The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature

BACKGROUND

Patient aggression is a longstanding problem in general hospital nursing. Staff training is recommended to tackle workplace aggression originating from patients or visitors, yet evidence on training effects is scarce.

AIMS

To review and collate current research evidence on the effect of aggression management training for nurses and nursing students working in general hospitals, and to derive recommendations for further research.

DESIGN

Systematic, narrative review.

DATA SOURCES

Embase, MEDLINE, the Cochrane library, CINAHL, PsycINFO, pubmed, psycArticles, Psychology and Behavioural Sciences Collection were searched for articles evaluating training programs for staff and students in acute hospital adult nursing in a 'before/after' design. Studies published between January 2000 and September 2011 in English, French or German were eligible of inclusion.

REVIEW METHODS

The methodological quality of included studies was assessed with the 'Quality Assessment Tool for Quantitative Studies'. Main outcomes i.e. attitudes, confidence, skills and knowledge were collated.

RESULTS

Nine studies were included. Two had a weak, six a moderate, and one a strong study design. All studies reported increased confidence, improved attitude, skills, and knowledge about risk factors post training. There was no significant change in incidence of patient aggression.

CONCLUSION

Our findings corroborate findings of reviews on training in mental health care, which point to a lack of high quality research. Training does not reduce the incidence of aggressive acts. Aggression needs to be tackled at an organizational level.

[Frequency of pressure ulcers in german hospitals]

The prevalence and incidence of pressure ulcers are increasingly used to assess the quality of care delivered by health systems and facilities and the effectiveness of the pressure ulcer prevention initiatives in place. Available results about pressure ulcer prevalence and incidence in German hospitals are contradictory. The comparison of 3 multicentre nationwide studies is proposed to provide a more accurate estimation of the pressure ulcer frequency. Pressure ulcer prevalence was compared by data provided by the Charité with data of the software-based data collection packet "Kinexus". Additionally, data on pressure ulcer incidence of Kinexus were compared with the results of the incidence data of the "Generalindikator Dekubitusprophylaxe" of the German Society of Quality Assurance (BQS, now AQUA Institute). Data from 2007 and 2008 and patients 75 years and older were considered. For the calculation of the outcome "pressure ulcer" recommendations of the EPUAP and the NPUAP were followed. As category I (non-bleaching erythema) pressure ulcers are difficult to diagnose, all proportions were calculated including and excluding category I. All 3 samples were comparable regarding the mean age of 81 years. Pressure ulcer prevalence categories I-IV (II-IV) of the Kinexus study was 11.8% (6.1%) and of the Charité study it was 11.0% (5.5%). Regarding pressure ulcer incidence, the rate that was calculated by the BQS categories I-IV (II-IV) was 1.3% (0.8%), in comparison to the incidence rate of Kinexus which was 6.7% (3.9%). There were no statistically significant differences between the 2 prevalence measurements but the odds-ratio of the Kinexus incidence in comparison to the BQS incidence was more than 4 times higher (p<0.001). Results of the Kinexus study are more comparable to incidence figures of international studies on pressure ulcer incidence. The results of this secondary data analysis indicate that published incidence figures by the BQS (now AQUA Institute) might be underestimated. Since this measurement is expensive and burdensome, this mandatory procedure is questionable.

[Pressure ulcer prevalence in German nursing homes and hospitals: what role does the National Nursing Expert Standard Prevention of Pressure Ulcer play?]

AIM OF THE STUDY

The aim of this study was to investigate the relationship between the use of the National Nursing Expert Standard Pressure Ulcer Prevention and the pressure ulcer prevalence in German nursing homes and hospitals.

METHODS

Data were collected within two nationwide surveys conducted by the Department of Nursing Science of the Charité, Berlin, Germany. The surveys, designed as cross-sectional prevalence studies, serve as an investigation of the amount of clinically relevant nursing phenomena, i. e., pressure ulcers. Prevalence per facility in the at-risk group was explored by a ranking procedure of the 95 nursing homes and hospitals. The facilities were divided into two groups according to whether they used the German Expert Standard to develop the local protocol or not.

RESULTS

The pressure ulcer prevalence of the at-risk group ranged from 0% to 24.6% in nursing homes and from 7% to 40% in hospitals. In about 40% of the hospitals and nursing homes the local protocol of pressure ulcer prevention was based on the German Expert Standard. The ranking figure indicates that there is no statistically significant relation between Expert Standard-based local protocols and the pressure ulcer prevalence in the at-risk group.

CONCLUSION

A clear advantage to use the German Expert Standard compared with other sources cannot be shown with these data. However, a uniform pressure ulcer prevention is an essential quality feature of nursing care. The degree of implementation and the consequent transfer of the recommendations to daily practice should be evaluated regularly.

