BACKGROUND:Patients with a transient loss of consciousness (T-LOC) present a complex clinical situation for ambulance professionals. The challenge arises from the complexity of the diverse aetiologies associated with T-LOC and the demanding nature of the pre-hospital work environment. Insights into the experiences, dilemmas, and challenges faced by ambulance professionals in the risk assessment and decision-making in this patient category could help to understand the support they need. Our study aimed to explore the risk assessment reasoning and decision-making process of ambulance professionals in patients with a T-LOC in current practice. METHODS:We conducted a qualitative study with focus group interviews in an emergency medical services (EMS) organisation in the Netherlands. Through purposive sampling, ambulance professionals were recruited for two online focus group interviews. An interview guide, based on literature and preliminary individual interviews, was used. The focus group interviews were transcribed verbatim and analysed using thematic analysis. RESULTS:A total of eleven participants participated in two focus group interviews. Three main themes emerged: (1) Clinical reasoning covering the (initial) approach of ambulance professionals on scene, the T-LOC specific assessment, complexity of the aetiology of T-LOC, and the medical conveyance decision, (2) Collaboration describing the difficulties and facilitating factors in the interprofessional collaboration with other healthcare professionals in the chain of emergency care (e.g., general practitioners, emergency physicians, etc.) and the involvement of patients and relatives, (3) Professionalism describing the influence of professionals' experiences (e.g. professional maturity), the sense of responsibility and accountability of the ambulance professional, and their subsequent need for reflection. CONCLUSION:Ambulance professionals follow a structured approach for the clinical assessment of a patient with a T-LOC. In addition to their professional experience, the complexity of the symptom and the patient's context play a crucial role in the risk assessment reasoning and decision-making process. Ambulance professionals collaborate with other healthcare professionals to enhance their process, with varying experiences. There is a delicate balance between professionals' sense of responsibility and accountability. A non-conveyance decision is considered precarious by professionals, and adequate support from management, education and interprofessional collaboration is required to feel confident in their decision-making.

AIM:Explore the perspectives of Clinical Academic Nurses and stakeholders on strategies for positioning Clinical Academic Nurses in Dutch hospitals. DESIGN:A descriptive qualitative study. METHODS:Semi-structured interviews and focus groups were conducted with Clinical Academic Nurses and stakeholders from five hospitals involved in the positioning of Clinical Academic Nurses. Data was analysed using thematic analysis to identify strategies for positioning these nurses. RESULTS:Four themes emerged: (1) 'Supportive vision and culture' is crucial for a shared vision and enables a culture for consistent support in the positioning, (2) A clear defined and strategic 'Position of Clinical Academic Nurses' is needed for uniform positioning, (3) 'Research infrastructure' describes the important supportive elements, and (4) 'Leadership' describes Clinical Academic Nurses' pioneering role in aligning research with organisational goals which strengthens their position. CONCLUSION:Positioning Clinical Academic Nurses in hospitals requires a vision, well-defined positions, a research infrastructure, and leadership support. Long-term strategic investments are needed to integrate research into clinical nursing practice and recognise Clinical Academic Nurses as strategic assets. IMPLICATIONS FOR POLICY AND PRACTICE:Positioning Clinical Academic Nurses requires visionary leadership, institutional commitment and investment in research infrastructure. The Nurse Advisory Board should support this by aligning positioning, support and evaluation with strategic policies. Strategic hospital-academic partnerships foster research, education, mentorship and grant support. Clinical Academic Nurses should set measurable goals, proactively align research with clinical priorities and increase visibility to advance nursing practice. IMPACT:This study identifies empirically grounded insights into strategies to position Clinical Academic Nurses and offers actionable insights for management, policymakers and Clinical Academic Nurses to strengthen knowledge infrastructure and improve patient care. REPORTING METHOD:COREQ. PATIENT OR PUBLIC CONTRIBUTION:Limited patient and public involvement, focusing on feedback on preliminary results.

