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Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases. Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists. Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29-33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS. Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role.

BACKGROUND: Acute postoperative pain is still inadequately managed, despite the presence of acute pain services (APSs). This study aimed to investigate the existence, structure, and responsibilities of Dutch APSs and to review the implementation of the Dutch Hospital Patient Safety Program (DHPSP).METHODS: Information was gathered by a digital questionnaire, sent to all 96 Dutch hospitals performing surgical procedures.RESULTS: Completed questionnaires were received from 80 hospitals (83%), of which 90% have an APS. Important duties of the APS are regular patient rounds, checking complex pain techniques (100%), supporting quality improvement of pain management (87%), pain education (100%), and pain research (21%).IMPLEMENTATION OF THE DHPSP: Regular in-hospital pain training is not provided in 46% of the hospitals. Thirteen percent of the hospitals offer no patient information about pain management.CONCLUSIONS: Almost all hospitals have an APS. They differ in both the way they are locally organized, along with the activities they employ. Future research needs to compare the effect of patient and nonpatient-related activities of APSs on outcomes related to pain management.

Contains fulltext : 153218.pdf (Publisher’s version ) (Closed access) BACKGROUND: In the Dutch maternity care system, primary care midwives provide care to low-risk women and refer to obstetricians if risks or complications occur. We examined reasons for referral, management of labor, and maternal and neonatal outcomes among women who were referred during labor. METHODS: In a retrospective cohort study, descriptive analyses were performed on data obtained from patient records. Six purposively chosen hospitals in The Netherlands participated in the study from June 2011 to February 2012. The study population included 600 pregnant women who were referred during labor from primary to secondary care. MAIN OUTCOME MEASURES: Reasons for referral, interventions after referral, mode of delivery, and maternal and neonatal outcomes. RESULTS: Of women who were referred during labor, three out of four women were referred for moderate risk indications: request for pain relief (30.5%), meconium-stained liquor (25.3%), failure to progress during first stage of labor (14.0%), and prolonged ruptured membranes without contractions (12.5%). Of all women, 65.7 percent had a spontaneous vaginal delivery and 59.7 percent received some kind of pain relief. Acute referral, meaning fetal distress, occurred in 5.5 percent. Of the newborns, 2.7 percent had an Apgar score of 7 or less after 5 minutes and 1.2 percent had an umbilical cord pH < 7.05. Postpartum complications occurred among 11.0 percent of women. CONCLUSION: Women who are referred during labor have a high probability of spontaneous vaginal delivery. To improve continuity of care and satisfaction for this group of women, management of labor could be continued by trained primary care midwives.

Contains fulltext : 154277.pdf (Publisher’s version ) (Open Access) OBJECTIVE: antenatal counselling for congenital anomaly tests is conceptualised as having both Health Education (HE) and Decision-Making Support (DMS) functions. Building and maintaining a client-midwife relation (CMR) is seen as a necessary condition for enabling these two counselling functions. However, little is known about how these functions are fulfilled in daily practice. This study aims to describe the relative expression of the antenatal counselling functions; to describe the ratio of client versus midwife conversational contribution and to get insight into clients' characteristics, which are associated with midwives' expressions of the functions of antenatal counselling. DESIGN: exploratory video-observational study. PARTICIPANTS AND SETTING: 269 videotaped antenatal counselling sessions for congenital anomaly tests provided by 20 midwives within six Dutch practices. MEASUREMENTS: we used an adapted version of the Roter Interaction Analysis System to code the client-midwife communication. Multilevel linear regression analyses were used to analyse associations between clients' characteristics and midwives' expressions of antenatal counselling in practice. FINDINGS: most utterances made during counselling were coded as HE (41%); a quarter as DMS (23%) and 36% as CMR. Midwives contributed the most to the HE compared to clients or their partners (91% versus 9%) and less to the DMS function of counselling (61% versus 39%). Multilevel analyses showed an independent association between parity and shorter duration of antenatal counselling; (beta=-3.01; p

Aims and objectives The objective of this study was to evaluate whether care provided in the care programmes matched the needs of older people. Background Care programmes were implemented in primary-care settings in the Netherlands to identify frail older people and to prevent further deterioration of health. Design and methods In total, 23 older people participated in in-depth interviews. Within this study, three older people participated as co-researchers; they gathered and analysed the data together with the academic researchers. Content analysis was used to analyse the data. Results Two categories emerged from the data: ‘Losing connections’ and ‘Receiving support to reconnect.’ ‘Losing connections’ reflects the needs of older people and ‘Receiving support to reconnect’ reflects their experience and the appreciated aspects of the provided care. A relationship of trust with the practice nurse (PN) appeared to be an important aspect of care, as it fostered the sharing of feelings and issues other than physical or medical problems that could not be shared with the general practitioner. The PNs are experienced as connectors, who help to restore feelings of connectedness and older peoples’ access to resources in the community. Conclusions The relationship with the PN was experienced as valuable because of the feelings of ‘connectedness’ it created. Through this connectedness, older people could discuss feelings of loneliness, depression and frustration in receiving and acquiring the appropriate resources and services with the PNs. Furthermore, the relationship with the PN helped the older people to gain access to other health professionals and services. Implications for practice The results imply that care for frail older people should include an awareness of the importance of the trusting relationship. Nurses can play a vital role in creating a trusting relationship and are able to bridge the gap between older people and other professionals and services.