Sturzprävention bei Menschen mit Demenzerkrankungen

Elderly persons suffering dementia are at increased risk for falls. Because of this, an investigation of the state of the science and the state of the art in fall prevention in patients suffering dementia has been made. A systematic literature review showed lack of documentation of effective interventions in preventing falls in persons with cognitive impairment. This was the reason for studying which measures nurses undertake in the field of long-term-care. Focus-group interviews with experienced geriatric nurses were undertaken. Nurses assume that there are specific risk factors in this patient group which have to be taken into account. Cognitive deficits are causing an increased fall risk in a specific manner. Geriatric nurses have ideas about how to adapt interventions for persons with dementia. They also assume that interventions primarily addressing cognitive disorders may also reduce the risk of falling. The interventions mentioned by the interviewed experts have not yet been examined concerning their effectiveness, therefore, fall prevention for people with dementia has to be further differentiated and systemized on a scientific basis.

Pressure ulcer risk factors in cardiac surgery: A review of the research literature

BACKGROUND

Pressure ulcer incidence in patients undergoing cardiac surgery is reported to be up to 29.5%. Common known risk factors for pressure ulcer development include compressive and shearing forces. However, knowledge about the specific risk factors in a defined population is helpful in the development of an effective prevention management. This literature review is part of a quality improvement project to reduce pressure ulcer incidence in the cardiac surgery population.

OBJECTIVES

The objective is to determine "which specific risk factors for pressure ulcer development in the cardiac surgery population are identified in the literature."

RESULTS

The results of this literature review indicate a high-risk potential in the tissue tolerance for oxygen as temperature manipulation, vasoactive drugs, hypotensive periods, and reduced hemoglobin and hematocrit levels. Time on the operating room table, frequency of repositioning, immobility time, older age, low albumin level, and corticosteroid are also found as significant risk factors in this population.

CONCLUSION

Diseases that influence oxygen supply in older patients in combination with the special demands of temperature and circulation regulation during the cardiac surgical procedure place the patient at risk for pressure ulcer development. Prevention measures should be aimed at supporting tissue tolerance for pressure and tissue tolerance for oxygen. These measures should be additional to pressure-relieving devices on the operating room table and, postoperatively in bed, a defined minimum frequency of postoperative turning and early mobilization after the surgical procedure should be considered.

Perception of aggression among psychiatric nurses in Switzerland

OBJECTIVE

To identify principal components and patterns in the perception of aggression by psychiatric nurses and to explore relationships between the perception of aggression and personal and workplace characteristics.

METHOD

Seven hundred and twenty-nine nurses working in psychiatric inpatient departments of German-speaking Switzerland completed the perception of aggression scale (POAS). Data analysis included factor analysis, group comparisons and multivariate analysis of covariance.

RESULTS

Two plausible factors were identified, representing different dimensions in the perception of aggression and accounting for 35% of the variance. Firstly, aggression is perceived as dysfunctional/ undesirable and, secondly, aggression is perceived as a functional/ comprehensible phenomenon. Only minor differences were found in the perception of aggression with regard to personal characteristics or work environment of the nurses.

CONCLUSION

Nurses perceive aggression not just as a negative phenomenon. The perception of aggression as measured by POAS is independent of many characteristics expected to be related to the perception of violence, such as grade of education, work experience, etc.

The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial

Nurses' attitudes towards patient aggression may influence their behaviour towards patients. Thus, their enhanced capacity to cope with aggressive patients may nurture more positive attitudes and alleviate adverse feelings emanating from patient aggression. This cluster randomised controlled trial conducted on six psychiatric wards tested the hypotheses that a 5 day training course in aggression management would positively influence the following outcome measures: Nurses' perception and tolerance towards patient aggression and resultant adverse feelings. A repeated measures design was employed to monitor change. No effect was found. The short time frame between the training course and the follow up measurement or non-responsiveness of the measurement instruments may explain this finding.

The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study

Systematic risk assessment and training courses have been suggested as interventions to deal with patient violence in psychiatric institutions. A dual centre prospective feasibility study was conducted on two Swiss psychiatric admission wards to test the hypothesis that such interventions will reduce the frequency and severity of violent events and coercion. A systematic aggression risk assessment, in combination with a standardized training course in aggression management was administered and the frequency and severity of aggressive incidents and the frequency of coercive measures were registered. The incidence rates of aggressive incidents and attacks showed no significant reduction from the baseline through risk prediction and staff training, but the drop in coercive measures was highly significant. A 'ward effect' was detected with one ward showing a decline in attacks with unchanged incidence rates of coercion and the other ward showing the opposite. The severity of the incidents remained unchanged whilst the subjective severity declined after the training course. We conclude that a systematic risk assessment and a training course may assist in reducing the incidence rate of coercive measures on psychiatric acute admission wards. Further testing of the interventions is necessary to measure the effect of the training alone and to counteract 'ward effects'.

