses about the importance of nutritional care for older adults is pivotal to increase the chance of successfully providing nursing nutritional care. Nurses should follow training for consolidation of nutritional care. Nurses are well-positioned to take a leadership role to improve continuity and quality of nutritional care across the care continuum between hospital and home.

Fasting habits over a 10-year period: An observational study on adherence to preoperative fasting and postoperative restoration of oral intake in 2 Dutch hospitals

BACKGROUND

Since 1999, international guidelines recommend fasting from solid foods up to 6 hours and clear liquids up to 2 hours before surgery. Early recovery after surgery programs recommend restoration of oral intake as soon as possible. This study determines adherence to these guidelines up to 20 years after its introduction.

METHODS

A 2-center observational study with a 10-year interval was performed in the Netherlands. In period 1 (2009), preoperative fasting time was observed as primary outcome. In period 2 (2019), preoperative fasting and postoperative restoration of oral intake were observed. Fasting times were collected using an interview-assisted questionnaire.

RESULTS

During both periods, 311 patients were included from vascular, trauma, orthopedic, urological, oncological, gastrointestinal, and ear-nose-throat and maxillary surgical units. Duration of preoperative fasting was prolonged in 290 (90.3%) patients for solid foods and in 208 (67.8%) patients for clear liquids. Median duration of preoperative fasting from solid foods and clear liquids was respectively 2.5 and 3 times the recommended 6 and 2 hours, with no improvements from one period to another. Postoperative food intake was resumed within 4 hours in 30.7% of the patients. Median duration of perioperative fasting was 23:46 hours (interquartile range 20:00-30:30 hours) for solid foods and 11:00 hours (interquartile range 7:53-16:00 hours) for clear liquids.

CONCLUSION

Old habits die hard. Despite 20 years of fasting guidelines, surgical patients are still exposed erroneously to prolonged fasting in 2 hospitals. Patients should be encouraged to eat and drink until 6 and 2 hours, respectively, before surgery and to restart eating after surgery.

Identifying patients with benign chronic intestinal failure on home parenteral nutrition in whom a psychological support intervention may improve quality of life

RATIONALE

Home parenteral nutrition (HPN) is the ultimate treatment for patients who suffering from chronic intestinal failure (CIF). We tested the feasibility and effects of Mindfulness Based Cognitive Therapy (MBCT) in patients on HPN. Because of the high dropout rate, however, we were next urged to develop and test a web-based coaching program (web-based MBCT). The aim of the present study was to compare the effects of MBCT with this web-based MBCT.

METHODS

A quasi-experimental pilot study was conducted in a tertiary referral center for CIF in the Netherlands to evaluate the feasibility of both a MBCT and the internet-based MBCT intervention. In 2016 we included 17 patients in the MBCT group. These patients followed MBCT training. End of 2016 an internet-based online MBCT program was constructed for which we invited 14 patients and their caregivers.

RESULTS

In the MBCT 5 out of 17 patients (29%) completed their therapy. Patients attributed positive effects to their acquired mindfulness skills and reported a better QoL. In the internet-based mindfulness therapy group 2 out of 14 patients (14%) fulfilled the training sessions. Also, six caregivers started the training in this latter group and one caregiver fulfilled the training.

CONCLUSION

The study suggests that both MBCT and the internet-based MBCT are no feasible strategies to decrease disease burden and improve QoL for CIF patients and their caregivers due to the intensity of these programs on one side and the experienced physical limitations on the other. The patients who fulfilled the program were positive and use MBCT in daily practice.

Quality of Care Perceived by Older Patients and Caregivers in Integrated Care Pathways With Interviewing Assistance From a Social Robot: Noninferiority Randomized Controlled Trial

Background

Society is facing a global shortage of 17 million health care workers, along with increasing health care demands from a growing number of older adults. Social robots are being considered as solutions to part of this problem.

Objective

Our objective is to evaluate the quality of care perceived by patients and caregivers for an integrated care pathway in an outpatient clinic using a social robot for patient-reported outcome measure (PROM) interviews versus the currently used professional interviews.