Purpose To gain qualitative insight into the rehabilitation needs of visually impaired young adults (18-25 years) and how these needs relate to the International Classification of Functioning, Disability and Health (ICF) and patient characteristics. Methods Rehabilitation needs and patient characteristics of young adults (N = 392) who applied for multidisciplinary services in 2012 and 2013 were obtained from structured and semi-structured intake records. Linking rules were used to assess how the needs related to Environmental Factors, Body Functions, Body Structures, and Activity and Participation (A&P) ICF components. The relationship between the type of rehabilitation goal and patient characteristics was assessed using multivariate logistic regression analyses. Results Most rehabilitation needs (67.6%; N = 510) were found on the A&P component of the ICF. Most prevalent needs were related to 'major life areas' (e.g. finding internship or job), followed by the chapters: 'mobility' (e.g. self-reliance in travelling), 'communication' (e.g. using communication devices and techniques), 'general tasks and demands' (e.g. psychological aspects of vision loss) and 'domestic life' (e.g. household tasks). Patients in one of the multidisciplinary rehabilitation centres (odds ratio (OR) = 7.07; 95% confidence interval (CI) [2.97-16.83]) and patients with comorbidity (OR = 3.82; 95% CI [1.62-9.02]) were more likely to report rehabilitation needs related to chapter E3 'support and relationships'. Conclusion 'Major life areas' prevail in the content of rehabilitation needs, but tend to overshadow topics regarding peer interaction and social, community and civic life. A suitable survey method for young adults with visual impairments is required that contains rehabilitation domains and goals relevant to their lives and development.

Our objective was to explore the needs and value of case management according to patients with amyotrophic lateral sclerosis (ALS), their spousal caregivers, and health care professionals in the context of multidisciplinary ALS care. We undertook semi-structured interviews with 10 patients with ALS, their caregivers (n = 10) and their ALS health care professionals (n = 10), and held a focus group (n = 20). We transcribed the audio-taped interviews and analysed all data thematically. Participants indicated that in certain circumstances case management can have an added value. They identified factors for receptiveness to case management: adequacy of usual care, rate of disease progression, and degree of social network support and personal factors of patients and spousal caregivers. Participants valued the time for consultation, house calls and proactive approach of the case manager. Patients with ALS and caregivers appreciated emotional support, whereas professionals did not mention the importance of emotional support by the case manager. In conclusion, ALS teams can consider implementation of valued aspects of case management (accessibility, ample time, proactive approach, emotional support) in the usual multidisciplinary ALS care. Additional support might be provided to patients with rapidly progressive disease course, passive coping style and small social network.

Beleidmakers, professionals en onderzoekers spreken steeds vaker over vitaliteit als een aan gezondheid gerelateerd begrip. Er bestaan verschillende omschrijvingen van vitaliteit en een geschikt instrument om vitaliteit te meten ontbreekt. Om het beeld over vitaliteit aan te scherpen is gewerkt aan een eenduidige omschrijving en een bijbehorend meetinstrument (de Vita-16) ontwikkeld. Vitaliteit is omschreven op basis van (wetenschappelijke) literatuur en de kennis en ervaring van experts. De ontwikkeling van een meetinstrument (de Vita-16) bestond uit vier stappen: na het samenstellen van een ‘pool’ items op basis van literatuur (stap 1) zijn de items gereduceerd na een Delphi studie onder beleidmakers, professionals en onderzoekers (stap 2) en samengevoegd tot een vragenlijst. Deze is in een pilotstudie (stap 3) getest op kenmerken zoals begrijpelijkheid en plafondeffect. De conceptvragenlijst is afgenomen bij 1300 volwassen Nederlanders voor reductie van items, en testen van de structurele en construct validiteit (stap 4: validatiestudie). In het begrip ‘vitaliteit’ zijn drie kerndimensies te onderscheiden: ‘Energie’, ‘Motivatie’ en ‘Veerkracht’. Energie wordt gekenmerkt door zich energiek voelen, motivatie door doelen stellen in het leven en moeite doen om deze te behalen, en veerkracht door het vermogen om met de dagelijkse problemen en uitdagingen van het leven om te gaan. Het resultaat van stap 1 was een pool van 151 items, waaruit overlappende items (n=38) en items die determinanten van vitaliteit meten (n=59) werden verwijderd. De resterende 54-itemslijst werd in de Delphi ronde gereduceerd tot 33 items. In de validatiestudie bleef een 16-item vragenmodule (de Vita-16) over die de drie kerndimensies van vitaliteit meet en die betrouwbaar (α:0,89-0,95) bleek en (afhankelijk van het criterium) een redelijk tot goede validiteit vertoonde. Het begrip vitaliteit is te omschrijven met drie kerndimensies die valide meetbaar zijn in de volwassen bevolking met een 16-item vragenmodule (de Vita-16).

Item does not contain fulltext BACKGROUND: video recording studies have been found to be complex; however very few studies describe the actual introduction and enrolment of the study, the resulting dataset and its interpretation. In this paper we describe the introduction and the use of video recordings of health care provider (HCP)-client interactions in primary care midwifery for research purposes. We also report on the process of data management, data coding and the resulting data set. METHODS: we describe our experience in undertaking a study using video recording to assess the interaction of the midwife and her client in the first antenatal consultation, in a real life clinical practice setting in the Netherlands. Midwives from six practices across the Netherlands were recruited to videotape 15-20 intakes. The introduction, complexity of the study and intrusiveness of the study were discussed within the research group. The number of valid recordings and missing recordings was measured; reasons not to participate, non-response analyses, and the inter-rater reliability of the coded videotapes were assessed. Video recordings were supplemented by questionnaires for midwives and clients. The Roter Interaction Analysis System (RIAS) was used for coding as well as an obstetric topics scale. FINDINGS: at the introduction of the study, more initial hesitation in co-operation was found among the midwives than among their clients. The intrusive nature of the recording on the interaction was perceived to be minimal. The complex nature of the study affected recruitment and data collection. Combining the dataset with the questionnaires and medical records proved to be a challenge. The final dataset included videotapes of 20 midwives (7-23 recordings per midwife). Of the 460 eligible clients, 324 gave informed consent. The study resulted in a significant dataset of first antenatal consultations involving recording 269 clients and 194 partners. CONCLUSION: video recording of midwife-client interaction was both feasible and challenging and resulted in a unique dataset of recordings of midwife-client interaction. Video recording studies will benefit from a tight design, and vigilant monitoring during the data collection to ensure effective data collection. We provide suggestions to promote successful introduction of video recording for research purposes.

