Perceptions of informed consent in the care of elderly people in five European countries

The focus of this article is on elderly patients' and nursing staff perceptions of informed consent in the care of elderly patients/residents in five European countries. The results suggest that patients and nurses differ in their views on how informed consent is implemented. Among elderly patients the highest frequency for securing informed consent was reported in Finland; the lowest was in Germany. In contrast, among nurses, the highest frequency was reported in the UK (Scotland) and the lowest in Finland. In a comparison of patients' and nurses' perceptions, nurses had more positive views than patients in all countries except Finland. Patients with less need for nursing interventions in Greece and Spain gave their consent less often. The German and Greek patients were older, and the results also point to an association between this and their lower frequency of giving consent. In Spain, patients who were married or who had a family member or friend to look after their personal affairs were more likely to be included in the group whose consent was sought less often. This is the fourth of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented.     

The effect of a training course on nursing students' attitudes toward, perceptions of, and confidence in managing patient aggression

Patient aggression is a problem in many health care settings, and nursing students are among the most vulnerable to experiencing such aggression. Training courses have been suggested to help nurses better manage patient aggression. Such courses can lead to changes in attitudes toward and perceptions of, as well as greater confidence in managing, aggression. In this quasi-experimental study, we investigated the effect of a training course on nursing students' attitudes toward, perceptions of, and confidence in managing patient aggression. Students in the intervention group demonstrated enhanced confidence but no change in attitude after the training course, while students in the control group remained stable on all measures. The short time frame of the study, the training course itself, and the instruments used for monitoring attitudes toward aggression are possible reasons for these results. We tentatively conclude that it is possible to enhance nursing students' perceived confidence in managing patient aggression without changing their fundamental views of it.     

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.     

An Analysis of the Nursing Diagnosis Ineffective Management of Therapeutic Regimen Compared to Noncompliance and Orem's Self-Care Deficit Theory of Nursing

The authors compare the nursing diagnosis ineffective management of therapeutic regimen with that of noncompliance and with Orem's concept of self-care deficit. The article describes how the diagnosis of ineffective management of therapeutic regimen is more comprehensive than noncompliance. A question of patient autonomy is raised considering how the patient manages his or her therapeutic regimen. The major conclusion is that the nursing diagnosis of ineffective management of therapeutic regimen is based on continuous interaction between patient and nurse. The authors recommend that noncompliance be eliminated as a nursing diagnosis.     

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.     

An interrater reliability study of the Braden scale in two nursing homes

Background

Adequate risk assessment is essential in pressure ulcer prevention. Assessment scales were designed to support practitioners in identifying persons at pressure ulcer risk. The Braden scale is one of the most extensively studied risk assessment instruments, although the majority of studies focused on validity rather than reliability.

Objectives

The first aim was to measure the interrater reliability of the Braden scale and its individual items. The second aim was to study different statistical approaches regarding interrater reliability estimation.

Design and methods

An interrater reliability study was conducted in two German nursing homes. Residents (n = 152) from 8 units were assessed twice. The raters were trained nurses with a work experience ranging from 0.5 to 30 years. Data were analysed using an overall percentage of agreement, weighted and unweighted kappa and the intraclass correlation coefficient.

Results

Differences between nurses rating the overall Braden score ranged from 0 up to 9 points. Interrater reliability expressed by the intraclass correlation coefficient ranged from 0.73 (95% CI 0.26-0.91) to 0.95 (95% CI 0.87-0.98). Calculated intraclass correlation coefficients for individual items ranged from 0.06 (95% CI −0.31 to 0.48) to 0.97 (95% CI 0.93-0.99) with the lowest values being measured for the items “sensory perception” and “nutrition”. There was no association between work experience and the level of interrater reliability. With two exceptions, simple kappa-values were always lower than weighted kappa-values and intraclass correlation coefficients.

Conclusions

Although the calculated interrater reliability coefficients for the total Braden score were high in some cases, several clinically relevant differences occurred between the nurses. Due to interrater reliability being very low for the items “sensory perception” and “nutrition”, it is doubtful if their assessment contributes to any valid results. The calculation of weighted kappa or intraclass correlation coefficients is the most appropriate interrater reliability estimates.     

