Gerrie J.J.W. Bours

Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review

AIM This paper is a report of a systematic review conducted to determine the effectiveness and feasibility of bedside screening methods for detecting dysphagia in patients with neurological disorders. BACKGROUND Dyspaghia affects 22-65% of patients with neurological conditions. Although there is a large variety of bedside tests to detect dysphagia, it is unknown which have the best psychometric properties and are feasible for nurses to use. DATA SOURCES AND REVIEW METHODS An electronic database search was carried out using Medline (PubMed), Embase, CINAHL, and PsychLit, including all hits up to July 2008. The search terms were dysphagia, sensitivity, specificity, diagnosis, and screening. The methodological quality of included studies was assessed. RESULTS Thirty-five out of 407 studies were included in the review. Eleven studies with sufficient methodological quality revealed that trial swallow tests using water had sensitivities between 27% and 85% and specificities between 63% and 88%. Trial swallow tests with different viscosities led to sensitivities ranging from 41% to 100% and specificities of 57% to 82%. Combining water tests with oxygen desaturation led to sensitivities between 73% and 98% and specificities between 63% and 76%. Single clinical features, such as abnormal gag, generally had low sensitivity and specificity. CONCLUSION A water test combined with pulse oximetry using coughing, choking and voice alteration as endpoints is currently the best method to screen patients with neurological disorders for dysphagia. Further research is needed to establish the most effective standardized administration procedure for such a water test, and to assess the value of pulse oximetry, in addition to a trial swallow to detect silent aspiration.

Relevance of the diagnosis ‘stage 1 pressure ulcer’: an empirical study of the clinical course of stage 1 ulcers in acute care and long‐term care hospital populations

Stage 1 pressure ulcers are difficult to diagnose. Several prevalence studies have shown that almost half of the pressure ulcers identified are stage 1. The present study investigated the importance of stage 1. The following research questions were formulated: Is there a difference between the prevalence of stage 1 pressure ulcers identified in the institutions participating in the present study and that found in the other institutions participating in the Dutch National Prevalence Survey? What percentage of stage 1 pressure ulcers are reversible within a few hours? What is the clinical course of stage 1 pressure ulcers? Which patient characteristics and preventive interventions are related to the clinical course of stage 1? The study used a prospective, descriptive and comparative design. All patients of six long-term care hospitals and six acute care hospitals in whom stage 1 pressure ulcers were identified during the 1999 National Prevalence Survey in the Netherlands were followed for 1 week (acute care hospitals; n = 68 patients) or 2 weeks (long-term care hospitals; n = 115 patients). The patients were reassessed using the questionnaire developed for the National Prevalence Survey (patient characteristics, assessment of risk of pressure ulcers, characteristics of the pressure ulcers and use of preventive methods) on the same day as the national survey itself, and again after 3 days, after 7 days and after 14 days (only long-term care hospitals). The results showed fewer stage 1 pressure ulcers in the institutions participating in the present study than in the National Prevalence Survey, the difference being almost 50%. The first reassessment found the prevalence of stage 1 to be further reduced by an average of almost 50%, a reduction which was greater for the long-term care hospitals than for the acute care hospitals. However, some of the ulcers that had disappeared reappeared in subsequent reassessments. In the long-term care hospitals, 8.7% of the stage 1 pressure ulcers deteriorated to a higher stage, vs. 22.1% in acute care hospitals. No significant patient characteristics were found to affect the course of stage 1, except that women in acute care hospitals more often had a stage 1 pressure ulcer at the first reassessment than men. In general, patients whose stage 1 ulcer deteriorated were undergoing more preventive interventions; not all differences were significant. We conclude that, although stage 1 is reversible in most cases, it can be interpreted as an important warning sign for nurses and patients to act. If no adequate interventions are applied, the pressure ulcer may deteriorate.

Nurse practitioners and physician assistants in Dutch hospitals: their role, extent of substitution and facilitators and barriers experienced in the reallocation of tasks.

AIMS   This paper is a report of a study exploring the role of nurse practitioners and physician assistants, the extent of substitution and the barriers and facilitators experienced by them as a consequence of substitution in public hospitals. BACKGROUND   Nurse practitioners and physician assistants are emerging worldwide. However, despite the large amount of evidence showing the added value of these professionals, little evidence is available concerning the role, extent of substitution and facilitators and barriers experienced by them as a consequence of substitution. METHODS   Interviews were conducted and a questionnaire was completed by 43 nurse practitioners and 13 physician assistants employed in public hospitals in the south of the Netherlands in 2007. Results.  Nurse practitioners and physician assistants performed a broad spectrum of tasks, but differed significantly in the time spent and the kind of tasks performed. Nurse practitioners spent 25% (10·4 hours; SD = 5·5) and physician assistants 40% (18·7 hours; SD = 7.6) of their time on medical procedures. They both also performed new tasks or tasks for which there previously was insufficient capacity. Many of them experienced policy/organizational, legal, financial or facility problems in the reallocation of tasks. CONCLUSION   Nurse practitioners and physician assistants have wide ranging but different responsibilities in public hospitals. By performing medical procedures and new tasks or tasks for which there was not enough capacity, they function as substitutes and supplements for doctors. However, barriers are affecting the extent of substitution. The challenge ahead is to remove the barriers experienced by nurse practitioners and physician assistants.

