Clara Pérez-Esteve

Objective: To develop a consensus-based framework of quality indicators for Neurorehabilitation Units. Design: Delphi consensus study with two-phase external validation. Setting: Expert consultation and external validation were conducted through online questionnaires. Participants: Twelve neurorehabilitation experts participated in the Delphi process. External validation involved 63 independent specialists and a multidisciplinary panel of nine professionals. Intervention: Development of quality indicators through a three-round Delphi process following Conducting and REporting DElphi Studies (CREDES) recommendations. Main measures: Expert agreement on candidate indicators, with consensus defined a priori as ≥75%. Results: An initial qualitative expert-generation phase produced 38 candidate indicators. These were subsequently refined through three Delphi rounds, during which indicators were retained, merged, reformulated, added, or disaggregated according to expert consensus and accreditation level. The final framework comprised 50 indicators categorized into structure (21), process (13), and outcome (16) domains. External validation confirmed the relevance and clarity of the framework, although implementation challenges were identified in centres with heterogeneous resources. Conclusions: The proposed framework provides a structured set of quality indicators that may support quality assessment, accreditation, and continuous improvement in neurorehabilitation services.

Background: Informal caregivers perform complex home-care tasks but often lack structured training, causing preventable safety risks and burden. Technology-enhanced simulation provides practice; psychoeducational programs that flag risky activities may strengthen safety behaviors and self-efficacy. Comparing costs guides scalable caregiver training. Objective: This study compared the cost-consequences of traditional and immersive digital simulation for home care, focusing on costs, errors avoided, and caregiver-burden reduction. Methods: This is a prospective observational comparative cohort study with secondary cost-consequence analysis and incremental cost-effectiveness ratios (ICERs) versus control, expressed in €/error avoided and €/burden point reduced. Costs are reported in euros. A prespecified synthesis of 3 coordinated studies yielded 3 active arms plus a control cohort, implemented independently between August 2023 and July 2025 under a shared core protocol in comparable Spanish home-care settings. Arms were psychoeducation, virtual reality (VR), 360° video training (360VT), and standard education as control. Outcomes were 3-month changes in self-reported errors and caregiver burden, measured with the Zarit Burden Interview-7 (ZBI-7; 0–28). Costing adopted a societal perspective and included staff time, caregiver time, and development costs amortized over 3 years at 200 participants/year. Downstream health care use was modeled by applying 1%–5% of follow-up incidents (base case 2%) to a €1,257 composite unit cost. Combined costs equaled direct plus downstream costs, with no discounting over 3 months. Costs and consequences were reported in natural units, including incremental and pairwise comparisons. Results: A total of 282 caregivers were included (psychoeducational n=71, VR n=70, 360VT n=71, and control n=70). Incident changes over a 3-month period were: +0.44 (95% CI 0.06 to 0.82) for control, −0.51 (95% CI −0.89 to −0.13) for psychoeducational, −0.56 (95% CI −0.97 to −0.20) for VR, and −0.20 (95% CI −0.66 to 0.09) for 360VT. Combined cost/per participant (direct +2% downstream) was: €46.88 for control, €77.04 for psychoeducational, €105.60 for VR, and €42.97 for 360VT. ICERs versus control were: (1) for errors avoided, —€31.75/error (95% CI €19.78 to −€54.98) for psychoeducation, €58.72/error (95% CI €39.40 to −€97.89) for VR, and 360VT was dominant, saving €6.11 (95% CI €4.24 to −€10.63) per error avoided, with €3.91 (95% CI €3.52 to −€4.29) saved per participant; (2) for burden reduced (ZBI-7), −€55.85/point (95% CI €38.27 to −€98.68) for psychoeducational, €45.88/point (95% CI €32.12 to −€76.67) for VR, and 360VT was dominant, saving €6.41 (95% CI €4.42 to −€11.23) per point reduced, with €3.91 (95% CI €3.52 to −€4.29) saved per participant. Pairwise for burden were as follows: (1) VR versus psychoeducational, €38.59 (95% CI €26.89 to −€66.13) per extra point; (2) 360VT versus psychoeducational dominant; and (3) VR versus 360VT, €93.48 (95% CI €64.41 to −€163.85) per extra point. Conclusions: This real-world cost-consequence analysis innovatively compares immersive and nonimmersive training for informal caregivers from a societal perspective, using harmonized safety, burden, and downstream cost outcomes. Findings support stepped adoption: 360VT as a scalable default, VR for higher-risk tasks or caregivers with greater burden, and psychoeducation as a complementary low-cost strategy when resources are constrained.