[The care dependency scale, an assessment instrument]

The Care Dependency Scale, an instrument for the assessment of patients'care dependency, has been translated into German. The scale was tested on (inter-) rater reliability and criterion and construct validity in a hospital population on geriatric, surgical and paediatric wards. As the results of this study were very satisfying, positive recommendations regarding the suitability of the scale for use in the German nursing care situation could be made. However further psychometric testing of the scale is important, for instance in other populations. A final conclusion is that the scale may be used in care settings in German-speaking countries.

Predicting inpatient violence in acute psychiatric wards using the Brøset-Violence-Checklist: a multicentre prospective cohort study

The Norwegian Brøset-Violence-Checklist (BVC) is one of the few instruments that is suitable for short-term prediction of violence of psychiatric inpatients by nursing staff in routine care. The instrument assesses the presence or absence of six behaviours or states frequently observed before a violent incident. We conducted a study to elucidate whether the predictive properties of the BVC are retained in other psychiatric settings than the original north-Norwegian validation dataset. During their admission period, 219 consecutive patients admitted to six acute psychiatric wards were assessed as to the risk for attack using a German version of the BVC (BVC-G). Data on preventive measures were concurrently collected. Aggressive incidents were registered using an instrument equivalent to the Staff Observation of Aggression Scale (SOAS-R). Fourteen attacks towards staff were observed with incident severity ranging from 5 to 18 of a possible 22 points. BVC-G sensitivity was 64.3%, the specificity 93.9%, the positive predictive value 11.1%, and the area under the receiver operating characteristic curve 0.88. In some false positive cases intense preventive measures had been implemented. The predictive accuracy of the BVC-G proved consistent with the Norwegian original.

The perception of aggression by nurses: psychometric scale testing and derivation of a short instrument

Patient aggression is a serious problem in psychiatric nursing. Nurses' attitudes towards aggression have been identified as mediating the choice of nursing interventions. To date, investigations are lacking which elucidate the stability of one of the few scales for measuring the attitude of aggression. This study aimed to investigate the test-retest stability of the Perception of Aggression Scale and to derive a shortened version. In order to test the reliability of the Perception of Aggression Scale items, three groups of psychiatric nurses were requested to fill in the Perception of Aggression Scale twice (30 student nurses after 4 days, 32 qualified nurses after 14 days and 36 qualified nurses after 70 days). We derived the shortened version from an independent data set obtained from 729 psychiatry nurses using principal component analysis, aiming to maximize parsimony and Cronbach's alpha. Amongst competing short versions, we selected those with the highest reliability at 70 or 14 day retest. A scale using 12 of the original 32 items was derived yielding alphas of r = 0.69 and r = 0.67 for the two POAS factors with retest reliabilities of r = 0.76 and r = 0.77. The shortened scale offers a practical and viable alternative to the longer version.

[Care dependency in nursing homes--a psychometric study]

The Dutch Care Dependency Scale, an instrument for the assessment of a patient's care dependency, has been translated into German. The purpose of this study was to examine the reliability and validity of the German version of the scale. The 15-item scale has been developed for the use in nursing homes. Data were collected from 81 people living in nursing homes in Berlin, Germany. The sample was measured three times. Cronbach's alpha was 0.94. Interrater and intrarater reliability revealed moderate to substantial Kappa statistics. As the results of this study were satisfying, positive recommendations regarding the suitability of the German version of the Care Dependency Scale for use in nursing homes could be made. However, further psychometric testing of the scale is recommended.

Patients' autonomy in surgical care: a comparison of nurses' perceptions in five European countries

BACKGROUND

This report forms part of the results of an international comparative study funded by the European Commission (1998-2001).

AIM

To describe and compare the maintenance of patients' autonomy on surgical wards, from the point of view of nursing staff, in five European countries (Finland, Spain, Greece, Germany and Scotland). Autonomy is defined in terms of information received and decision making by patients.

METHOD

The data were collected using a questionnaire specifically designed for use in this study. Responses (response rate 66%) were obtained from 1280 nurses working on surgical wards. Data analysis was based on descriptive statistics, t-tests, analysis of variance (ANOVA) with posthoc Tukey's HSD test and logistic regression.