While older people live in developing countries, little is known about the relative importance of features of their communities in influencing their liveability. We examine components of home and neighbourhood among older South Africans. Linear regression analyses revealed that features of home (basic amenities, household composition, financial status and safety) and neighbourhood (ability to shop for groceries, participate in organizations and feel safe from crime) are significantly associated with life satisfaction. Approaches to liveability that are person-centred and also set within contexts beyond home and neighbourhood are needed to address boundaries between home and neighbourhood; incorporate personal resources into liveability models and import broader environmental contexts such as health and social policy.

To investigate the pattern of associations between changes in unmet needs and treatment motivation in elderly patients with severe mental illness. Observational longitudinal study in 70 patients treated by an assertive community treatment team for the elderly. Unmet needs and motivation for treatment were measured using the Camberwell assessment of needs for the elderly and the stages-of-change (SoC) scale, respectively, at baseline, after 9 and 18 months. SoC scores were dichotomized into two categories: motivated and unmotivated. Multinomial logistic regression analyses were conducted to determine whether changes in motivation were parallel to or preceded changes in unmet needs. The number of patients who were not motivated for treatment decreased over time (at baseline 71.4 % was not motivated, at the second measurement 51.4 %, and at 18 months 31.4 % of the patients were not motivated for treatment). A decrease in unmet needs, both from 0–9 to 0–18 months was associated with remaining motivated or a change from unmotivated to becoming motivated during the same observational period (parallel associations). A decrease in unmet needs from 0 to 9 months was also associated with remaining motivated or a change from unmotivated to motivated during the 9–18 months follow-up (sequential associations). Our findings suggest that a decrease in unmet needs is associated with improvements in motivation for treatment.

Despite more attention being given to geriatrics in medical curricula, few new physicians are seeking training in this field. So far, there has been no exploration of factors in the hidden curriculum that could potentially influence the persisting lack of interest in this field of medicine. To study this hidden curriculum in medical education in relation to medical care of elderly patients, the authors used a qualitative research design including participant observations on two internal medicine wards in a teaching hospital and semistructured interviews. The results showed that elderly patients with multiple problems are seen as frustrating and not interesting. Medical students were not stimulated to go into the totality of medical problems of elderly patients. They picked up a lot of disparaging remarks about these patients. The mainly negative attitudes demonstrated by role models, in particular the residents, may potentially influence the development of future doctors and their choice of career.

Objective: To investigate the latent structure of somatic symptom reports in the general population with a bi-factor model and apply the structure to the analysis of change in reported symptoms after the emergence of an uncertain environmental health risk. Methods: Somatic symptoms were assessed in two general population environmental health cohorts (AMIGO, n = 14,829 & POWER, n = 951) using the somatization scale of the four-dimensional symptom questionnaire (4DSQ-S). Exploratory bi-factor analysis was used to determine the factor structure in the AMIGO cohort. Multi-group and longitudinal models were applied to assess measurement invariance. For a subsample of residents living close to a newly introduced power line (n = 224), we compared a uni- and multidimensional method for the analysis of change in reported symptoms after the power line was put into operation. Results: We found a good fit (RMSEA = 0.03, CFI = 0.98) for a bi-factor model with one general and three symptom specific factors (musculoskeletal, gastrointestinal, cardiopulmonary). The latent structure was found to be invariant between cohorts and over time. A significant increase (p < .05) was found only for musculoskeletal and gastrointestinal symptoms after the power line was put into operation. Conclusions: In our study we found that a bi-factor structure of somatic symptoms reports was equivalent between cohorts and over time. Our findings suggest that taking this structure into account can lead to a more informative interpretation of a change in symptom reports compared to a unidimensional approach.

Ruijs CDM, Kerkhof AJFM, Van der Wal G, Onwuteaka-Philipsen BD.Ondraaglijk lijden van terminale kankerpatienten. Huisarts Wet2015;58(5):238-41. Bij kankerpatienten in de laatste levensmaanden in de eerste lijn hebben we onderzoek verricht naar de prevalentie van ondraaglijke symptomen, de relatie tussen symptoomintensiteit en ondraaglijk lijden, en de kwalitatieve kenmerken van ondraaglijke symptomen. Gedurende drie jaar hebben 44 huisartsen kankerpatiёnten geincludeerd die naar verwachting binnen een half jaar zouden overlijden. Met een onderzoeksinstrument, de State of Suffering-V, hebben we bij de deelnemende patienten om de twee maanden intensiteit en ondraaglijkheid van 69 symptomen gemeten. Ook hebben we algeheel ondraaglijk lijden gemeten. Met open vragen hebben we de aard van ondraaglijke symptomen geexploreerd. De laatste interviews voor overlijden hebben we geanalyseerd. De beschrijvingen van ondraaglijk lijden hebben we gecategoriseerd volgens een schema van kwalitatieve kenmerken van lijden. Van de 148 patienten die we hebben gevraagd aan ons onderzoek deel te nemen heeft 51% geparticipeerd; 64 patienten hebben we gevolgd tot aan hun overlijden. Algehele zwakte was ondraaglijk bij 57%; pijn was ondraaglijk bij een op de vier patiёnten. Bij een hoge symptoomintensiteit waren pijn, verlies van controle over het eigen leven en angst voor toekomstig lijden vaak ondraaglijk (89-92%). Bij een lage symptoomintensiteit waren verlies van controle over het eigen leven, overgeven en het niet kunnen doen van belangrijke dingen vaak ondraaglijk (52-80%). Terminale kankerpatienten in de eerste lijn kunnen worden geconfronteerd met een breed scala aan ondraaglijke symptomen van fysieke, psychische, sociale en existentiele aard. Zwakte was het meestvoorkomende ondraaglijke symptoom. Zowel symptomen met een hoge intensiteit als symptomen met een lage intensiteit kunnen ondraaglijk zijn.