Shared decision making in chronic care in the context of evidence based practice in nursing

In the decision-making environment of evidence-based practice, the following three sources of information must be integrated: research evidence of the intervention, clinical expertise, and the patients values. In reality, evidence-based practice usually focuses on research evidence (which may be translated into clinical practice guidelines) and clinical expertise without considering the individual patients values. The shared decision-making model seems to be helpful in the integration of the individual patients values in evidence-based practice. We aim to discuss the relevance of shared decision making in chronic care and to suggest how it can be integrated with evidence-based practice in nursing. We start by describing the following three possible approaches to guide the decision-making process: the paternalistic approach, the informed approach, and the shared decision-making approach. Implementation of shared decision making has gained considerable interest in cases lacking a strong best-treatment recommendation, and when the available treatment options are equivalent to some extent. We discuss that in chronic care it is important to always invite the patient to participate in the decision-making process. We delineate the following six attributes of health care interventions in chronic care that influence the degree of shared decision making: the level of research evidence, the number of available intervention options, the burden of side effects, the impact on lifestyle, the patient group values, and the impact on resources. Furthermore, the patients willingness to participate in shared decision making, the clinical expertise of the nurse, and the context in which the decision making takes place affect the shared decision-making process. A knowledgeable and skilled nurse with a positive attitude towards shared decision making—integrated with evidence-based practice—can facilitate the shared decision-making process. We conclude that nurses as well as other health care professionals in chronic care should integrate shared decision making with evidence-based practice to deliver patient-centred care.

Development and usability of the MAINtAIN, an inventory assessing nursing staff behavior to optimize and maintain functional activity among nursing home residents: a mixed-methods approach

BackgroundFunctional decline is common in nursing home residents. Nursing staff can help prevent this decline, by encouraging residents to be more active in functional activities. Questionnaires measuring the extent to which nursing staff encourage functional activity among residents are lacking. In addition, there are no measurement instruments to gain insight into nursing staff perceived barriers and facilitators to this behavior. The aim of this study was to develop, and study the usability, of the MAastrIcht Nurses Activities INventory (MAINtAIN), an inventory assessing a) the extent to which nursing staff perceive to perform behaviors that optimize and maintain functional activity among nursing home residents and b) the perceived barriers and facilitators related to this behavior.MethodsUsing a mixed-methods approach the MAINtAIN was developed and its usability was studied. Development was based on literature, expert opinions, focus group (N = 3) and individual interviews (N = 14) with residents and staff from nine nursing homes in the Netherlands. Usability was studied in a cross-sectional study with 37 nurses and certified nurse assistants; data were analyzed using descriptive statistics.ResultsDevelopment of the MAINtAIN resulted in two distinctive parts: MAINtAIN-behaviors and MAINtAIN-barriers. MAINtAIN-behaviors, targeting nursing staff behavior to optimize and maintain functional activity, includes 19 items covering activities of daily living, household activities, and miscellaneous activities. MAINtAIN-barriers addresses the perceived barriers and facilitators related to this behavior and comprises 33 items covering barriers and facilitators related to the residents, the professionals, the social context, and the organizational and economic context. The usability study showed that the inventory was not difficult to complete, that items and response options were clear, and that the number of missing values was low. Few items showed a floor or ceiling effect.ConclusionsThe newly developed inventory MAINtAIN provides a usable method for researchers and nursing homes to obtain insight into nursing staff perceived behavior in optimizing functional activity among residents and their perceived barriers and facilitators related to this behavior. Outcomes of the MAINtAIN may contribute to change in nursing staff behavior and may improve nursing care. Further research with regard to the psychometric properties of the MAINtAIN is recommended.

Do nursing staff encourage functional activity among nursing home residents? : a cross-sectional study of nursing staff perceived behaviors and associated factors