Methods

A multicenter, two-parallel-group, nonblinded, randomized controlled trial was used to test for noninferiority of the quality of care delivered through robot-assisted care. The randomization was performed using a computer-generated table. The setting consisted of two outpatient clinics, and the study took place from July to December 2019. Of 419 patients who visited the participating outpatient clinics, 110 older patients met the criteria for recruitment. Inclusion criteria were the ability to speak and read Dutch and being assisted by a participating health care professional. Exclusion criteria were serious hearing or vision problems, serious cognitive problems, and paranoia or similar psychiatric problems. The intervention consisted of a social robot conducting a 36-item PROM. As the main outcome measure, the customized Consumer Quality Index (CQI) was used, as reported by patients and caregivers for the outpatient pathway of care.

Results

In total, 75 intermediately frail older patients were included in the study, randomly assigned to the intervention and control groups, and processed: 36 female (48%) and 39 male (52%); mean age 77.4 years (SD 7.3), range 60-91 years. There was no significant difference in the total patient CQI scores between the patients included in the robot-assisted care pathway (mean 9.27, SD 0.65, n=37) and those in the control group (mean 9.00, SD 0.70, n=38): P=.08, 95% CI –0.04 to 0.58. There was no significant difference in the total CQI scores between caregivers in the intervention group (mean 9.21, SD 0.76, n=30) and those in the control group (mean 9.09, SD 0.60, n=35): P=.47, 95% CI –0.21 to 0.46. No harm or unintended effects occurred.

Conclusions

Geriatric patients and their informal caregivers valued robot-assisted and nonrobot-assisted care pathways equally.

Trial Registration

ClinicalTrials.gov NCT03857789; https://clinicaltrials.gov/ct2/show/NCT03857789

Using intervention mapping to develop an outpatient nursing nutritional intervention to improve nutritional status in undernourished patients planned for surgery

BACKGROUND

Undernutrition in surgical patients leads to a higher risk of postoperative complications like infections and delayed recovery of gastrointestinal functions, often resulting in a longer hospital stay and lower quality of life. Nurses at outpatient clinics can deliver nutritional care during outpatient preoperative evaluation of health status to ensure that patients are properly fed in preparation for hospital admission for surgery. However, nutritional nursing care was not determined in research yet. This paper describes the structural development of an Outpatient Nursing Nutritional Intervention (ONNI).

METHODS

A project group followed the steps of the Intervention Mapping. The needs assessment included assessment of delivery of nutritional care and nutritional care needs at two anaesthesia outpatient clinics of an academic and a teaching hospital. Also, outpatient clinic nurses and patients at risk for undernutrition were interviewed. Determinants resulted from these methods were matched with theories on behaviour change and nutritional support.

RESULTS

Both patients and nurses were unaware of the consequences of undernutrition, and nurses were also unaware of their roles with regard to nutritional support. The intervention goals were: 1) enabling surgical patients to improve or maintain their nutritional status before hospital admission for surgery, and 2) enabling nurses to deliver nutritional support. The ONNI was developed for outpatients at risk for or with undernutrition. A training was developed for nurses. The ONNI included the five following components: 1) identification of the causes of undernutrition; 2) provision of a nutritional care plan including general and individually tailored advice; 3) self-monitoring of nutrient intake; 4) counselling and encouragement; and 5) support during a telephone follow-up meeting. The intervention and training were tested. A multifaceted implementation strategy was used to deliver the intervention in daily practice.

CONCLUSIONS

Despite the unique position of the nurses at outpatient clinics, nurses were unaware of their role with regard to nutritional care. The ONNI was developed and implemented along with a training program for nurses. The test confirmed that the training can improve nurses' knowledge, skills, and sense of responsibility for nutritional support. The intervention may empower patients to actively improve their nutritional status.

Speaking Up for Fundamental Care: the ILC Aalborg Statement

OBJECTIVE

The International Learning Collaborative (ILC) is an organisation dedicated to understanding why fundamental care, the care required by all patients regardless of clinical condition, fails to be provided in healthcare systems globally. At its 11th annual meeting in 2019, nursing leaders from 11 countries, together with patient representatives, confirmed that patients' fundamental care needs are still being ignored and nurses are still afraid to 'speak up' when these care failures occur. While the ILC's efforts over the past decade have led to increased recognition of the importance of fundamental care, it is not enough. To generate practical, sustainable solutions, we need to substantially rethink fundamental care and its contribution to patient outcomes and experiences, staff well-being, safety and quality, and the economic viability of healthcare systems.