RESULTS

There were clear between-country differences in nurses' perceptions, especially on a north-south axis (Finland and Scotland vs. Greece and Spain), regarding the extent to which the autonomy of surgical patients is supported by nursing staff. Training and ethics education, in particular, were associated with nurses' perceptions of the maintenance of patient autonomy in Finland and Greece.

CONCLUSION

Further research is needed to establish whether the results obtained are caused by differences in cultures, nursing practices or roles of health-care personnel or patients in different European countries.

Autonomy, privacy and informed consent 4: surgical perspective

This is the fourth article in a four-part series that considers the issues of patient autonomy, privacy and informed consent. The article discusses these issues in the context of surgical patients and their nurses. There is an abundance of references to issues of autonomy and informed consent within the healthcare literature, although there are few empirical studies investigating these issues within practice. The issue of privacy has been somewhat less explored than that of autonomy or consent, particularly in the UK literature. This article reports the findings of a Scottish study that formed part of a multisite comparative study funded by the European Commission. A convenience sample of surgical patients (n = 282) and their nurses (n = 260) participated in the study. Data were collected by means of a self-completion questionnaire for both patients and nursing staff. Results indicated that there are significant differences in patient and staff perceptions on issues of patient autonomy, privacy and informed consent. However, the most marked difference in perceptions of patients and staff were found on the information-giving element of the autonomy subscale. Implications for nursing practice, education and research are highlighted.

Autonomy, privacy and informed consent 3: elderly care perspective

Despite the growing interest in clinical healthcare ethics, there is a dearth of empirical studies investigating the ethical elements of day-to-day clinical practice from the perspective of either patients or staff. This article, the third in a four-part series, reports the results of a Scottish Study that formed part of a multi-site comparative study funded by the European Commission. It explores patient autonomy, privacy and informed consent in the care of elderly people in long-stay care facilities (i.e. nursing homes and continuing care units). A convenience sample of 101 elderly residents and their nurses (n = 160) participated in the study. Data were collected by means of a self-completion questionnaire for staff and a structured interview schedule for elderly residents. Results indicate marked differences between staff's and residents' responses on three of the four dimensions explored: information-giving, and opportunity to participate in decision-making about care and consent. There was much closer agreement between staff's and residents' responses regarding protection of patient privacy. From the results of this study there is indication of a clear need for further empirical studies exploring issues of patient autonomy, privacy and informed consent in the day-to-day nursing care of older people. Findings to date suggest there is still a significant need to educate staff concerning ethical awareness and sensitivity to the dignity and rights of patients.

Autonomy, privacy and informed consent 2: postnatal perspective

The nursing and healthcare ethics literature over the past 10 years has focused on issues of patient autonomy and patient rights. Despite the growing volume of literature exploring such topics, there is little empirical work investigating what is actually happening in clinical nursing or midwifery practice in relation to patient autonomy, privacy or informed consent, from the perspective of either patients or staff. This four-part series reports the results of a Scottish study that formed part of a multisite comparative research project funded by the European Commission, investigating issues of patient autonomy, privacy and informed consent. This article, the second of four, explores the issues of autonomy, privacy and informed consent in maternity care. The research questions asked were: (1) What is the perception of mothers' autonomy, privacy and informed consent in Scottish NHS hospitals, from the point of view of both mothers and midwives? (2) Are there differences in the perceptions of mothers and midwives on these issues? Data were collected by a self-completion questionnaire for mothers (n = 243) and staff (n = 170) on postnatal units in both district general and university teaching hospital. Results indicated that there are differences between the perceptions of mothers and midwives in relation to mothers' autonomy, privacy and informed consent. Most differences were found in the information-giving and decision-making elements of autonomy.

Autonomy, privacy and informed consent 1: concepts and definitions

This article is the first in a four-part series that explores the concepts of patient autonomy, privacy and informed consent in the context of the provision of nursing care. In this first article an overview of the concepts is provided, and some of the difficulties with definitions of these concepts are considered. The dearth of empirical exploration of the operationalization of the concepts of patient autonomy, privacy and informed consent within nursing practice is highlighted. The second, third and fourth articles report a series of empirical studies carried out with patients and staff in postnatal care, in continuing care of elderly people and in acute surgical care within Scottish NHS settings. These studies are part of a concerted effort to address the lack of empirical investigation of the ethical dimension of nursing care provision and clinical nursing practice.

[Frequency of falls in german hospitals]

PURPOSE

So far, there are no statistics on falls by patients in German hospitals. This study records data on the frequency and results of inpatient falls and compares patients who suffered from falls, with the other patients.

METHODS

In a prevalence study, we collected data from 3012 patients in 11 hospitals in Berlin and surrounding areas.