Background/Objectives: Adequate nutrition in older adults is essential to maintaining health, functionality, and quality of life, particularly in long-term care hospitals (HACLEs). Previous studies suggest that dissatisfaction with hospital food is linked to longer stays, more complications, and negative perceptions of care. Given these concerns, this study aimed to assess patients’ experiences with hospital food over a 15-year period in a HACLE in Spain, identify key influencing factors, and validate an updated PREM (Patient Reported Experience Measure) tool for food services. Methods: A retrospective, observational, repeated cross-sectional study was conducted using annual PREM surveys administered between 2011 and 2025 to patients on oral diets. Psychometric validation of the updated 8-item version (2024) was conducted. Results: Out of 1618 surveys, 1540 were included in the final analysis. The updated PREM showed strong internal consistency (α = 0.85, ω = 0.87), a two-factor structure (food quality and service conditions), and adequate model fit. Perceptions worsened after a catering company change in 2022 but improved following the implementation of new food distribution carts in 2025. The PREM total score showed a strong positive association with the global satisfaction item, providing supportive evidence based on a closely related anchor measure (Spearman’s rho = 0.80, 95% CI 0.77–0.82; p < 0.001). Scores differed significantly by diet type: patients receiving a pureed diet reported the highest average satisfaction score, followed by those on a soft diet and a regular diet. The group on a soft diet excluding foods that pose a choking hazard had the lowest mean score. Conclusions: The validated PREM scale is a reliable tool to monitor patient experience with hospital food. It enables early detection of quality issues and supports targeted improvements. Routine use in long-term care settings may foster personalized, patient-centered nutrition strategies and enhance care quality.

Background: Informal caregivers play a crucial role in home care and many lack formal training, potentially compromising patient safety. Immersive virtual reality (VR) offers an innovative approach to training by simulating real-life caregiving scenarios in a risk-free environment. Prior to implementation, the environments and the technique’s feasibility and acceptability must be assessed by the professionals who will use it to train caregivers, establishing a performance benchmark based on experienced health care professionals. Objective: This study aims to test feasibility and develop exploratory benchmarks and acceptability of immersive VR training for home caregiving tasks, using experienced professionals to establish a reference standard for execution quality. Methods: This observational study was conducted in health care centers in Andalusia, the Valencian Community, and Madrid (Spain). A structured process was followed, including the identification of key home care tasks, the development of best practice guidelines, creation of immersive VR training materials, and the design of a performance evaluation rubric. Health care professionals (n=75) were recruited using a convenience sampling approach. They performed caregiving tasks in VR, and their performance was recorded and assessed using a standardized rubric, which included 205 predefined errors. Participants also completed a posttraining survey evaluating usability, comprehension, and perceived applicability to real-world caregiving. Results: A total of 75 professionals participated, completing 257 caregiving simulations in a fully immersive VR environment. A total of 417 errors were identified (417/3142, 13.3% of the maximum number of predefined errors), with a mean average of 5.6 (SD 6.8) errors per participant. The most frequent errors occurred in medication management, insulin administration, diaper changing, broncho aspiration prevention, blood pressure monitoring, and hand hygiene. The perceived usefulness of VR training was rated 8.1 out of 10 points (SD 1.9), with 98.7% (74/75) of the participants stating that the time spent in the simulation was worthwhile and 85.3% (64/75) agreeing that the tasks were appropriately represented. Conclusions: Immersive VR training for informal caregivers is a feasible and well-accepted approach, demonstrating high perceived usefulness among health care professionals. The study establishes a preliminary benchmark for home caregiving task execution, providing a basis for future research evaluating informal caregivers’ performance and targeted training interventions to enhance patient safety. Further studies are needed to explore the long-term impact of VR training on caregiver competence and home care quality.

Background/Objectives: Schizophrenia Spectrum Disorder (SSD) represents a major challenge for healthcare systems due to its chronic nature, comorbid conditions, and high socioeconomic impact. Ensuring high-quality care for patients with SSD requires well-defined quality criteria based on consensus from healthcare professionals, patients, and caregivers. This study aims to identify and prioritize quality criteria for SSD care. Methods: A qualitative research approach was applied, including incorporating two focus groups—one with patients and caregivers (n = 7) and another with healthcare professionals (n = 8)—alongside the Delphi technique. The Delphi panel included 32 participants from psychiatry, primary care, mental health nursing, social work, and patient associations. The first round had an 88.9% response rate, while the second round achieved full participation (100%). The Delphi process was conducted and reported according to recommended guidelines for consensus methods (ACCORD checklist), specifying panel composition, rounds, predefined consensus thresholds, and controlled feedback between rounds. Results: A total of 26 quality criteria were ultimately selected, categorized into 16 identified barriers to effective care. Key priorities included early diagnosis protocols, coordinated multidisciplinary care, and improved access to specialized mental health services. Conclusions: The findings underscore the necessity of integrating patient experience into healthcare evaluation and highlight the potential for implementing a certification system to standardize SSD care across healthcare settings.