KEY ARGUMENTS

We present five propositions for radically transforming fundamental care delivery:Value: fundamental care must be foundational to all caring activities, systems and institutionsTalk: fundamental care must be explicitly articulated in all caring activities, systems and institutions.Do: fundamental care must be explicitly actioned and evaluated in all caring activities, systems and institutions.Own: fundamental care must be owned by each individual who delivers care, works in a system that is responsible for care or works in an institution whose mission is to deliver care.

RESEARCH

fundamental care must undergo systematic and high-quality investigations to generate the evidence needed to inform care practices and shape health systems and education curricula.

CONCLUSION

For radical transformation within health systems globally, we must move beyond nursing and ensure all members of the healthcare team-educators, students, consumers, clinicians, leaders, researchers, policy-makers and politicians-value, talk, do, own and research fundamental care. It is only through coordinated, collaborative effort that we will, and must, achieve real change.

A context analysis on how oral care is delivered in hospitalised patients: A mixed-methods study

AIMS AND OBJECTIVES

To analyse oral care delivery in one hospital through exploring experiences from both nurses' and patients' perspectives and examining patients' oral health.

BACKGROUND

Oral health problems are associated with undernutrition and other general health outcomes. Although oral care belongs to the essentials of nursing, it is often neglected. Improving oral health may require behaviour change of both nurses and patients. Defining tailored strategies need a clear view on the context.

DESIGN

A context analysis in one hospital using a convergent parallel mixed-methods design was reported following the EQUATOR guidelines using two checklists: COnsolidated criteria for REporting Qualitative research (qualitative research) and STROBE (observational research).

METHODS

Semi-structured interviews were conducted with 19 nurses and 11 patients. The topic list was based on the Integrated Change Model. Prospective oral examination was performed among 91 surgical patients using the Oral Health Assessment Tool (OHAT).

RESULTS

Nurses acknowledged that they did not prioritise oral care in daily practice. Furthermore, they lacked knowledge and skills to identify and provide care for oral problems. Nurses mentioned helpful resources to perform oral care, like standardised language and instruments. However, they had no access to or were unaware of them. Patients admitted that they did not prioritise oral care due to their sickness during hospitalisation, were unaware of the importance of oral care, but felt responsible for their oral care. The most prominent oral problems identified with the OHAT were unclean mouths (n = 75, 82%), unhealthy gum and tissues (n = 55, 60%) and dry mouth (n = 42, 46%).

CONCLUSIONS

This context analysis identified inadequate oral care due to lack of positive attitude and knowledge in both nurses and patients, skills for nurses, and resources.

RELEVANCE TO CLINICAL PRACTICE

The behavioural factors indicate strategies for development of a multicomponent intervention to improve oral care in this hospital, nutritional status and general health outcomes.

Exploring person-centred fundamental nursing care in hospital wards: A multi-site ethnography

Objective

To explore how nurses in hospitals enact person‐centred fundamental care delivery.

Background

Effective person‐centred care is at the heart of fundamental nursing care, but it is deemed to be challenging in acute health care as there is a strong biomedical focus and most nurses are not trained in person‐centred fundamental care delivery. We therefore need to know if and how nurses currently incorporate a person‐centred approach during fundamental care.

Design

Focused ethnography approach.

Methods

Observations of 30 nurses on three different wards in two Dutch hospitals during their morning shift. Data were collected through passive observations and analysed using framework analysis based on the fundamentals of care framework. The COREQ guideline was used for reporting.

Results

Some nurses successfully integrate physical, psychosocial and relational elements of care in patient interactions. However, most nurses were observed to be mainly focused on physical care and did not take the time at their patients’ bedside to care for their psychosocial and relational needs. Many had a task‐focused way of working and communicating, seldom incorporating patients’ needs and experiences or discussing care planning, and often disturbing each other.

Conclusions

This study demonstrates that although some nurses manage to do so, person‐centred fundamental care delivery remains a challenge in hospitals, as most nurses have a task‐focused approach and therefore do not manage to integrate the physical, relational and physical elements of care. For further improvement, attention needs to be paid to integrated fundamental care and clinical reasoning skills.