RESULTS

3.5 % of all patients fell during their clinical stay. 13 % of the patients who fell suffered a fracture or a joint injury, 20 % another injury while 67 % had no any injuries. The patients who fell were older and more care-dependent than the other patients. Most of the patients fell on geriatric wards.

CONCLUSION

Older patients fall more frequently than other patients while in hospital.

A reliability and utility study of the care dependency scale

The purpose of this study was to examine the reliability and utility of the Care Dependency Scale (CDS). This 15-item scale has been developed recently for assessing the care dependency of demented or mentally handicapped inpatients. Data for this study were collected from 153 demented and 139 mentally handicapped inpatients. The sample was measured three times. Internal consistency was determined using Cronbach's alpha and ranged from 0.95 to 0.97. Interrater reliability revealed moderate to substantial weighted Kappa statistics between 0.51 and 0.83. Test-retest reliability analysis resulted in substantial weighted Kappas between 0.66 and 0.89. Utility tests also revealed satisfactory results. The findings support the reliability and utility of the CDS.

Coercive procedures and facilities in Swiss psychiatry

BACKGROUND

Coercive measures in psychiatry,although in many cases effective in violence management and injury reduction, have been criticised from a consumerist point of view.

METHOD

A questionnaire regarding coercive facilities and procedures was dispatched to the charge nurses of 86 acute psychiatric admission wards in German speaking Switzerland covering a catchment area of 75% of the Swiss population.

RESULTS

95% of all wards responded rendering the survey representative. The majority of wards have seclusion rooms and 55% of charge nurses perceive seclusion facilities as adequate. Two to twenty staff members are involved in overwhelming dangerous patients and some discontent is expressed at the haphazard fashion in which such events occur. Almost 70% of the wards use a form for reporting, 42 % of wards keep statistics on violent incidents and 17% of wards have access to these data. Of all wards 84% register injections against patients' will, 83% seclusion, and 78% mechanical restraint and a minority of wards register the coercive administration of oral medication, forced nutrition, threats of coercive measures in case of pharmacological non-compliance.

DISCUSSION

Isolation, the coercive administration of medicine and restraint techniques are sensitive forms of treatment. Deficits reported by the charge nurses point to the need for enhanced facilities and improved forms of coercion management such as training in the use of mechanical restraints and the overwhelming of dangerous patients.

CONCLUSION

The data show considerable differences in the facilities, the use, and the recording of coercive measures in the area under scrutiny.

Coercive procedures and facilities in Swiss psychiatry

BACKGROUND

Coercive measures in psychiatry,although in many cases effective in violence management and injury reduction, have been criticised from a consumerist point of view.

METHOD

A questionnaire regarding coercive facilities and procedures was dispatched to the charge nurses of 86 acute psychiatric admission wards in German speaking Switzerland covering a catchment area of 75% of the Swiss population.

RESULTS

95% of all wards responded rendering the survey representative. The majority of wards have seclusion rooms and 55% of charge nurses perceive seclusion facilities as adequate. Two to twenty staff members are involved in overwhelming dangerous patients and some discontent is expressed at the haphazard fashion in which such events occur. Almost 70% of the wards use a form for reporting, 42 % of wards keep statistics on violent incidents and 17% of wards have access to these data. Of all wards 84% register injections against patients' will, 83% seclusion, and 78% mechanical restraint and a minority of wards register the coercive administration of oral medication, forced nutrition, threats of coercive measures in case of pharmacological non-compliance.

DISCUSSION

Isolation, the coercive administration of medicine and restraint techniques are sensitive forms of treatment. Deficits reported by the charge nurses point to the need for enhanced facilities and improved forms of coercion management such as training in the use of mechanical restraints and the overwhelming of dangerous patients.

CONCLUSION

The data show considerable differences in the facilities, the use, and the recording of coercive measures in the area under scrutiny.

Privacy: a review of the literature

The concept of privacy is used in many disciplines and is recognised as one of the important concepts also in nursing. In this review, a description about the perspectives and dimensions of the concept will be made and empirical studies in the area will be analysed. Perspectives include units experiencing privacy, desired-achieved state, and reactiveness. Dimensions are divided into physical, psychological, social and informational. In the empirical studies, the concept of the privacy has mainly been studied in hospital organisations using the physical dimension. The concept needs further clarification in future.

The role of CNSs in promoting elderly patients' autonomy in long-term institutions: problems and implications for nursing practice and research

Autonomy has become an important focus within healthcare. Elderly patients, however, are often denied the right to independent decision making on grounds of incompetence and incapacity. In long-term institutions there are several ways in which the clinical nurse specialist can promote the autonomy of elderly patients. This article provides an overview of the concept of autonomy and discusses some of the problems in its realization in long-term nursing institutions. It also outlines strategies for supporting autonomy in elderly patients and concludes with a discussion of the implications of autonomy to nursing practice and research.