Background The global nursing shortage poses a critical challenge to healthcare systems. The World Health Organization projects a shortage of 4.5 million nurses by 2030. Contributing factors include an aging workforce and an increasing rate of nurse turnover, driven by high workloads, limited development opportunities, and a lack of managerial support. Intentions to leave predict actual departure and threaten the quality of care, increase patient mortality, and impose high replacement costs. While retention strategies exist, many are not tailored to nurses because nurses’ subjective experiences and perspectives are lacking, potentially limiting their effectiveness. Engaging nurses in designing these interventions may enhance their relevance and impact. Objectives (i) Identify the key factors associated with nurses’ retention in hospitals, and (ii) provide an in-depth understanding of why nurses perceive these factors as critical in shaping their retention. Design A mixed-methods approach, utilizing Q-methodology and semi-structured interviews, was employed. Setting Dutch hospitals. Participants A diverse group of 26 practicing and three former nurses. Methods Participants ranked 58 statements in response to the prompt: “I am willing to continue working as a nurse within the organization if…” Consecutively, individual interviews were conducted to provide further insight into the reasoning behind nurses’ choices. Quantitative data were analyzed using centroid factor analysis with varimax rotation to identify shared viewpoints. Qualitative interview data were analyzed using the rigorous and accelerated data reduction method to deepen the understanding of the factors shaping nurses’ retention. Results A total of 29 Q-sorts and interviews were analyzed. This resulted in three factors: (A) ‘Challenging work and inclusive positioning for high-quality care’, (B) ’Room to excel in nursing roles’, and (C) ‘Being seen, heard, and valued’. Together, these perceptions shaped participants’ intention to stay. Additionally, a common pattern across all factors was participants’ perception of being structurally unheard. Conclusions A multifaceted interplay of factors influenced nurse retention. While meaningful and challenging tasks were essential, professional recognition, support systems, and growth opportunities were equally important. A systemic approach that addresses these various dimensions may be crucial for enhancing retention rates, maintaining a high-quality of patient care, and ultimately mitigating the impact of the nursing shortage in healthcare organizations. Nurses may play a crucial role in designing and implementing retention strategies. Their input is not just valuable but most likely necessary for the relevance and effectiveness of these strategies.

BackgroundAddressing the growing challenge of nurse retention requires coordinated actions at national and global levels to improve recruitment, retention policies, and investments in the nursing work environment. The nursing work environment, defined as the "organizational characteristics of a work setting that facilitate or constrain professional nursing practice", is critical in influencing whether nurses decide to leave their jobs. This study investigates the impact of differentiated nursing practices - which involved tailoring roles and responsibilities based on nurses' training, skills, and experience in Dutch hospitals - and investigated their impact on the nursing work environment and turnover intention (i.e., nurses' intentions to leave their organization). We also explored whether the work environment mediates this relationship.MethodsA multicenter longitudinal cohort study was conducted across 19 Dutch hospitals between 2019 and 2023. Nursing professionals participated via digital surveys administered before (T0) and after (T1) differentiated nursing practices were introduced. The nursing work environment was assessed using the Practice Environment Scale of the Nursing Work Index. A multilevel analysis with a random intercept and fixed slope was used to evaluate the impact of differentiated nursing practices on the work environment and on nurses' turnover intentions.ResultsWe received 5411 responses to our questionnaire - 4259 at T0 and 1152 at T1. Results showed that, while the overall work environment improved, particularly in the dimensions of staffing and resource adequacy, collegial nurse-physician relationships, and participation in hospital affairs, there were no significant improvements in nursing foundation for quality of care or nurse managers' ability, leadership, and support of nurses. Additionally, differentiated nursing practices did not significantly impact turnover intention, nor did the work environment mediate this relationship.ConclusionsThis study is the first to explore the unique effects of practice differentiation on turnover intention mediated by the work environment. The findings suggest that, while differentiated practices can enhance certain aspects of the work environment, a more systemic and integrated approach is required for sustained improvements. Future research should include longer term studies to fully understand the complex relationship and accompanying mechanisms between differentiated nursing practices, the nursing work environment, and turnover intention.Trial registrationClinical trial number not applicable.