Relevance to clinical practice

Although most nurses have a compassionate approach, this study shows that nurses do not incorporate psychosocial care or encourage patient participation when helping patients with their physical fundamental care needs, even though there seems to be sufficient opportunity for them to do so.

Students' perspectives on basic nursing care education

AIMS AND OBJECTIVES

To explore the perspectives of nursing students on their education concerning basic nursing care, learned either during theoretical education or clinical placement, with a specific focus on nutrition and communication.

BACKGROUND

Basic care activities lie at the core of nursing, but are ill-informed by evidence and often poorly delivered. Nursing students' education on basic care might be lacking, and the question remains how they learn to deliver basic care in clinical practice.

DESIGN

Descriptive study, using an online questionnaire.

METHODS

Nursing students at the vocational and bachelor level of six nursing schools in the Netherlands were invited to complete an online questionnaire regarding their perception of basic nursing care education in general (both theoretical education and clinical placement) and specifically in relation to nutrition and communication.

RESULTS

Nursing students (n = 226 bachelor students, n = 30 vocational students) completed the questionnaire. Most students reported that they learned more about basic nursing care during clinical placement than during theoretical education. Vocational students also reported learning more about basic nursing care in both theoretical education and clinical practice than bachelor students. In terms of nutrition, low numbers of students from both education levels reported learning about nutrition protocols and guidelines during theoretical education. In terms of communication, vocational students indicated that they learned more about different aspects of communication during clinical practice than theoretical education and were also more likely to learn about communication (in both theoretical education and clinical practice) than were bachelor students.

CONCLUSION

Basic nursing care seems to be largely invisible in nursing education, especially at the bachelor level and during theoretical education.

RELEVANCE TO CLINICAL PRACTICE

Improved basic nursing care will enhance nurse-sensitive outcomes and patient satisfaction and will contribute to lower healthcare costs. This study shows that there is scope within current nurse education in the Netherlands to focus more systematically and explicitly on basic nursing care.

Outpatient preoperative oral nutritional support for undernourished surgical patients: A systematic review

AIMS AND OBJECTIVES

To evaluate the effects of preoperative nutritional support using a regular diet for undernourished surgical patients at the outpatient clinic.

BACKGROUND

Undernutrition (or malnutrition) in surgical patients has severe consequences, that is, more complications, longer hospital stay and decreased quality of life. While systematic reviews show the effects of oral nutritional supplements (ONS), enteral and parenteral nutrition in surgical patients, the effects of normal foods and regular diets remain unclear.

DESIGN

A systematic review.

METHODS

PubMed, CINAHL, Web of Science, PsycINFO, Cochrane Library and EMBASE were searched up to July 24, 2017. Studies on undernourished patients receiving nutritional support using regular or therapeutic diet, performed preoperatively at the outpatient clinic, were considered eligible. Risk of bias was assessed using the Cochrane Risk of Bias tool. Two reviewers independently performed study selection, quality assessment and data extraction.

RESULTS

Six studies with moderate risk of bias were included. Interventions were preoperatively performed in mainly oncological outpatients by dieticians and aimed to reach nutrient requirements. Interventions included consults for counselling and advice, follow-up meetings and encouragements, and ONS. Nutritional status, nutrient intake and quality of life improved in supported patients. Improvements were better in counselled patients compared to patients using supplements. Unsupported patients experienced worse outcomes.

CONCLUSION

Frequent consults with counselling and advice as nutritional support for undernourished patients before surgery result in improvements to nutritional status, intake and quality of life. This statement is supported by weak evidence due to few studies and inadequate methods.

RELEVANCE TO CLINICAL PRACTICE

Nutritional support should be provided to all undernourished surgical patients during preoperative course. Nurses are in key position to provide nutritional support during outpatient preoperative evaluations.

Tailoring of the Tell-us Card communication tool for nurses to increase patient participation using Intervention Mapping

AIMS AND OBJECTIVES

To describe the tailoring of the Tell-us Card intervention for enhanced patient participation to the Dutch hospital setting using Intervention Mapping as a systematic approach.

BACKGROUND

Even though patient participation is essential in any patient-to-nurse encounter, care plans often fail to take patients' preferences into account. The Tell-us Card intervention seems promising, but needs to be tailored and tested before implementation in a different setting or on large scale.