Heidegger’s understanding of death in terms of possibility has been debated for more than three decades. The main dispute is about the coherence of the concept of possibility. To advance the debate, we analyse the meaning of “death as a possibility” in three steps. Firstly, we delineate the notions of death and possibility in Heidegger’s fundamental ontology. Secondly, we analyse and evaluate the main opposed interpretations of death as a possibility. Thirdly, we discuss Heidegger’s assertion that death is a distinctive [ausgezeignete] possibility of Dasein. On the basis of the results, we claim that Heidegger provides an ontic-ontological and multilayered framework for the understanding of death. We further argue that one of those layers relates to death as a transcendent possibility for Dasein, which can be further characterised in terms of non-genuine, genuine and—what we call—deconstructive [Abbauende] authenticity. Finally, we suggest that deconstructive authenticity refers to Dasein’s authentic relationship to its own ontological annihilation. As this annihilation cannot be phenomenologically depicted, deconstructive authenticity implies that Dasein is, to a certain extent, free to depict the meaning of its death.

Item does not contain fulltext STUDY QUESTION: Do in vitro fertilization (IVF) multiples generate higher hospital costs than IVF singletons, from birth up to age 5? SUMMARY ANSWER: Hospital costs from birth up to age 5 were significantly higher among IVF/ICSI multiple children compared with IVF/ICSI singletons; however, when excluding the costs incurred during the birth admission period, hospital costs of multiples and singletons were comparable. WHAT IS KNOWN ALREADY: Concern has risen over the long-term outcome of children born after IVF. The increased incidence of multiple births in IVF as a result of double-embryo transfer predisposes children to a poorer neonatal outcome such as preterm birth and low birthweight. As a consequence, IVF multiples require more medical care. Costs and consequences of poorer neonatal outcomes in multiples may also exist later in life. STUDY DESIGN, SIZE, DURATION: All 5497 children born from IVF in 2003-2005, whose parents received IVF or ICSI treatment in one of five participating Dutch IVF centers, served as a basis for a retrospective cohort study. Based on gestational age, birthweight, Apgar and congenital malformation, children were assigned to one of three risk strata (low-, moderate- or high-risk). PARTICIPANTS/MATERIALS, SETTING, METHODS: To enhance the efficiency of the data collection, 816 multiples and 584 singletons were selected for 5-year follow-up based on stratified (risk) sampling. Parental informed consent was received of 322 multiples and 293 singletons. Individual-level hospital resource use data (hospitalization, outpatient visits and medical procedures) were retrieved from hospital information systems and patient charts for 302 multiples and 278 singletons. MAIN RESULTS AND THE ROLE OF CHANCE: The risk of hospitalization (OR 4.9, 95% CI 3.3-7.0), outpatient visits (OR 2.6, 95% CI 1.8-3.6) and medical procedures (OR 1.7, 95% CI 1.2-2.2) was higher for multiples compared with singletons. The average hospital costs amounted to euro10 018 and euro2093 during the birth admission period (P < 0.001), euro1131 and euro696 after the birth admission period to the first birthday (not significant (n.s.)) and euro1084 and euro938 from the second to the fifth life year (n.s.) for multiples and singletons, respectively. Hospital costs from birth up to age 5 were 3.3-fold higher for multiples compared with singletons (P < 0.001). Among multiples and singletons, respectively, 90.8 and 76.2% of the total hospital costs were caused by hospital admission days and 8.9 and 25.2% of the total hospital costs during the first 5 years of life occurred after the first year of life. LIMITATIONS, REASONS FOR CAUTION: Resource use and costs outside the hospital were not included in the analysis. WIDER IMPLICATIONS OF THE FINDINGS: This study confirms the increased use of healthcare resources by IVF/ICSI multiples compared with IVF/ICSI singletons. Single-embryo transfer may result in substantial savings, particularly in the birth admission period. These savings need to be compared with the extra costs of additional embryo transfers needed to achieve a successful pregnancy. Besides costs, health outcomes of children born after single-embryo transfer should be compared with those born after double-embryo transfer. STUDY FUNDING/COMPETING INTERESTS: This study was supported by a research grant (grant number 80-82310-98-09094) from the Netherlands Organization for Health Research and Development (ZonMw). There are no conflicts of interest in connection with this article. TRIAL REGISTRATION NUMBER: Not applicable.

Despite a growing diversity within society and health care, there seems to be a discrepancy between the number of cultural minority physicians graduating and those in training for specialization (residents) or working as a specialist in Dutch academic hospitals. The purpose of this article is to explore how performance appraisal in daily medical practice is experienced and might affect the influx of cultural minority physicians into specialty training. A critical diversity study was completed in one academic hospital using interviews (N = 27) and focus groups (15 participants) with cultural minority physicians and residents, instructing specialists and executives of medical wards. Data were digitally recorded and transcribed verbatim. A thematic and integral content analysis was performed. In addition to explicit norms on high motivation and excellent performance, implicit norms on professionalism are considered crucial in qualifying for specialty training. Stereotyped imaging on the culture and identity of cultural minority physicians and categorical thinking on diversity seem to underlie daily processes of evaluation and performance appraisal. These are experienced as inhibiting the possibilities to successfully profile for selection into residency and specialist positions. Implicit criteria appear to affect selection processes on medical wards and possibly hinder the influx of cultural minority physicians into residency and making academic hospitals more diverse. Minority and majority physicians, together with the hospital management and medical education should target inclusive norms and practices within clinical practice.