AIM:To explore the associations of (1) shift-to-shift Nurse Perceived Adequacy of Staffing Scale (NPASS) scores and (2) the relative contribution of individual NPASS items to nurse-perceived quality of care (NPQoC) and job enjoyment. DESIGN:Multihospital prospective observational study. METHODS:The study was conducted across 15 medical, surgical or acute admission hospital wards in three teaching hospitals in the Netherlands. Vocationally and bachelor-trained nurses conducted 1550 measurements of perceived adequacy of staffing using the NPASS, NPQoC and job enjoyment in 797 shifts. Multilevel models were used to assess associations between NPASS scores and NPASS items and the outcome variables. RESULTS:Higher NPASS scores were significantly associated with improved NPQoC and job enjoyment. An increase in 1.0 point NPASS score leads to an increase of 0.97 points in NPQoC and 1.04 points in job enjoyment. Of the NPASS items, energy level, adherence to protocols and the opportunity for adequate breaks had the most positive effect on both outcomes. CONCLUSION:Perceived adequacy of staffing as measured by the NPASS is highly relevant for improvements in both NPQoC and job enjoyment. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:Decision-makers on nurse staffing should incorporate the NPASS in staffing methods to ensure adequate staffing and the associated benefits. Policies that ensure adequate breaks, adherence to protocols and maintenance of nurses' energy levels during the shift should be implemented with special attention. IMPACT:This study provides supportive evidence for incorporating nurses' perceived adequacy of staffing, as measured by the NPASS, to ensure adequate staffing. This is crucial for nurse retention, and therefore vital to maintaining accessible healthcare given the global nursing shortages. REPORTING METHOD:The STROBE checklist was used to conduct and describe the study. PATIENT OR PUBLIC CONTRIBUTION:This study did not include patient or public involvement in its design, conduct or reporting.

Aim This study aims to identify key determinants and strategies for effectively implementing a reflection method to support adequate use of the ‘Informal Care’ guideline within community nursing. The SPARK (Self & Peer Assessment to Reflect on Quality Standards) reflection method, developed in an earlier participatory design-based study, is a structured group reflection approach designed to help nurses and nursing assistants reflect on and apply guideline recommendations in daily practice.Design A mixed method study.Setting Six community care organisations in the Netherlands.Participants and interventions This mixed-method study collected qualitative data through observations and video recordings of group meetings with community nurses, nursing assistants and a patient representative, alongside quantitative questionnaires. This project included design and test group meetings to develop and evaluate prototypes of the reflection method. Observations were discussed, and video recordings were thematically analysed. The Measurement Instrument for Determinants of Innovations questionnaire was used to identify key determinants for effective implementation. The questionnaire results were analysed descriptively, using the Tailored Implementation in Chronic Diseases (TICD) framework to present preliminary determinants for validation. Implementation strategies were then selected in a group meeting. Based on this input, the research group operationalised the selected implementation strategies.Results Twenty-nine determinants for implementing the reflection method were identified across seven TICD domains, including barriers such as limited support, knowledge and time, and facilitators such as team collaboration and prevention of caregiver overload. Based on these findings, three implementation strategies, namely knowledge enhancement, coaching development and leadership strengthening, were formulated to support integration into community nursing practice.Conclusion This study identified key determinants and strategies for implementing a reflection method in community nursing. While several determinants align with existing literature, context-specific determinants related to the heterogeneous group of registered nurses and certified nursing assistants also emerged. Strengthening guideline knowledge, coaching competencies and leadership is essential for sustainable, guideline-based reflection in practice.