DESIGN

Description of the Intervention Mapping framework to systematically tailor the Tell-us Card intervention to the Dutch hospital setting.

METHODS

Intervention Mapping consists of: (i) identification of the problem through needs assessment and determination of fit, based on patients and nurses interviews and focus group interviews; (ii) developing a logic model of change and matrices, based on literature and interviews; (iii) selection of theory-based methods and practical applications; (iv) producing programme components and piloting; (v) planning for adoption, implementation and sustainability; and (vi) preparing for programme evaluation.

RESULTS

Knowledge, attitude, outcome expectations, self-efficacy and skills were identified as the main determinants influencing the use of the Tell-us Card. Linking identified determinants and performance objectives with behaviour change techniques from the literature resulted in a well-defined and tailored intervention and evaluation plan.

CONCLUSIONS

The Tell-us Card intervention was adapted to fit the Dutch hospital setting and prepared for evaluation. The Medical Research Council framework was followed, and the Intervention Mapping approach was used to prepare a pilot study to confirm feasibility and relevant outcomes.

RELEVANCE TO CLINICAL PRACTICE

This article shows how Intervention Mapping is applied within the Medical Research Council framework to adapt the Tell-us Card intervention, which could serve as a guide for the tailoring of similar interventions.

Effect of organisational factors on the variation in incidence of delirium in intensive care unit patients: A systematic review and meta-regression analysis

BACKGROUND

Delirium occurs frequently in intensive care unit (ICU) patients and is associated with numerous deleterious outcomes. There is a large variation in reported delirium occurrence rates, ranging from 4% to 89%. Apart from patient and treatment-related factors, organisational factors could influence delirium incidence, but this is currently unknown.

OBJECTIVE

To systematically review delirium incidence and determine whether or not organisational factors may contribute to the observed delirium incidence in adult ICU patients.

METHODS

Systematic review of prospective cohort studies reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Included articles were independently assessed by two researchers. Quality of the articles was determined using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Subsequently, apart from patient characteristics, a meta-regression analysis was performed on available organisational factors, including hospital type, screening method and screening frequency.

DATA SOURCES

PubMed, Embase, CINAHL, and Cochrane Library databases were searched from inception to 27 January 2017, without language limitation.

RESULTS

A total of 9357 articles were found, of which 19 articles met the inclusion criteria and were considered as true delirium incidence studies. The articles were of good methodological quality (median [interquartile range] 32/38 [30-35] points), published between 2005 and 2016, originated from 17 countries. A total of 9867 ICU patients were included. The incidence rate of delirium varied between 4% and 55%, with a mean ± standard deviation of 29 ± 14%. Data relating to three organisational factors were included in the studies, but they were not significantly associated with the reported delirium incidence: hospital type (p 0.48), assessment methods (p 0.41), and screening frequency (p 0.28).

CONCLUSIONS

The mean incidence of delirium in the ICU was 29%. The organisational factors found including methods of delirium assessment, screening frequency, and hospital type were not related to the reported ICU delirium incidence.

Problems Experienced by Patients Receiving Parenteral Nutrition at Home: Results of an Open Interview Study

BACKGROUND

Home parenteral nutrition (HPN) is offered to patients who are unable to absorb sufficient nourishment from normal oral food intake or tube feeding. Major causes include severe motility disorders and limited resorption surface in the small intestine. HPN is a lifesaving therapy but has severe consequences on daily life. The aim of this study was to make an inventory of the problems experienced by patients receiving HPN.

METHODS

Open interviews were held with 48 patients from the 2 major centers for HPN in the Netherlands, centered around the question: Which 3 HPN problems have the most severe impact on your daily life? Data were analyzed using content analysis.

RESULTS

The respondents mentioned 7 central problems: negative emotions, physical problems, social limitations, dependence on others, incapability, complications, and patient-care provider problems. In addition, practical problems were mentioned: sleeping problems, financial problems, and the "hospital atmosphere" at home. The latter issues formed less of a problem for the patients.

CONCLUSION

The main underlying elements in the lives of many HPN patients appeared to be loss, longing, and grief. In contrast, a smaller proportion of the patients expressed that they had clearly adapted to life with HPN. By means of the HPN, they were still alive and enjoying all the things they could still do.