Background: Hand hygiene is a critical strategy for preventing health care–associated infections (HAIs) and reducing health care costs. However, adherence remains low, particularly among health care assistants (HCAs) and informal caregivers (ICs), who often lack formal training. Virtual reality (VR) delivers standardized, immersive practice with active learning and real-time feedback. It has shown favorable effects on skill execution and acceptability in training paramedics and caregivers. To our knowledge, VR has not been systematically applied to train World Health Organization (WHO)–aligned hand hygiene techniques. Given its portability and suitability for brief, repeatable drills, VR is a plausible solution to upskill HCAs and ICs in both hospital and home-care settings. Objective: This study aims to assess the immediate training effectiveness and implementation feasibility of a brief VR-based hand hygiene program for HCAs and ICs in Colombia. We quantified pre-post changes in correct execution (primary outcome), timing, errors, and knowledge. Success was defined a priori as achieving ≥75% correct execution after training, consistent with adherence levels associated with HAI reductions when embedded in WHO-aligned bundles in prior studies. Methods: In this quasi-experimental, one-group pretest-posttest study, 215 participants (94 HCAs, 121 ICs) completed up to three 15-minute VR training sessions with real-time feedback on hand hygiene technique following the WHO recommendations for hand hygiene. Data were collected at baseline (pre) and immediately after the VR intervention (post). Variables assessed included correct execution (primary; binary), error counts, timing adequacy, knowledge assessment, and acceptability. Results: Correct hand hygiene performance increased from 26.6% to 97.9% among HCAs (95% CI 92.6-99.4; P<.001) and from 9.9% to 95.9% among ICs (95% CI 90.7-98.2; P<.001), with paired odds ratios of 34.5 (95% CI 8.46-140.72) and 21.8 (95% CI 8.90-53.43), respectively. Wide intervals were driven by the very small number who performed worse after training. Timing adequacy improved significantly in both groups, reaching 46.6 (SD 6.7) and 48 (SD 6.6) seconds, respectively (P<.001). Common errors, such as insufficient fingertip coverage and incomplete thumb cleaning, were reduced to near 0 (P<.001). Knowledge scores also improved significantly in both groups, and VR training was rated as “very useful” or “extremely useful” for skill acquisition. Conclusions: VR training significantly improved hand hygiene technique and knowledge. The high acceptance rates observed suggest that these technologies can effectively enhance infection prevention skills in undertrained populations, supporting broader adoption in health care education. Because this brief, portable, and highly acceptable intervention can be embedded in routine onboarding, refresher microdrills, and caregiver education—including home care and resource-constrained settings—VR is well-suited for scale-up. When implemented within WHO-aligned multimodal bundles and with adherence sustained above pragmatic thresholds, this approach may contribute to downstream reductions in HAIs. Definitive confirmation will require a controlled effectiveness trial. Trial Registration: ClinicalTrials.gov NCT07005544; https://clinicaltrials.gov/study/NCT07005544

BACKGROUND Hand hygiene is a critical strategy for preventing health care–associated infections (HAIs) and reducing health care costs. However, adherence remains low, particularly among health care assistants (HCAs) and informal caregivers (ICs), who often lack formal training. Virtual reality (VR) delivers standardized, immersive practice with active learning and real-time feedback. It has shown favorable effects on skill execution and acceptability in training paramedics and caregivers. To our knowledge, VR has not been systematically applied to train World Health Organization (WHO)–aligned hand hygiene techniques. Given its portability and suitability for brief, repeatable drills, VR is a plausible solution to upskill HCAs and ICs in both hospital and home-care settings. OBJECTIVE This study aims to assess the immediate training effectiveness and implementation feasibility of a brief VR-based hand hygiene program for HCAs and ICs in Colombia. We quantified pre-post changes in correct execution (primary outcome), timing, errors, and knowledge. Success was defined a priori as achieving ≥75% correct execution after training, consistent with adherence levels associated with HAI reductions when embedded in WHO-aligned bundles in prior studies. METHODS In this quasi-experimental, one-group pretest-posttest study, 215 participants (94 HCAs, 121 ICs) completed up to three 15-minute VR training sessions with real-time feedback on hand hygiene technique following the WHO recommendations for hand hygiene. Data were collected at baseline (pre) and immediately after the VR intervention (post). Variables assessed included correct execution (primary; binary), error counts, timing adequacy, knowledge assessment, and acceptability. RESULTS Correct hand hygiene performance increased from 26.6% to 97.9% among HCAs (95% CI 92.6-99.4; P<.001) and from 9.9% to 95.9% among ICs (95% CI 90.7-98.2; P<.001), with paired odds ratios of 34.5 (95% CI 8.46-140.72) and 21.8 (95% CI 8.90-53.43), respectively. Wide intervals were driven by the very small number who performed worse after training. Timing adequacy improved significantly in both groups, reaching 46.6 (SD 6.7) and 48 (SD 6.6) seconds, respectively (P<.001). Common errors, such as insufficient fingertip coverage and incomplete thumb cleaning, were reduced to near 0 (P<.001). Knowledge scores also improved significantly in both groups, and VR training was rated as “very useful” or “extremely useful” for skill acquisition. CONCLUSIONS VR training significantly improved hand hygiene technique and knowledge. The high acceptance rates observed suggest that these technologies can effectively enhance infection prevention skills in undertrained populations, supporting broader adoption in health care education. Because this brief, portable, and highly acceptable intervention can be embedded in routine onboarding, refresher microdrills, and caregiver education—including home care and resource-constrained settings—VR is well-suited for scale-up. When implemented within WHO-aligned multimodal bundles and with adherence sustained above pragmatic thresholds, this approach may contribute to downstream reductions in HAIs. Definitive confirmation will require a controlled effectiveness trial. CLINICALTRIAL ClinicalTrials.gov NCT07005544; https://clinicaltrials.gov/study/NCT07005544