Background Evidence-based practice (EBP) is crucial for appropriate, effective, and affordable care. Despite EBP education, barriers like low self-efficacy and outcome expectancy limit nurses’ engagement in EBP. Reliable scales are essential to evaluate interventions aimed at improving self-efficacy and outcome expectancy in EBP. The English Self-efficacy and Outcome Expectancy in EBP scales are psychometrically sound. Objectives To describe the translation, construct validity and internal consistency of the Dutch Self-efficacy and Outcome Expectancy in EBP Scales. Method The scales were translated forward and backward, piloted for comprehensibility and completeness and then administered among Dutch nurses and nursing students. Results Pilot testing confirmed comprehensibility, completeness, and relevance of the items. Confirmatory factor analysis (CFA) (n=769) tested a second-order model for the Self-efficacy scale (Comparative Fit Index (CFI)=0.96, Tucker-Lewis Index (TLI)=0.95, Root Mean Square Error of Approximation (RMSEA)=0.06, Standardized Root Mean Residual (SRMR)=0.04) and a single-factor model for the Outcome Expectancy Scale (CFI=0.99, TLI=0.99, RMSEA=0.06, SRMR=0.01). Chi-squared tests remained significant. Hypothesis testing confirmed construct validity of the Self-efficacy (r=0.77) and Outcome Expectancy Scale (r=0.74). Both scales exhibited high internal consistency with McDonald's Omega and Cronbach's Alpha values above 0.95. Discussion Both scales exhibit theoretical soundness and positive fit indices. Significant chi-square tests and high correlations between weighted and unweighted scores support using unweighted scores over utilizing the estimated model to calculate weighted scores. Conclusions Construct validity and internal consistency of the Dutch Self-efficacy and Outcome Expectancy in EBP Scales are good. Future research should prioritize responsiveness and test-retest reliability.

Objective: To explore the experiences and preferences of patients with wounds treated with negative pressure wound therapy (NPWT) regarding shared decision-making and patient participation. Method: Semi-structured interviews were conducted with adult patients treated with NPWT. Interview topics included shared decision-making and patients’ active participation in wound treatment. Thematic analysis was applied to identify themes. Results: The interview cohort comprised ten patients. Four themes emerged: (1) Having a wound makes patients uncertain and thus influences their quality of life; (2) NPWT influences patients’ daily lives; (3) Patients consider professional treatment decisions most important in the decision-making processes; (4) Self-management of wounds is accepted by patients only for low-complexity and well-healing wounds under supervision. Participants emphasised their worries about the future and the impact of the wound/treatment on their families. After being thoroughly informed, participants preferred that health professionals decide on the treatment choice. In addition, participants and/or their relatives did not want to actively participate in complex wound care. As well as expressing a need for qualified wound care professionals, participants reported that they did not want to be or feel responsible for the wound treatment. Conclusion: Shared decision-making and active patient participation are underused and underexposed topics in wound care. Patients’ recognition of the importance of their personal preferences can facilitate shared decision-making.

AIM:To develop a reflection method for community nurses and certified nursing assistants to support the implementation of a professional reporting guideline for nurses and certified nursing assistants in daily care and to identify its key features. DESIGN:Design-based research. METHODS:This study was conducted in the Netherlands from February 2021 to April 2022. The reflection method was developed by a design group (community nurses, certified nursing assistants and a patient representative) and four test groups of nurses. Experiences of participants were explored with video recordings and observational notes from test group meetings. The data were thematically analysed to refine the reflection method and identify key features. RESULTS:A final reflection method was developed. We identified three main themes: (1) Impact on behaviour change, (2) group learning and (3) conditional factors for critical reflection. Seven key features emerged as essential, forming the building blocks of the reflection method: focus on critical reflection, allocate time to formulate themes, include participants from various backgrounds and organisations, ensure the group is appropriately sized, allow for sufficient time, keep it simple and attractive and stimulate the group to make the transfer of learning to their clinical practice. CONCLUSIONS:The final method included two 2 h meetings with up to six participants and a coach. Participants learned from critical reflection and feedback to improve the reporting quality and critical assessment of daily practices, especially from colleagues with varying team affiliations and educational backgrounds. IMPACT:This reflection method enables community nurses and certified nursing assistants to learn collaboratively, aligning with the 'Nursing and Caring Reporting' guideline and bridging the gap between research and clinical practice. REPORT METHOD:The COREQ guideline was used. PATIENT OR PUBLIC CONTRIBUTION:The study design facilitated close collaboration among researchers, community nurses, certified nursing assistants and clients.