Undernutrition screening survey in 564,063 patients: patients with a positive undernutrition screening score stay in hospital 1.4 d longer

BACKGROUND

Undernutrition is a common complication of disease and a major determinant of hospital stay outcome. Dutch hospitals are required to screen for undernutrition on the first day of admission.

OBJECTIVE

We sought to determine the prevalence of the screening score "undernourished" with the use of the Short Nutritional Assessment Questionnaire (SNAQ) or Malnutrition Universal Screening Tool (MUST) and its relation to length of hospital stay (LOS) in the general hospital population and per medical specialty.

DESIGN

We conducted an observational cross-sectional study at 2 university, 3 teaching, and 8 general hospitals. All adult inpatients aged ≥18 y with an LOS of at least 1 d were included. Between 2007 and 2014, the SNAQ/MUST score, admitting medical specialty, LOS, age, and sex of each patient were extracted from the digital hospital chart system. Linear regression analysis with ln(LOS) as an outcome measure and SNAQ ≥3 points/MUST ≥2 points, sex, and age as determinant variables was used to test the relation between SNAQ/MUST score and LOS.

RESULTS

In total, 564,063 patients were included (48% males and 52% females aged 62 ± 18 y). Of those, 74% (419,086) were screened with SNAQ and 26% (144,977) with MUST, and 13.7% (SNAQ) and 14.9% (MUST) of the patients were defined as being undernourished. Medical specialties with the highest percentage of the screening score of undernourished were geriatrics (38%), oncology (33%), gastroenterology (27%), and internal medicine (27%). Patients who had an undernourished screening score had a higher LOS than did patients who did not (median 6.8 compared with 4.0 d; P < 0.001). Regression analysis showed that a positive SNAQ/MUST score was significantly associated with LOS [SNAQ: +1.43 d (95% CI: 1.42, 1.44 d), P < 0.001; MUST: +1.47 d (95% CI: 1.45, 1.49 d), P < 0.001].

CONCLUSIONS

This study provides benchmark data on the prevalence of undernutrition, including more than half a million patients. One out of 7 patients was scored as undernourished. For geriatrics, oncology, gastroenterology, and internal medicine, this ratio was even greater (1 out of 3–4). Hospital stay was 1.4 d longer among undernourished patients than among those who were well nourished.

Feasibility and Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands

BACKGROUND

Currently available tools for the management of safety in health care are largely based on quantitative management information. Executive WalkRounds (WalkRounds [WR]) seems useful as a leadership tool to detect "soft signals"-alerts of unsafe situations or practices-and to enhance the mutual trust between frontline staff and the board of directors. The majority of the research on WR has been performed in hospitals. Therefore, a study was conducted to assess how the boards of directors of long term care organizations value WR as a leadership tool to perceive soft signals, and whether soft signals are of added value to enhance patient safety.

METHODS

WRs were introduced in a convenience sample of six organizations-two mental health care institutions, two nursing homes and home care organizations, and two institutions for the physically and intellectually disabled-between July 2012 and December 2013. Data were gathered from observation and reporting forms. Feasibility was evaluated by open-group interviews. A mixed-method analysis was performed using descriptive statistics and content analysis.

RESULTS

WRs were considered feasible, and the added value for the boards of directors consisted of an increased sense of urgency and safety awareness. The dialogue between the board of directors and frontline staff in each organization was essential for a collective patient safety culture. In total, WRs were used 68 times, and 298 soft signals were identified; most addressed care delivery and communication. Overall, 245 improvement activities were reported, of which 109 related to work environment.

CONCLUSION

WRs were considered useful and feasible for detecting soft signals in long term care organizations. These signals are valuable for enhancing patient safety and can be used by the board of directors in addition to the current quality management systems.

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.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0950-5) contains supplementary material, which is available to authorized users.

Predicting fatigue in patients using home parenteral nutrition: a longitudinal study

Background

Home parenteral nutrition (HPN) is a life-saving therapy for patients with diseases that preclude adequate oral or enteral food intake. HPN has a large impact on daily life. Many patients suffer from fatigue and depression, and they experience limits in social activities. This all contributes to a lower quality of life.

Purpose

Fatigue is the most frequently mentioned problem in Dutch HPN patients. Therefore, we studied the prevalence, course and predictors of fatigue in these patients.