Background/Objectives: This study aims to explore how gender influences the role of informal caregivers aged 65 years, considering the increasing involvement of men in caregiving due to longer life expectancy and societal norms. Methods: A two-year cross-sectional study was conducted in the Valencian Community, Spain, involving informal caregivers of 65 years of age and older who provided home-based care for dependent individuals with chronic conditions. The participants were recruited through public health schools, carers’ associations, and clinical consultations. The caregivers completed a comprehensive semi-structured interview, which included items from the Zarit Brief Scale (seven items) to assess caregiver burden and questions about their caregiving responsibilities, training, and experience, as well as the self-perceived frequency of medication errors. Results: A sample of 80 caregivers over 65 years old was analyzed, including 23 men (28.8%) and 57 women (71.2%). Male caregivers were significantly less experienced (mean = 3.1 years, SD = 5.9) compared to female caregivers (mean = 10.1 years, SD = 13.0; p = 0.004). Men reported lower emotional and physical burdens than women (p-value = 0.003), as reflected in the Zarit scores. Caregiving performance, measured by self-reported errors, was comparable between genders. Conclusions: This study explores the growing role of older male caregivers, highlighting their lower experience and training compared to those of women but similar caregiving performance and lower burden. Additionally, trained caregivers demonstrated significantly lower odds of experiencing burden, underscoring the importance of training as a modifiable factor. The findings emphasize the need for gender-sensitive support and tailored training programs to address disparities, reduce caregiver burden, and enhance caregiving quality and equity.

Background: Providing support to second victims in workplaces is crucial for maintaining high-quality performance. Peer support approach has proven to be one of the most effective and well-accepted approaches. However, the specific competencies required for peer supporters remain unclear. This review aims to address this gap by identifying and categorising these competencies. Objective: This scoping review examines the competencies (skills, attitudes and knowledge) needed to support workers where the pressure of their roles may lead to errors that could cause harm to others. In such situations, these individuals may experience intense feelings of responsibility, potentially impacting their ability to perform their duties. In the healthcare sector, these workers are commonly referred to as ‘second victims’. Eligibility criteria: This review includes studies that define the competencies necessary for peer supporters assisting second victims in any industry. It covers all professional roles susceptible to human errors affecting people’s well-being. The focus is on peer support and psychological first aid, encompassing relevant competencies, attitudes and knowledge for addressing safety-related incidents and workplace errors. Sources of evidence: The scoping review was conducted following Arksey and O’Malley’s framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. Studies were identified through a comprehensive search of databases, including Embase, ProQuest, PsycINFO, PubMed, Scopus and Web of Science. References from eligible studies were also considered. Charting methods: Data were extracted and categorised into competency domains through a standardised process. Two reviewers independently performed data extraction, with discrepancies resolved by consensus. Results: A total of 34 studies were included in the review. Across five identified domains, 91 specific and 30 general competencies were categorised. Additionally, the review identified 29 types of peer-based interventions designed to support professionals following incidents or stressful situations. Conclusions: The findings underscore the need for well-defined competencies for peer supporters of second victims, emphasising training in communication, emotional support and role-specific knowledge. Tailoring peer support programmes to the professional context and industry-specific characteristics is essential for providing effective assistance.