AIM(S):To evaluate the effects of a multifaceted de-implementation strategy (RENEW) on the volume (time in minutes) of care spent by home-based nursing care teams on three widely used low-value nursing practices: (1) 'washing the client with water and soap by default' & 'washing the client from head to toe daily', (2) 'application of zinc cream, powders or pastes when treating intertrigo' and (3) 'assisting with putting on/taking off compression stockings while the client can do this him/herself (possibly with an aid)'. DESIGN:A multicenter, quasi-experimental study using a multiple interrupted time series design. METHODS:The RENEW-strategy with components on education, persuasion, enablement, incentives and training was introduced in 31 Dutch home-based nursing care teams from two healthcare organisations. Data was collected before and after the implementation of the strategy (two before and three post measurements). For each team a separate Auto Regressive Integrated Moving Average model was fitted, looking for a difference in the underlying trend over time. The effect of the RENEW-strategy was based on a meta-analysis of the team effects using a weighted inverse-variance approach and stratified for the three low-value home-based nursing care practices. RESULTS:The RENEW-strategy reduced the weighted mean time per client per week, spent on (1) 'washing the client with water and soap by default' & 'washing the client from head to toe daily' by 13.61 min (95 % CI 12.04 to 15.18) and for the practice (3) 'assisting with putting on/taking off compression stockings while the client can do this him/herself (possibly with an aid) by 4.42 min (95 % CI: 2.49 to 6.35). However, the strategy increased the time spent on 'application of zinc cream, powders or pastes when treating intertrigo' by 1.25 min (95 % CI: 1.04 to 1.45). The small and limited changes in time trends indicate that the effects for practices (1) and (2) were sustained for three months after the implementation phase. CONCLUSION:The RENEW-strategy is capable to lead to a reduction of widely used low-value care for two of the three selected low-value care practices. The increase in time of one practice, is surpassed by the savings in time of the other two practices. By making use of available alternatives, care aids and working according to clinical nursing guidelines, this study supports the hypothesis that reducing low-value nursing care saves time to deliver more appropriate, high-value care (for example: health promotion and patient education) and work on professional development. REPORTING METHOD:Standards for Reporting Implementation Studies (StaRI) guidelines. REGISTRATION:Not registered.

BACKGROUND:Low-value care provides little or no benefit to patients, or its risk of harm outweighs the potential benefits. Non-nursing tasks refer to tasks performed by nurses below their scope of practice. With increasing pressure on the global nursing workforce, it is necessary to identify these concepts to deliver fundamental care. AIM(S):To assess the prevalence, influencing factors and associations of low-value nursing care, and to identify non-nursing tasks and potential solutions in surgical hospital care settings. DESIGN:The study followed a cross-sectional study design using a self-developed questionnaire. METHODS:A questionnaire on low-value care and non-nursing tasks was distributed to surgical wards in four hospitals in The Netherlands. RESULTS:A total of 302 nurses responded to the survey. Five most prevalent low-value care practices were identified, including routine preoperative fasting (84.8%), taking over blood glucose monitoring (59.3%) and leaving in place any type of venous catheter (42.1%). These practices were mainly performed due to habitual practice, in accordance with an established protocol, or upon physicians' request. Most reported non-nursing tasks were administrative duties and cleaning patient rooms and equipment. Provided solutions included clearly defining responsibilities and taking personal responsibility. CONCLUSION:Low-value care, provided by surgical nurses, is common in daily practice. This requires targeted de-implementation of each low-value care practice, based on influencing factors. Additionally, 85.8% of nurses perform non-nursing tasks daily or several times a day, underlining the need to re-organise nursing tasks. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:De-implementing low-value care and reducing non-nursing tasks is necessary to ease pressure on the global nursing workforce and to improve fundamental care. IMPACT:Low-value nursing care and non-nursing tasks persist when nurses lack leadership responsibility. REPORTING METHOD:STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION:No patient contribution.