BackgroundNursing home residents are mainly inactive. Nursing staff can encourage residents to perform functional activities during daily care activities. This study examines 1) the extent to which nursing staff perceive that they encourage functional activity in nursing home residents and 2) the associations between these nursing behaviors and professional characteristics, contextual factors, and information-seeking behaviors.MethodsIn this cross-sectional study, 368 registered nurses and certified nurse assistants, working in somatic and psychogeriatric wards of forty-one nursing homes throughout the Netherlands participated. Self-reported data were collected with a questionnaire, comprising the MAINtAIN-behaviors, which assesses the extent to which nursing staff encourage functional activities, including different activities of daily living (ADL), household activities, and miscellaneous encouraging activities (e.g., discouraging informal caregivers from taking over activities residents can do themselves). Additional data collected included professional characteristics (e.g., age), contextual factors (e.g., ward type), and information-seeking behaviors (e.g., reading professional journals). Descriptive statistics were used to determine the extent to which functional activities were encouraged. Hierarchical linear regression analyses were performed to determine the associations between the encouragement of functional activities and other factors.ResultsNursing staff perceived that household activities (mean 4.1 (scale range 1–9), SD 1.9) were less often encouraged than ADL (mean 6.9, SD 1.2) or miscellaneous activities (mean 6.7, SD 1.5). The percentage of nursing staff stating that different household activities, ADL, or miscellaneous activities were almost always encouraged ranged from 11 to 45%, 41 to 86%, and 50 to 83% per activity, respectively. The extent to which these activities were encouraged differed for some of the professional characteristics, contextual factors, or information-seeking behaviors, but no consistent pattern in associations emerged.ConclusionsAccording to nursing staff, household activities are not as often encouraged as ADL or miscellaneous activities. Professional characteristics, contextual factors, and information-seeking behaviors are not consistently associated with the encouragement of functional activity. Nursing staff should also focus on improving the encouragement of household activities. Future research could examine the role of other factors in encouraging functional activity, such as experienced barriers, and assess to what extent the perception of nursing staff corresponds with their actual behavior.

Promoting Functional Activity Among Nursing Home Residents: A Cross-Sectional Study on Barriers Experienced by Nursing Staff:

Objective: To obtain insight into (a) the prevalence of nursing staff–experienced barriers regarding the promotion of functional activity among nursing home residents, and (b) the association between these barriers and nursing staff–perceived promotion of functional activity. Method: Barriers experienced by 368 nurses from 41 nursing homes in the Netherlands were measured with the MAastrIcht Nurses Activity INventory (MAINtAIN)-barriers; perceived promotion of functional activities was measured with the MAINtAIN-behaviors. Descriptive statistics and hierarchical linear regression analyses were performed. Results: Most often experienced barriers were staffing levels, capabilities of residents, and availability of resources. Barriers that were most strongly associated with the promotion of functional activity were communication within the team, (a lack of) referral to responsibilities, and care routines. Discussion: Barriers that are most often experienced among nursing staff are not necessarily the barriers that are most strongly associated with nursing staff–perceived promotion of functional activity.

A conversation approach based on shared goal-setting and shared decision-making for nurses in cancer aftercare: A developmental study

PURPOSE This study aimed to develop and pretest a systematic conversation approach for nurses to tailor aftercare to oncology patients goals, unmet needs and wishes. METHODS We used an iterative developmental process for complex interventions: 1. Identifying problems 2. Identifying overall objectives 3. Designing the intervention 4. Pretesting and adapting the intervention. RESULTS The main results of the problem identification were: non-systematic and incomplete screening of potential issues, caveats in providing information, and shared decision-making. The overall objective formulated was: To develop a model for aftercare conversations based on shared goal-setting and decision-making. The conversation approach consists of four phases: 1. Preparation of the consultation including a questionnaire, 2. Shared goal-setting by means of a tool visualizing domains of life, and 3. Shared care planning by means of an overview of possible choices in aftercare, a database with health care professionals and a cancer survivorship care plan. 4. EVALUATION The results of the pretest revealed that the conversation approach needs to be flexible and tailored to the patient and practice setting, and embedded in the care processes. The conversation approach was perceived as enhancing patient-centeredness and leading to more in-depth consultations. CONCLUSION The conversation approach was developed in co-creation with stakeholders. The results of the pretest revealed important implications and suggestions for implementation in routine care. The aftercare conversation approach can be used by nurses to provide tailored patient-centered evidence-based aftercare. Tailored aftercare should support oncology patients goals, unmet needs and wishes. Further tailoring is needed.

Zelfmanagement ondersteunen op maat

SamenvattingZelfmanagement stimuleren: het wordt gezien als een goede manier om gezondheidsuitkomsten te verbeteren, de eigen regie van patiënten te vergroten en de zorgkosten te verlagen. Eikelenboom en collega’s onderzochten of op-maat-ondersteuning van zelfmanagement helpt om patiënten te activeren. Met beperkt resultaat, maar dat kan worden verklaard door vertekening in de studie. Onderzoeker Gerrie Bours legt uit waarom.

Teaching and Implementing Evidence-Based Practice in a Hospital Unit With Secondary Vocational Trained Nurses: Lessons Learned

Evidence-based practice (EBP) was systematically implemented using the implementation model by Grol et al. Barriers and facilitators for change were diagnostically analyzed. Implementation strategies were directed at the barriers. The two main implementation interventions were (a) a tailored interactive outreach training course about EBP and (b) a patient case discussion based on EBP principles. The authors learned that it is important to simplify the five EBP steps to suit the level of education of the nurses by formulating PICO questions around major patient care topics such as pain, and having a search strategy focusing on (Dutch) clinical practice guidelines and other summarized evidence, such as systematic reviews and critically appraised topics. The authors advised the hospital management to appoint nurse practitioners or other nurses with a masters degree to help the nurses on the ward with the EBP process steps, especially regarding efficiently searching the research literature and critically appraising the evidence. J Contin Educ Nurs. 2017;48(9):407-412.