Context. The practice of euthanasia and physician-assisted suicide (EAS) is always complex, but some cases are more complex than others. The nature of these unusually complex cases is not known.Objectives. To identify and categorize the characteristics of EAS requests that are more complex than others.Methods. We held in-depth interviews with 28 Dutch physicians about their perception of complex cases of EAS requests. We also interviewed 26 relatives of patients who had died by EAS. We used open coding and inductive analysis to identify various different aspects of the complexities described by the participants.Results. Complexities can be categorized into relational difficulties-such as miscommunication, invisible suffering, and the absence of a process of growth toward EAS-and complexities that arise from unexpected situations, such as the capricious progress of a disease or the obligation to move the patient. The interviews showed that relatives of the patient influence the process toward EAS.Conclusion. First, the process toward EAS may be disrupted, causing a complex situation. Second, the course of the process toward EAS is influenced not only by the patient and his/her attending physician but also by the relatives who are involved. Communicating and clarifying expectations throughout the process may help to prevent the occurrence of unusually complex situations. (C) 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Contains fulltext : 139247.pdf (Publisher’s version ) (Open Access) Physician gender is associated with differences in the male-to-female ratio between specialities and with preferred working hours. We explored how graduating students' sex or full-time or part-time preference influences their speciality choice, taking work-life issues into account. Graduating medical students at Radboud University Medical Centre, the Netherlands participated in a survey (2008-2012) on career considerations. Logistic regression tested the influence of sex or working hour preference on speciality choice and whether work-life issues mediate. Of the responding students (N = 1,050, response rate 83, 73.3 % women), men preferred full-time work, whereas women equally opted for part time. More men chose surgery, more women family medicine. A full-time preference was associated with a preference for surgery, internal medicine and neurology, a part-time preference with psychiatry and family medicine. Both male and female students anticipated that foremost the career of women will be negatively influenced by family life. A full-time preference was associated with an expectation of equality in career opportunities or with a less ambitious partner whose career would affect family life. This increased the likelihood of a choice for surgery and reduced the preference for family medicine among female students. Gender specifically plays an important role in female graduates' speciality choice making, through considerations on career prospects and family responsibilities.

Objective: Hearing loss at high frequencies produces perceptual difficulties and is often an early sign of a more general hearing loss. This study reports the development and validation of two new speech-based hearing screening tests in English that focus on detecting hearing loss at frequencies above 2000 Hz. Design: The Internet-delivered, speech-in noise tests used closed target-word sets of digit triplets or consonant–vowel–consonant (CVC) words presented against a speech-shaped noise masker. The digit triplet test uses the digits 0 to 9 (excluding the disyllabic 7), grouped in quasi-random triplets. The CVC test uses simple words (e.g., “cat”) selected for the high-frequency spectral content of the consonants. During testing, triplets or CVC words were identified in an adaptive procedure to obtain the speech reception threshold (SRT) in noise. For these new, high-frequency (HF) tests, the noise was low-pass filtered to produce greater masking of the low-frequency speech components, increasing the sensitivity of the test for HF hearing loss. Individual test tokens (digits, CVCs) were first homogenized using a group of 10 normal-hearing (NH) listeners by equalizing intelligibility across tokens at several speech-in-noise levels. Both tests were then validated and standardized using groups of 24 NH listeners and 50 listeners with hearing impairment. Performance on the new high frequency digit triplet (HF-triplet) and CVC (HF-CVC) tests was compared with audiometric hearing loss, and with that on the unfiltered, broadband digit triplet test (BB-triplet) test, and the ASL (Adaptive Sentence Lists) speech-in-noise test. Results: The HF-triplet and HF-CVC test results (SRT) both correlated positively and highly with high-frequency audiometric hearing loss and with the ASL test. SRT for both tests as a function of high-frequency hearing loss increased at nearly three times the rate as that of the BB-triplet test. The intraindividual variability (SD) on the tests was about 2.1 (HF-triplet) and 1.7 (HF-CVC) times less than that for the BB-triplet test. The effect on the HF-triplet test of varying presentation method (professional or cheap headphones and loudspeakers) was small for the NH group and somewhat larger, but nonsignificant for the hearing-impaired group. Test repetition produced a moderate, significant learning effect for the first and second retests, but was small and nonsignificant for further retesting. The learning effect was about two times larger for the HF-CVC test than for the HF-triplet test. The sensitivity of both new tests for high-frequency hearing loss was similar, with an 87% true-positive and 7% false-positive ratio for detecting an average high-frequency hearing loss of 20 dB or more. Conclusions: The new HF-triplet and HF-CVC tests provide a sensitive and accurate method for detecting high-frequency hearing loss. The tests may signal developing hearing impairment at an early stage. The HF-triplet is preferred over the HF-CVC test because of its smaller learning effect, smaller error rate, greater simplicity, and lower cultural dependency., We have developed 2 new simple, internet-delivered, speech-innoise tests for high-frequency (HF) hearing loss. They may be used at home or in the clinic/lab as screening tests or as outcome measures for hearing rehabilitation. The new tests, HF-triplet and HFCVC (Consonant-Vowel-Consonant), both showed better sensitivity for detecting HF hearing loss (HL) than the standard broadband BBtriplet test. The accuracy of the HF-triplet was 2.5 times that of the BB-triplet test. A small training effect for the HF-triplet was about half that of the HF-CVC. The HF-triplet out performed the HF-CVC test in both accuracy and test repeatability and is recommended for screening HFHL.

Objectives: To assess insomnia and its correlates as part of the Services and Health for Elderly in Long TERm care (SHELTER) study, funded by the 7th Framework Programme of the European Union. Design: Cross-cultural investigation. Setting: Long-term care facilities (LTCFs) in eight European countries (Czech Republic, France, Finland, Germany, England, the Netherlands, Italy) and one non-European country (Israel). Participants: Elderly residents (N = 4,156) of 57 LTCFs. Measurements: Information on insomnia, age, sex, activities of daily living (ADLs), cognitive status, depression, major stressful life events, physical activity, fatigue, pain, and sleep medication use was extracted from the International Resident Assessment Instrument (interRAI)LTCF instrument. Rates of insomnia and its correlates were analyzed. Multivariate logistic regression was used to assess factors associated with insomnia, controlling for demographic variables. Results: The prevalence of insomnia was 24% (range 13–30%), with significant differences between countries (P < .001). More insomnia complaints were reported in older than younger residents (P < .001). Higher rates of insomnia were associated with hypnosedatives and depression in all countries (P < .001) and with stressful life events, fatigue, and pain in most countries (P < .001). No associations were found between insomnia and ADLs, physical activity, or cognitive status. Age, depression, stressful life events, fatigue, pain and hypnosedatives were independent significant predictors of insomnia, controlling for all other variables and for country. Conclusion: Hypnosedatives and depression were strong predictors of insomnia beyond cultural differences. Overall, psychosocial variables were more strongly related to insomnia than functional and mental capacities.