Aim To evaluate nurses' perspectives on factors influencing the acceptability and practicality of comfort rounding, focussing on personalised nutritional and mobility care.Design Mixed-methods feasibility study.Methods Focus group interviews with nurses were conducted before, during and at the end of the implementation period (2022-2023). A questionnaire assessed acceptability and practicality among nurses at the end of the implementation. Data were analysed using directed content analyses and descriptive statistics.Results Comfort rounding's acceptability and practicality were influenced by nurses' attitudes, knowledge and skills, patient characteristics and the nurse-patient relationship. Barriers included workload, time pressure, team culture and the extensive, rigid design of comfort rounding. Questionnaire responses demonstrated nurses perceived added value of comfort rounding and frequently engaged patients in activities related to nutrition and mobility. However, it was not performed as originally intended.Conclusion Nurses considered personalised nutritional and mobility care important and frequently provided it during 'usual care'. However, nurses were critical of comfort rounding's acceptability and practicality and did not perform it as intended.Implications for the Profession and/or Patient Care Comfort rounding's concept does not align well with current nursing practice. Greater tailoring to nurses' preferences or alternative approaches to structuring personalised nutritional and mobility care are recommended.Impact What problem did the study address: Hospitalised patients often receive suboptimal nutritional care and are largely inactive. The challenge is to integrate personalised nutritional and mobility care effectively into standard nursing practice to enhance patient safety and well-being. Comfort rounding could improve patient safety and satisfaction; however, there is no research evaluating the feasibility of comfort rounding in relation to personalised nutritional and mobility care. What were the main findings: Comfort rounding was generally perceived as valuable and aligned with existing care routines, but its rigid structure was often considered impractical. Comfort rounding was not performed as originally intended due to the influence of individual, social and organisational factors. Flexibility in execution emerged as a critical factor for successful integration. Where and on whom will the research have an impact?: Comfort rounding can enhance attention to nutrition, mobility and patient participation when adapted to local contexts and delivered with flexibility. Policymakers and nurse leaders should avoid rigid protocols and instead support tailored implementation strategies alongside the practical delivery of locally tailored interventions.Reporting Method Consolidated criteria for reporting qualitative research and Checklist for Reporting of Survey studies.Patient or Public Contribution Nurses were involved in all stages of the study, contributing through focus group interviews and completing a questionnaire to help develop and evaluate comfort rounding.Trial Registration PaNaMa Research Management System, number 112832

Abstract Introduction The outbreak of COVID-19 showed the devastating effect of large disease outbreaks. Future pandemics and epidemics can have a significant impact on the healthcare system and, thus, the healthcare workers. Moreover, it is crucial to understand how hospital managers can manage to retain their nurses and physicians during future outbreaks. Method A meta-analysis of determinants impacting the intention to leave (ITL) during the COVID-19 pandemic was conducted. Secondly, a systematic review of other potential determinants impacting ITL during the COVID-19 pandemic was carried out. Results A comprehensive search was fulfilled within three electronic databases on 17 March 2023. Twenty-nine papers fulfilled the eligibility of criteria for the meta-analysis, and 44 papers were included in the systematic review. Meta-analysis showed a prevalence of ITL the current job of 37% for nurses (I2 >95%, p<0.001) and 33% for physicians (I2 >95%, p<0.001), whereas ITL the profession for nurses 27% (I2>95%, p<0.001) and 24% for physicians (I2>95%, p<0.001). The systematic review showed the determinants impacting ITL into six themes: personal characteristics, job demands, employment services, working conditions, work relationships, and organisational culture. Discussion/Conclusion This paper showed that over one-third of the nurses and physicians working during COVID-19 had intentions to leave their job and approximately one-third had intention to leave the profession. Understanding the influence of determinants on retention during COVID-19 offers an opportunity to formulate prospective strategies for retaining nurses and physicians within hospital settings. These insights lay the foundations for effective policies to ensure workforce stability during potential future pandemics or crisis situations.