Interpreting interrater reliability coefficients of the Braden scale: a discussion paper

There are many studies investigating psychometric properties of the Braden scale, a scale that predicts the risk for pressure ulcers. The main focus of these studies is validity as opposed to reliability. In order to estimate the degree of interrater reliability a literature review revealed that numerous statistical approaches and coefficients were used (Pearson's product-moment correlation, Cohen's kappa, overall percentage of agreement, intraclass correlation). These coefficients were calculated for the individual items and the overall Braden score and were used inconsistently. The advantages and limitations of every coefficient are discussed and it is concluded that most of them are inappropriate measures. Therefore, estimating the degree of the Braden scale interrater reliability is limited to a certain extent. It is shown that the intraclass correlation coefficient is an appropriate statistical approach for calculating the interrater reliability of the Braden scale. It is recommended to present intraclass correlation coefficients in combination with the overall percentage of agreement.     

Differences in prevalence of pressure ulcers between the Netherlands and Germany--associations between risk, prevention and occurrence of pressure ulcers in hospitals and nursing homes

Aim. This study compares pressure ulcer prevalence and prevention activities in nursing homes and hospitals within two European countries. Background. Over three years stable differences have been found between the Netherlands (NL) and Germany (GER) with higher pressure ulcer rates in the NL. As previous analyses have shown, the differences cannot be entirely explained by differences in the population’s vulnerability to pressure ulcers because they still remain after risk adjustment. Therefore, the differences in prevalence must be caused by other factors. The purpose of this study is to analyse if any potential differences in preventive activities can account for the varying occurrence of pressure ulcers. Method. In both countries, nation-wide surveys were conducted annually using the same standardised questionnaires. Trained nurses examined all consenting patients of the voluntarily participating facilities. This examination included a skin assessment of the entire body. Data regarding risk factors, prevention and details about wounds were then collected. Results. In-patients of 29 German (n = 2531) and 71 Dutch (n = 10 098) nursing homes and 39 German (n = 8515) and 60 Dutch (n = 10 237) hospitals were investigated. The use of pressure-reducing devices was more common in the NL than in GER, but all other interventions were more frequently provided to German risk patients than to their Dutch counterparts. The pressure ulcer prevalence was significantly higher in the Dutch sample. After adjusting for gender, age, Braden Score and prevention, the probability of having a pressure ulcer was 8·1 times higher for Dutch nursing home residents than for German residents. Conclusion. Some of the variance in pressure ulcer prevalence between the two countries can be explained by varying pressure ulcer prevention. However, some remarkable differences still remain unexplained. Relevance to clinical practice. The extent of pressure ulcer prevention, especially repositioning and nutrition intervention provided to patients at risk, is not in accordance with international guidelines.     

Interrater reliability of the Braden scale

Pressure ulcer risk assessment scales can assist nurses in determining the individual pressure ulcer risk. Although the Braden scale is widely used throughout Germany, its psychometric properties are yet unknown. The aim of the study was to determine the interrater reliability of the Braden scale and to compare the results with those of published data. A literature review was conducted. 20 studies measuring the interrater reliability of the Braden scale were evaluated. Only three of those studies investigated the interrater reliability of single items. The Pearson product-moment correlation coefficient (0.80 to 1.00) was calculated in most studies for an evaluation of the Braden scale as a whole. However, the use of correlation coefficients is inappropriate for measuring the interrater reliability of the Braden scale. Measures of the intraclass correlation coefficient varied from 0.83 to 0.99. The investigation of the interrater reliability of the Braden scale's German version was conducted in a German nursing home in 2006. Nurses independently rated 18 and 32 residents twice. Nurses achieved the highest agreement when rating the items "friction and shear" and "activity" (overall proportion of agreement = 0.67 to 0.84, Cohen's Kappa = 0.57 to 0.73). The lowest agreement was achieved when the item "nutrition" (overall proportion of agreement = 0.47 to 0.51, Cohen's Kappa = 0.28 to 0.30) was rated. For 66% of the rated residents the difference in the obtained Braden scores was equal or less than one point. Intraclass correlation coefficients were 0.91 (95% confidence interval 0.82 to 0.96) and 0.88 (95% confidence interval 0.61 to 0.96). This indicates that the interrater reliability of the Braden scale was high in the examined setting.