Ziel: Einsicht in moralische Dilemmata von Mitarbeitern einer psychiatrischen Station in Bezug auf freiheitseinschrankende Masnahmen, Darstellung des Nutzens ethischer Fall-Deliberationen und der Implementierung dieser klinischen Ethikberatung auf Station. Methodik: Qualitative Studie mit Interviews, Fokusgruppen und teilnehmender Beobachtung. Ergebnisse: Die Dilemmata der Mitarbeiter betreffen Kamerauberwachungen und Freiheitseinschrankungen durch Abschliesen der Station (Privatsphare bzw. Freiheit versus Sicherheit) sowie Zwangsbehandlungen (Freiheit versus Gesundheit). Die Einfuhrung ethischer Fall-Deliberationen verbessert die Behandlungsqualitat, die Professionalitat der Mitarbeiter und die Teamzusammenarbeit. Voraussetzung ist eine Atmosphare des Vertrauens sowie die Expertise der Gesprachsleitung und der aktive Einsatz eines lokalen Koordinators. Hindernisse konnen in der Verfugbarkeit von Arzten und dem Zeitaufwand liegen. Schlussfolgerung: Ethische Fall-Deliberationen starken die moralische Kompetenz der Mitarbeiter im Umgang mit Dilemmata in der psychiatrischen Versorgung.

Evaluation is often used as a vehicle to improve program implementation. To evaluate the implementation of programs that provide care for frail older people a Community of Practice (COP) was developed in the Netherlands. The purpose of this paper is to describe and reflect on the role of a CoP in the implementation of these programs. Using a responsive evaluation approach this study was based on interviews with participating stakeholders and transcripts of the CoP meetings with 13 professionals, project managers and patient representatives. Findings showed that CoP members had unanticipated concerns regarding the pro-active approach of the programs and older people not being open to receiving care. The heterogenic composition was appreciated and fostered learning. A social infrastructure was created for active learning inside and outside the CoP. We conclude that a CoP is a useful strategy as part of an evaluation aimed at improving program implementation. Lessons learned include the importance of creating ownership among CoP members by sharing responsibilities and paying attention to the heterogenic group composition and professional language spoken to involve all members.

Worldwide, transgender women are a high burden population for sexually transmitted diseases. Neovaginal high-risk human papillomavirus (hrHPV) infection has been documented among transgender women, but its prevalence remains unclear. The objective of this study was to determine the prevalence of neovaginal hrHPV in a sample of transgender women in The Netherlands.Between June 2015 and December 2015, neovaginal samples were obtained from all transgender women who underwent vaginoplasty and attended our outpatient clinic for postoperative follow-up at least 1 year after surgery. High-risk HPV DNA detection and partial genotyping was performed by the HPV-risk assay. Genotyping of non-16/18-hrHPV-positive samples was subsequently performed by GP5+/6+-PCR followed by Luminex suspension array technology. Physical examination and standardized (sexual) history taking was conducted.Valid neovaginal swabs were obtained from 54 transgender women (median age, 40.7 years [range, 19.2-60.3]; median postoperative time, 2.4 years [range, 1.0-34.2]). No transgender women were employed in the commercial sex industry. Of 28 sexually active transgender women, 6 (20%) tested positive for neovaginal hrHPV including types 16, 45, 51, 59, 66, and X. There were no concomitant neovaginal lesions nor neovaginal symptoms. All sexually inactive transgender women tested negative for neovaginal hrHPV.A prevalence of neovaginal hrHPV infection of 20% is observed in Dutch transgender women, who self-reported to be sexually active. The clinical consequences neovaginal hrHPV infection in transgender women require further attention.

Integrated care programs have been developed to enhance the quality care for older adults in primary care. These programs usually consist of a multidisciplinary approach, with personalised care based on comprehensive geriatric assessments. However, there is limited evidence for the effectiveness of these programs in frail older people. In this article, we review the results of three recent intervention studies carried out as part of the Dutch National Care for the Elderly Programme. The results illustrate how difficult it is to improve outcomes in community-dwelling frail older adults by means of integrated care. Furthermore, we discuss the implications of these studies for future research into frailty interventions.

Predictive brain implants enable forecasting neuronal events, and advising the patient to prepare for the consequences or even prevent them. They may also be used for automatic delivery of the medi...

Purpose: The construct validity, test–retest reliability, and measurement error of the Arm Function in Multiple Sclerosis Questionnaire (AMSQ) were examined. Additionally, the influence of administration-method on reliability and measurement error was investigated. Method: 112 Dutch adult MS-patients from an academic- and a residential care-facility participated. Questionnaires were administered on paper, online or as interview, and patients performed several performance tests. Construct validity was assessed by testing pre-defined hypotheses. Reliability was assessed using Intraclass Correlation Coefficients (ICCs), Standard Error of Measurements (SEMs) and Smallest Detectable Changes (SDCs). Results: For construct validity (N = 105) 9 of 13 hypotheses were confirmed (69%). As expected, the AMSQ showed moderate to strong relationships with the instruments measuring similar constructs. The test–retest reliability coefficient was 0.96 (95% Confidence Interval 0.94–0.97); SEM was 6.3 (6.3% of scale range); SDC was 17.5 (on a sale from 0 to 100). Different administration-methods showed good reliability (ICC 0.88–0.94) and small standard errors (SEM 5.6–7.2). Conclusion: The AMSQ shows satisfying results for validity and excellent reliability; allowing for proper use in research. Due to a large SDC value, caution is needed when using the AMSQ in individual patient care. Further research should determine whether the SDC is smaller than the minimal important change.Implications for Rehabilitation The Arm Function in Multiple Sclerosis Questionnaire (AMSQ) measures activity limitations due to hand and arm functioning in patients with Multiple Sclerosis (MS). Results of this study confirm adequate validity and reliability of the AMSQ in patient with MS. The equivalence of scores from online, paper or interview administration is supported. A change score of ≥18 points on the scale of the AMSQ (on a scale 0–100) needs to occur to be certain a change beyond measurement error has occurred in an individual patient.