Autonomy and clinical practice. 3: Issues of patient consent

In this, the last in a three-part series considering how the concepts of autonomy, privacy and informed consent are articulated in nursing and the related literature, the authors focus on the notion of consent. Definitions of consent are considered, as are the legal elements of valid consent. Obtaining a patient's consent to treatment has several important functions. This article looks at some of these functions, such as safeguarding patient autonomy and encouraging patient participation in health care. Finally, a number of the difficulties in obtaining an informed consent from patients are considered. Some empirical studies which consider patients' understanding of the information and consent process are also discussed. From a review of the literature it appears that the issue of informed consent is very much tied up with the perceived power struggle between doctors and nurses and doctors and their patients.

Autonomy and clinical practice. 2: Patient privacy and nursing practice

This article, the second in a series of three considering issues of autonomy, privacy and informed consent in nurse/patient interactions, focuses on the wider conceptions of patient privacy and confidentiality. Given that patients in institutional care are likely to suffer intrusions into their privacy which would be considered unusual in normal social interaction, it is interesting to note the dearth of literature in this area. Some definitions of privacy are considered in an attempt to begin to raise readers' awareness of the complexity of this notion. It can be argued that privacy is a pertinent notion to consider, both in order to gain a greater understanding of what is meant by the term and in terms of the implications of this understanding for clinical practice.

Autonomy and clinical practice. 1: Identifying areas of concern

This article, the first of three parts, presents an analysis of the use of the concept of autonomy in the nursing and healthcare ethics literature in the UK. It commences by considering some definitions of autonomy as they appear in the literature. Some of the confusions with the use of autonomy in the nursing literature are also identified and discussed, e.g. the frequent lack of clarity regarding how closely the concept is tied to notions of freedom. In addition, it also examines the lack of any indications in the nursing literature and that when one is considering the notion of autonomy it is also useful to consider the idea of constraining factors. In the nursing literature, discussions of autonomy largely appear to centre around the power imbalance between nurses and doctors. Issues of patient autonomy thus appear to be often of only secondary concern.

An international psychometric testing of the care dependency scale

In an international study, psychometric properties of the Care Dependency Scale (CDS) were examined by analysing data gathered in Dutch, Canadian, Italian and Norwegian nursing homes. For that purpose, from these countries a convenience sample was developed consisting of 525 patients with dementia. The English, Italian and Norwegian research instruments were translations of the original Dutch CDS. Psychometric evaluations of the CDS were carried out for each country separately as well as for the four countries combined. High alpha coefficients between 0.94 and 0.97 were calculated. Subsequent test-retest and inter-rater reliability revealed moderate to substantial Kappa values. Factor analysis resulted in a one-factor solution. The scalability of the CDS was demonstrated by means of Mokken scale analysis. One of the main outcomes of the cross-cultural comparison was that the findings in the four countries show more similarities than differences, so that the scale can be used appropriately in nursing home practice.

German nursing students' knowledge of and attitudes to HIV and AIDS: two decades after the first AIDS cases

German nursing students' knowledge of and attitudes to HIV and AIDS: two decades after the first AIDS case This study describes German nursing students' (n=180) knowledge and attitudes relating to HIV/AIDS, their homophobia level, willingness to care for people with AIDS, and their approach to possible sexual risk behaviours. A questionnaire was used to collect the data (response rate 97.8%). The results indicated that the nursing students had a rather high knowledge level concerning AIDS. However, there were gaps of knowledge, such as regarding AIDS immunopathology or the symptoms of the disease. Single nursing students and those having cared for a person with AIDS had a more thorough knowledge about the disease. In general, the attitudes towards AIDS and people with AIDS were tolerant and positive, and homophobia was only found with a small minority. Students having positive attitudes towards people with HIV/AIDS had less homophobia compared to those having negative attitudes towards persons suffering from AIDS. Those with positive attitudes were more willing to care for patients with HIV/AIDS, while those with a high homophobia level were less willing to do so. In addition, students having a high AIDS knowledge level tended less towards negative attitudes and homophobia than those with a low level of knowledge. The implications of the research for nursing education will be discussed.