Background/Objectives: The nursing work environment is a critical element in healthcare delivery and a strong predictor of both patient and nurse outcomes. Understanding the complexity and multifaceted nature of this environment is essential for improving nursing practices and optimizing healthcare systems. This study aimed to gain insights into the perceived characteristics of the nursing work environment, considering it as a complex and multifaceted system. Methods: A qualitative research approach was employed, involving 42 semi-structured interviews with 43 nurses and managers from academic, teaching, and general hospitals in The Netherlands. Data were collected between July 2020 and August 2021 through convenience sampling. Thematic coding was conducted to identify key patterns and themes. Results: The findings revealed that nurses demonstrated flexibility and a strong commitment to high-quality care, despite grappling with rigorous organizational tasks and processes. Four key themes emerged: (1) direct patient care as a standard feature of nursing work; (2) nurses’ flexibility for hospital productivity; (3) interdependencies, which decrease autonomous nursing practices; and (4) organizational structures that determine how nurses can shape their work. Nurses found it difficult to balance direct care with broader tasks due to organizational rigidity, revealing a gap between ideal nursing practices and daily reality. Conclusions: This study highlighted the challenges within the nursing work environment, particularly in balancing direct care with organizational demands. Addressing this gap between ideal nursing practice and reality requires a systems approach. This includes autonomous practices, supportive management, and flexible structures, allowing nurses to shape their work and enhance job satisfaction and care quality.

IntroductionThe World Health Organization defines quality of care as providing effective, evidence-based care, and avoiding harm. Low-value care provides little or no benefit to the patient, causes harm, and wastes limited resources. In 2017, shortly after the start of the International Choosing Wisely campaign, the first Dutch nursing "Do-not-do" list was published and has become a widely used practical tool for nurses working in daily practice. However, over the last years new guidelines are published. Therefore, an update of the list is necessary with an addition of high-value care recommendations as alternative care practices for low-value care.Design/methodsIn this study, a combination of designs was used. First, we searched Dutch clinical practice guidelines for low-value or high-value care recommendations. All nursing care recommendations were assessed and specified to several healthcare sectors, including hospital care, district care, nursing home care, disability care, and mental health care. Second, a prioritization among nurses regarding low-value care recommendations was done by a cross-sectional survey for each healthcare sector.ResultsIn total, 66 low-value care recommendations were found, for example, "avoid unnecessary layers under the patient at risk of pressure ulcers" and "never flush the bladder to prevent urinary tract infection." Furthermore, 414 high-value care recommendations were selected, such as "use the Barthel Index to assess and to evaluate the degree of ADL independence" and "application of cold therapy may be considered for oncological patients with pain." In total, 539 nurses from all healthcare sectors prioritized the low-value care recommendations, resulting in a top five low-value care practices per healthcare sector. The top five low-value care recommendations differed per healthcare sector, although "do not use physical restraints in case of a delirium" was prioritized by four out of five sectors.ConclusionsAssessing low-value and high-value care recommendations for nurses will help and inspire nurses to deliver fundamental care for their patients. These initiatives regarding low-value and high-value care are essential to generate a culture of continuous quality improvement based on evidence. This is also essential to meeting the current challenges of the healthcare delivery system.Clinical relevanceThis paper provides an update of low-value care recommendations for nurses based on Dutch guidelines from 2017 to 2023, specified to five healthcare sectors, including hospital care, district care, nursing home care, disability care and mental health care, with an accompanying prioritization of these low-value care recommendations to facilitate de-implementation. This paper provides a first overview of high-value care recommendations to reflect on and create alternative care practices for low-value care. The recommendations regarding low-value and high-value care are essential to generate a culture of continuous improvement of appropriateness based on evidence, finally leading to better quality of care and improving patient outcomes.