Outcomes of proactive home visit programs for frail, older people might be influenced by aspects of the caregiver–receiver interaction. We conducted a naturalistic case study to explore the interactional process between a nurse and an older woman during two home visits. Using an ethics of care, we posit that a trusting relationship is pivotal for older people to accept care that is proactively offered to them. Trust can be build when nurses meet the relational needs of older people. Nurses can achieve insight in these needs by exploring older people’s value systems and life stories. We argue that a strong focus on older people’s relational needs might contribute to success of proactive home visits for frail, older people.

BACKGROUND: A "less than good" experience during childbirth can affect a mother's early interaction with her child and may significantly influence a woman's emotional well-being. In this study, we focus on clients who experienced midwifery care provided during childbirth as "less than good" care. The aim of this study was to understand the relationship between client-related factors and the experience of midwifery care during childbirth to improve this care.METHODS: This study was part of the "DELIVER study" where mothers report on the care they received. We used generalized estimation equations to control for correlations within midwife practices. Forward multivariate logistic regression analyses were conducted to model the client-related factors associated with the experienced midwifery care during childbirth.RESULTS: We included the responses of 2,377 women. In the multivariable logistic regression model, odds of reporting "less than good care" were significantly higher for women who experienced an unplanned cesarean birth (OR 2.21 [CI 1.19-4.09]), an instrumental birth (OR 1.55 [CI 1.08-2.23]), and less control during the dilation phase (OR 0.98 [CI 0.97-0.99]) and pushing phase (OR 0.98 [CI 0.97-0.99]).DISCUSSION: Birth-related factors were more likely than maternal characteristics to be associated with the experience of midwifery care during childbirth. We conclude that there is room for midwives to improve their care for women during childbirth particularly in improving the patient centeredness of the care provider, using strategies to enhance sense of control, and focusing on the particular needs of those who experience instrumental vaginal or unplanned cesarean births.

Summary The number of compulsory admissions in Dutch psychiatry has increased in the past 25 years. The reduction of coercion with Family Group Conferences in youth care has been successful. How, when and under what conditions can Family Group Conferences reduce coercion in adult psychiatry, is subject of an extensive inquiry. This paper, however, focusses on the reverse question, namely, in what circumstances can Family Group Conferences not be deployed? An answer to this question provides insights regarding situations in which Family Group Conferences may (not) be useful. Barriers in 17 cases were examined using multiple case studies. Findings The following barriers emerged: (1) the acute danger in coercion situations, the limited time available, the fear of liability and the culture of control and risk aversion in mental health care; (2) the severity of the mental state of clients leading to difficulties in decision-making and communication; (3) considering an Family Group Conference and involving familial networks as an added value in crisis situation is not part of the thinking and acting of professionals in mental health care; (4) clients and their network (who) are not open to an Family Group Conference. Applications Awareness of the barriers for Family Group Conferences can help to keep an open mind for its capacity to strengthen the partnership between clients, familial networks and professionals. The application of Family Group Conferences can help to effectuate professional and ethical values of social workers in their quest for the least coercive care.

In this manuscript, we evaluated the effectiveness of an intervention programme consisting of integrated care and a participatory workplace intervention on supervisor support, work instability and at-work productivity after 6 months of follow-up among workers with rheumatoid arthritis (RA). We conducted a randomized controlled trial; we compared the intervention programme to usual care. Eligible patients were diagnosed with RA, had a paid job (> 8 h per week) and who experienced, at least, minor difficulties in work functioning. Supervisor support was measured with a subscale of the Job Content Questionnaire, work instability with the Work Instability Scale for RA, and at-work productivity with the Work Limitations Questionnaire. Data were analyzed using linear regression analyses. A beneficial effect of the intervention programme was found on supervisor support among 150 patients. Analyses revealed no effects on work instability and at-work productivity. We found a small positive effect of the intervention on supervisor support, but did not find any effects on work instability and at-work productivity loss. Future research should establish whether this significant but small increase in supervisor support leads to improved work functioning in the long run. This study shows clinicians that patients with RA are in need of efforts to support them in their work functioning. Implications for Rehabilitation Rheumatoid arthritis (RA) is a chronic inflammatory disease with a severe impact on work functioning, even when a patient is still working. It is important to involve the workplace when an intervention is put in place to support RA patients in their work participation. Supervisor support influences health outcomes of workers, and it is possible to improve supervisor support by an intervention which involves the workplace and supervisor

Purpose – For accountability purposes, performance information sharing and clear divisions of responsibilities between medical specialists and executive boards are critical. The purpose of this paper is to explore whether these aspects of clinical governance have been taken up by executive boards and medical specialists in the Netherlands. Design/methodology/approach – This cross-sectional study aimed to explore the information-sharing between medical specialists and executive boards in Dutch hospitals as one key aspect of clinical governance. Between November 2010 and February 2011, 67 medical staff board chairs and 40 chief executive officers completed an online questionnaire concerning information-sharing and the clinical governance practices within their respective hospitals. Findings – Almost all respondents acknowledged the importance of information-sharing. However, the actual sharing differed per type of performance information. Policy/management information was shared more often than patient care information. Similarly, medical specialists differ in the degree of responsibility the take for specific clinical governance tasks. Almost all were involved in managing complication registries (99 per cent), while few managed hospital accreditation (55 per cent). Research limitations/implications – With executive boards and medical specialists being increasingly dependent of a shared budget, they have an extra incentive to share information and to take up clinical governance tasks. The study showed that Dutch medical specialists are sharing many types of performance information with the executive board, but that this should be increased to comply with the codes. Thus far, few hospital managers in the study have formalised this in an information protocol, which is potentially the next step for other hospital staff to incorporate as well. Those who have an information protocol seem to be aware of the business case for quality. Originality/value – This study is the first attempt to explore to what extent Dutch medical specialists share performance information with their respective executive boards and take up clinical governance tasks.