[Knowledge of professional rules of ethics among professional nurses]

During recent years numerous publications on ethical issues appeared in German nursing literature. Nursing theorists repeatedly refer to the Code of Ethics of the International Council of Nursing (ICN). The implementation of codes of ethics is discussed as an indispensable stage within the development of independent nursing ethics. However, it is not clear whether nurses in Germany know about the ICN Code of Ethics or other codes of ethics. The authors' objective is to learn more about how much is known about codes of ethics by practical nurses in four selected hospitals. In addition, it is of interest to know, which advantages nurses might associate with codes of ethics and secondly from which sources nurses prefer to receive ethical education. The study shows that only 25% of the participants know about codes of ethics. It also reveals that further education offered by hospitals or the basic nursing education are seen as the most important source of information related to ethics. The major advantage of codes of ethics seen by the participants is to provide guidance in the decision-making process of ethical dilemma situations in nursing. Secondly the Code of Ethics is regarded as a useful framework to define obligations and rights of nurses in the relationship with patients and relatives. The results of the study indicate that the ICN Code of Ethics is practically unknown among nurses and should be discussed more extensively by practical nurses and nursing theorists.

Predictors of care dependency in Alzheimer's disease after a two-year period

This paper presents the results from a panel study in the Netherlands of 68 female in-patients with Alzheimer's disease. The main focus of this study was to investigate longitudinal changes and differences in care dependency. Descriptive statistics indicated an increase in almost all 15 features of dependency in a two-year period. A stepwise regression procedure revealed that the loss of social relationships, the loss of the ability to communicate, and the degree of care dependency at entry to the study were the strongest predictors of the follow-up ratings. The pattern of findings reveals that the Care Dependency Scale is sensitive to care dependency increase after a two-year period, and that the scale has utility in establishing longitudinal patterns of care dependency.

Nursing interventions in crisis-oriented and long-term psychiatric home care

Psychiatric nurses in The Netherlands are moving out of residential mental health institutions and are pioneering home care for the acutely and chronically mentally ill. The purpose of this study was to identify the interventions nurses currently use and to describe the differences between crisis-oriented and long-term psychiatric home care. Data was collected of 159 nursing care plans from four participating crisis-oriented and two long-term psychiatric home care teams. All stated nursing activities were identified and subsequently labelled and classified using the Nursing Intervention Classification (NIC). Results revealed that in both crisis-oriented and long-term psychiatric home care, nurses used a wide range of nursing interventions. Medication Management, Coping Assistance and Activity Therapy were the most frequently undertaken nursing interventions in both types of care. Within crisis-oriented care, Emotional Support and Self-esteem Enhancement dominated, whereas long-term care focused on Socialization Enhancement and Home Maintenance Assistance. The results will be used for further research and for standardization of nursing care plans within these categories of nursing practice.

Construct validity of the Nursing Care Dependency Scale

This paper describes the results of a study determining construct validity aspects of the Nursing Care Dependency (NCD) Scale. This 15-item instrument has been developed recently for the assessment of the care dependency of dementia or learning-disabled inpatients. Data was collected for 450 dementia and 203 learning-disabled patients using the NCD instrument. Factor analysis of the NCD instrument resulted in one Factor. With Mokken scale analysis an H-coefficient of 0.75 was found, which implied a strong hierarchical scale. Cronbach's alpha coefficients (0.97) were high enough to use the NCD instrument in clinical practice, at both group and individual levels.

Operationalization of the concept of 'nursing care dependency' for use in long-term care facilities

Nursing care dependency and similar terms are frequently used in nursing literature. However, their meanings are still to be adequately defined. This paper seeks to operationalize the concept of dependency for use in long-term nursing care practice. An analysis of the concept of dependency, specifically with regard to nursing care, will present a frame of reference from which a theoretical definition can be stated. Variable dimensions, observable indicators and means for measuring the indicators are presented. The paper concludes with implications for further research.

A criterion-related validity study of the Nursing-Care Dependency (NCD) scale

The purpose of this study was to examine some aspects of the criterion-related validity of the Nursing-Care Dependency (NCD) scale. This 15-item counting scale has recently been developed for assessing the care dependency of demented or mentally handicapped in-patients. Its criterion-related validity was investigated by studying the relationship between the Nursing-Care Dependency scale, the Rating Scale for Elderly Patients (RSEP), the Behavior Observation Scale for Intramural Psychogeriatrics (BOSIP) and the Scale for Social Functioning (SSF). Data were collected from 322 demented and 105 mentally handicapped patients using the mentioned instruments. High correlations were found between NCD and RSEP, and NCD and SSF. There was a low relationship between the NCD sumscore and BOSIP subscales-scores. The NCD was able to purposefully distinguish diagnostic groups of demented patients when an external criterion was used.