ObjectivesA positive work environment (WE) is paramount for healthcare employees to provide good quality care. To stimulate a positive work environment, employees' perceptions of the work environment need to be assessed. This study aimed to assess the reliability and validity of the Dutch version of the Culture of Care Barometer (CoCB-NL) survey in hospitals.MethodsThis longitudinal validation study explored content validity, structural validity, internal consistency, hypothesis testing for construct validity, and responsiveness. The study was conducted at seven departments in two Dutch university hospitals. The departments were included based on their managers' motivation to better understand their employees' perception of their WE. All employees of participating departments were invited to complete the survey (n = 1,730).ResultsThe response rate was 63.2%. The content of the CoCB-NL was considered relevant and accessible by the respondents. Two factor models were found. First, confirmative factor analysis of the original four-factor structure showed an acceptable fit (X2 2006.49; df 399; p = <0.001; comparative fit index [CFI] 0.82; Tucker-Lewis index [TLI] 0.80; root mean square error of approximation [RMSEA] 0.09). Second, explanatory factor analysis revealed a five-factor model including 'organizational support', 'leadership', 'collegiality and teamwork', 'relationship with manager', and 'employee influence and development'. This model was confirmed and showed a better fit (X2 1552.93; df 395; p = < 0.00; CFI 0.87; TLI 0.86; RMSEA 0.07). Twelve out of eighteen hypotheses were confirmed. Responsiveness was assumed between the measurements.ConclusionsThe CoCB-NL is a valid and reliable instrument for identifying areas needing improvement in the WE. Furthermore, the CoCB-NL appears to be responsive and therefore useful for longitudinal evaluations of healthcare employees' work environments.

Background The nursing work environment is crucial for nurses' well-being and patients’ quality of care. Despite effective interventions to improve the nursing work environment, understanding the most effective types and integration mechanisms for nurses remain challenging. As nursing practices evolve amid complex care demands and staff shortages, understanding nurses’ challenges, support systems, and adoption mechanisms is vital to optimize the work environment and to enhance quality of care, job satisfaction, and staff retention. Purpose To explore strategies for promoting and supporting nurse-led changes to improving their work environment. Methods The study employed a participatory action research design on three nursing wards in a Dutch academic hospital. Action research teams with diverse ward nurses were established on each ward. The research took place between September 2022 and October 2023. Data were collected during observations, PhotoVoice workshops, and individual interviews. Data were analyzed using the rigorous and accelerated data reduction technique. Results Nurses and managers showed patterns of behavior that either hindered or facilitated changes, leading to the emergence of three themes: strengthening relationships, taking the lead, and being up to the task. These themes highlight the importance of fostering collaboration, encouraging proactive attitudes, and building capabilities to address challenges and drive positive changes in their work environment. Feelings of uncertainty emerged in all themes, and this uncertainty hindered nurses from taking responsibility for facilitating change. Conclusions This study demonstrated different mechanisms that either facilitate or hinder nurse-led changes and how feelings of uncertainty play a role. Nurses emphasized the importance of collaboration and proactive attitudes but faced challenges in recognizing responsibility and their perceived competencies. Strengthening nurses' resilience to and management of uncertainty is essential. Healthcare organizations should help nurses navigate uncertainty to foster positive changes. Tweetable abstract Collaboration, proactivity, and competency are key in nurse-led changes. Strengthening nurses' resilience and uncertainty management is crucial.