Methods

Patients completed questionnaires at baseline and follow-up (12 months later). Measurements included fatigue, depression, functional impairment, social support, self-efficacy, coping, anxiety and acceptance. Laboratory measures, including total bilirubin, creatinine, albumin and haemoglobin levels, were obtained from the medical records. Descriptive statistics, correlations and linear regression analysis were performed.

Results

The response rate was 71% (n = 75). Sixty-five per cent of the patients were severely fatigued (n = 49). Eighty-nine per cent experienced persistent fatigue. Baseline fatigue predicted 57% of the variance of fatigue at follow-up, and avoidance was responsible for 3% of the variance. No significant correlations between fatigue and laboratory measures were found. A cross-sectional analysis showed that 46% of the variance of fatigue was explained by functional impairment, self-efficacy and depression.

Conclusion

Severe fatigue is a persistent problem for HPN patients. Baseline fatigue was the strongest predictor of fatigue at follow-up. Functional impairment, self-efficacy and depression are strongly related to fatigue. Early recognition and treatment of fatigue are important.

The impact of home parenteral nutrition on daily life-a review

BACKGROUND

Total parenteral nutrition (TPN) is a lifesaving therapy in patients with severe intestinal failure that can be administered at home. However, patients have to face complex technological nutritional support issues at home, which will influence their personal life.

OBJECTIVES

This review aims to describe the implications of home parenteral nutrition (HPN) on the quality of life, as experienced by patients, as well as to describe the caregiver's reactions regarding these notions.

SEARCH STRATEGY

A systematic review of the literature published between 1965 and 2005 was conducted. Cinahl, Medline, and Psychlit databases were searched. Systematic data extraction and narrative data synthesis were performed.

SELECTION CRITERIA

Papers were included if they described original research published in a peer reviewed journal, with a focus on adult patients on HPN and/or their family caregivers. DATA COLLECTION (AND ANALYSIS): A standardised record was used for data extraction.

MAIN RESULTS

A total of 26 studies were included. The quality of life reported by patients was moderate to good, but psychological problems, e.g. depression and anxiety, were common. Social life was disturbed due to the venous access device, the time schedule for HPN administration, the inability to have normal oral intake, gastrointestinal mobility problems, and physical complaints. Frequently mentioned somatic problems included fatigue, diarrhoea, pain, polyuria during infusion and sleep disruption. Despite social restrictions, depression and fatigue, caregivers reported their overall QoL as similar to the norms for healthy populations.

CONCLUSION

Patients on HPN meet a broad range of problems. Apart from the well-known metabolic and infectious complications, many of these are psychological or social in nature.

Impact of long-term HPN on daily life in adults

BACKGROUND AND AIMS

Home parenteral nutrition (HPN) is a therapy that changes life radically and often means lifelong dependence on parenteral feeding. The aim of this study was to gain insight into problems experienced by adult patients who were dependent on long-term HPN.

METHODS

A survey was performed on all patients at the ambulatory care clinics of two university centres. We used two techniques: written questionnaires and interviews. The questionnaires addressed fatigue (CIS), quality of sleep, anxiety, depression (BDI), social impairment (subscale SIP68), and sexual functioning. Data were analysed descriptively. Structured interviews inquired about the negative influence of HPN dependence on daily life. These data were quantified by content analysis.

RESULTS

The response rate was 76% (n = 48). Questionnaire results: all the respondents had multiple physical symptoms, which they attributed to the underlying disease. Furthermore, severe fatigue (63%), sleeping disorders, (severe) depression (65%), social impairment (55%), and sexual disorders (33%) were present. Quality of life (QoL) correlated with fatigue, sleeping disorders, anxiety, depression, and social impairment (P<0.02). Interview results: psychosocial problems were the main complaints in daily life due to HPN dependence, e.g. negative changes in moods and feelings (including anxiety), lack of freedom, limitations in social life and being dependent.

CONCLUSIONS

Although many somatic symptoms were present, HPN-dependent patients reported primarily psychosocial problems in daily life. To improve QoL, HPN teams should assess somatic as well as psychosocial aspects standard. Given the large proportion of patients with depressive disorders, therapies such as anti-depressant medication, psychosocial support and cognitive training, should be offered.