Criteria for nursing information systems as a component of the electronic patient record. An international Delphi study

In many countries nurses lack an adequate tool to assist in determining the essentials of an information policy in health care institutions and to outline the nursing component of the electronic patient record. In the United States criteria exist for systems that support the nursing process and for the electronic patient record, and the United Kingdom has the disposal of an Information Management and Technology Strategy that includes nursing information. The objective of this study was to determine international criteria for nursing information systems when such systems become part of the electronic patient record. Using the Delphi methodology, criteria for nursing information systems development, content, structure, and use are established by an international panel of 36 experts in three succeeding rounds. Most criteria gained consensus and are useful for application in practice for development of information policy and information systems for nursing. Eventually, the list of criteria will be included in a nursing information reference model. Nursing will benefit from the application of the reference model and the criteria to develop adequate information and communication technology.

The perception of aggression

Several academic and clinical disciplines are involved in clarifying the concept of aggression by formulating operational and descriptive definitions. In the present paper the validity of the definitions of aggression, reported by nurses in an earlier qualitative study, is examined, using a survey approach among nurses of five general psychiatric hospitals in the Netherlands. Three dimensions of aggression were found; aggression as a normal, adaptive reaction, aggression as a violent reaction and aggression as a functional reaction. These findings match the results of the qualitative study. It was investigated whether there was a relation between personal and environmental characteristics of the nurses and the way they perceive aggression. The gender of the respondents, the setting in which they were working, the degree to which they used constraint measures and whether patients were voluntarily admitted or not, were related to the perception of aggression. The study points out that different instruments are needed to measure the prevalence or incidence of aggression and to diagnose or to intervene on aggression in clinical practice.

Nursing-care dependency. Development of an assessment scale for demented and mentally handicapped patients

This article describing the first phase in the development of an assessment scale of nursing-care dependency (NCD) for Dutch demented and mentally handicapped patients focuses on the background to the study and the content validation of the nursing-care dependency scale. The scale aims to characterize the patients' nursing-care dependency as part of the assessment step in the nursing process, and is based on Henderson's 14 human needs. The Delphi technique, using two panels of experts (n = 44), was applied to reach consensus on significant indicators of nursing-care dependency. The experts' reasoning was used to develop criteria for the assessment of nursing-care dependency. Ultimately, the Delphi rounds generated 15 NCD items with their descriptions and item criteria. There was no fundamental difference between the NCD scales for demented and mentally handicapped patients. Nevertheless, there are two versions of the NCD scale because of the need to apply specific concepts in the nursing care of either population. The original Dutch version of the NCD is also available in English and in Norwegian.

Problems of cardiac patients in early recovery

Most studies of the problems and information needs of patients describe these only for the period of hospitalization. In this study, however, the authors focused on the first 6 months after discharge. Eighty-two cardiac patients, admitted to a university hospital with a myocardial infarction (MI) or for coronary artery bypass surgery (CABS), were interviewed 6 months after discharge. Questions required them to describe problems they experienced in early recovery and what information they needed. All but one of the 82 patients stated they had experienced problems during the first 6 months after discharge. Most problems described concerned: emotional reactions (59%), their change in physical condition (59%), deleterious effects of treatment (56%) and convalescence (54%). Topics on which most patients needed additional or different information were: deleterious effects of the treatment (26%), physical condition (24%), risk factors (24%), convalescence (24%) and knowledge of the disease (24%).

Aggression in psychiatry: a qualitative study focusing on the characterization and perception of patient aggression by nurses working on psychiatric wards

The present study focuses on the characterization and perception of patient aggression by nurses working in a psychiatric hospital in The Netherlands. Data have been collected by interviewing nurses working on open and closed wards. The results have been compared and related to the existing literature on aggression. An expert panel has collaborated in the assessment of part of the research findings. Nurses perceive and describe aggression in different ways. Since the descriptions of aggression varied considerably, it was not possible to formulate a general definition of aggression on the basis of the results of the study. Despite the fact that on the whole the general public have a negative view of aggression, the descriptions nurses gave were not always negative. Most of the nurses acknowledged positive as well as negative aspects of aggressive behaviour by patients. Interventions in cases of aggressive behaviour depend on different factors, e.g. the individual nurse's perception of the situation, the (mostly unwritten) rules, and the type of ward (open or closed). The same interventions are often used both to prevent aggression and to stop it. The difference lies in the moment of execution. Most interventions are aimed at stopping aggressive behaviour by acting in a non-restrictive way, e.g. by talking to the patient, touching the patient and giving unexpected responses. Nurses express the belief that aggression is mainly caused by a combination of patient-related, situational and interactional factors. This is not in accordance with the opinion of the North American Nursing Diagnosis Association, who relate aggressive behaviour mainly to patient characteristics.