Objectives: Many breast cancer patients suffer from (severe) menopausal symptoms after an early onset of menopause caused by cancer treatment. The standard treatment for these complaints is hormone replacement therapy, which, however, is contraindicated for this group, as it may have tumor-promoting effects. The aim of this study was to assess the cost-effectiveness of three interventions aimed at alleviating these symptoms: cognitive-behavioral therapy (CBT), physical exercise (PE), and the combination of both (CBT+PE).Methods: A cost-effectiveness analysis was performed from a health care system perspective. The primary outcome was incremental health care costs (IHCC) per patient with a clinically relevant improvement after six months of treatments. The secondary outcome was incremental costs per quality-adjusted life years (QALYs) gained over a five-year time period. This was assessed using a Markov model, populated with data from a recent randomized controlled trial evaluating the effectiveness of CBT, PE, and CBT+PE in the clinical setting and additional cost data. The robustness of the results was analyzed through one-way and probabilistic sensitivity analyses.Results: IHCCs for alleviating one patient of the perceived symptom burden by a clinically relevant difference after six months of treatment were EUR€605 for CBT, EUR€1,847 for CBT+PT, and EUR€1,250 for PE alone, compared to the waiting list control group. CBT generated 0.009 additional QALYs at an additional cost of EUR€162, compared to the control group, leading to an Incremental Cost Utility Ratio (ICUR) of EUR€18,655 per QALY gained and The ICUR of CBT+PE was EUR€42,375 per QALY in comparison to the control group. CBT had a high probability (circa 61%) of being cost-effective at prevailing ceiling ratios.Conclusions: CBT is likely the most cost-effective of the three interventions investigated for alleviating treatment-induced menopausal symptoms in breast cancer patients.

Objectives: To explore changes in specialty preferences and work-related topics during the theoretical phase of Dutch medical education and the role of gender. Methods: A cohort of medical students at Radboudumc, the Netherlands, was surveyed at start (N=612, 69.1% female) and after three years (N=519, 69.2% female), on specialty preferences, full-time or part-time work, motivational factors, and work-life issues. Chi square tests were performed to analyze gender-differences, and logistic regression to explore the influence of gender on considerations. Results: A total of 214 female and 78 male students completed both surveys. After three years, the male students remained highly interested in surgery, but the female students increasingly preferred gynecology. These initial preferences were predictive. Four out of five male students versus three out of five female students continued to show a full-time preference. Women increasingly preferred part-time work. After three years, the combination of work, care, and patient contact motivated female students more, whereas salary remained more important to male students. Female students indicated that their future careers would influence their family life; male students assumed having a family would only affect their partners' careers. Conclusions: Against an international background of the feminization of medicine, our study shows that career considerations are reinforced early in medical studies. Women prefer to work fewer hours and anticipate care tasks more often. Students' preferences reflect Dutch cultural norms about working men and women. Therefore, guidance in choice-making much earlier in medical education can create opportunities. Gender Challenges in Medical Education

Grote verschillen in arbeidssatisfactie onder bedrijfsartsen waren aanleiding voor het uitvoeren van een kwalitatief onderzoek naar wat bedrijfsartsen motiveert in hun werk (satisfiers) en wat hen frustreert (dissatisfiers) in relatie tot de werksetting. Er zijn elf focusgroepinterviews afgenomen met Intercollegiale toetsingsgroepen waarbij 87 bedrijfsartsen waren betrokken. In dit artikel wordt verslag gedaan van de dissatisfiers. Deze zitten vooral in de grote commerciele arbodiensten en hebben betrekking op organisatie en leiding. Hoewel ook zelfstandigen worden geconfronteerd met minimale contracten en hinder ervaren van casemanagementbureaus, hebben zij geen management aan wie zij dit kunnen verwijten. Hun dissatisfiers hebben betrekking op financiele onzekerheid en druk vanuit bedrijven. In alle settings is er bij de klanten sprake van een toegenomen zakelijkheid, hogere eisen, een kritischer opstelling en juridisering.

Over the last decades, international research, policy, and practice in the field of mental health care and a complementary variety of social work and social service delivery methods have been focused on recovery as a dominant concept. Emphasizing the service user’s responsibility appears to be a central component in the empowering process of recovery. Using a critical disability studies perspective, we aimed to untangle the relationship between the individual citizen with mental health problems and the society in which the recovery discourse operates in Belgium. In this article we explore the social dynamics in the unique life story of Jimmy Sax and analyze a diversity of discourses and practices that turned him into a nonrecyclable citizen. While exploring the different modes through which Jimmy’s subjectivity was transformed throughout the course of his life, we expose the convoluted nature of the recovery paradigm, which leads to a reconceptualization of the notion of responsibility in recovery.

In recent years there has been a distinguishable trend towards user involvement in ageing research. Researchers and policy makers both are increasingly convinced that user involvement is necessary to adapt research questions and methods to meet the needs of older people. Little is known, however, about the quality of collaborations between older people and researchers. This study systematically evaluates a collaboration undertaken between two academic researchers and three older people acting as co-researchers in an effort to identify the conditions required for equal collaboration. To evaluate the collaboration the co-researchers and academic researchers took part in individual in-depth interviews (after six months) and two reflection meetings (after six and 12 months). Throughout the collaboration, field notes were taken by both academic researchers and co-researchers. A detailed description of the collaboration is provided here, using the metaphor of a journey to illustrate the dynamics and the learning process of the participants. Interim reflection meetings – at which mutual expectations were expressed along with a frank discussion of prejudices, tasks and role divisions, and the sharing of personal and project-related needs and information – were found to be fruitful in achieving a positive working relationship and fostering an effective collaboration. We conclude that a learning perspective on participation can be a resource for learning and adaptive change.

Article-at-a-Glance Background Given growing awareness of the crucial role of nontechnical skills in providing safe patient care, crew resource management (CRM) training is being increasingly used to improve them. Implementing the plans of action that are formulated during CRM training may constitute an important first step in the successful uptake of skills. Accordingly, understanding the factors that determine why participants do or do not carry out those plans should help improve CRM training and enhance its impact. A study was conducted to examine the impact of pretraining readiness factors and posttraining barriers and facilitators on follow-up on plans of action. Methods Three ICUs, each at a different nonacademic teaching hospital in the Netherlands, received two-day classroom-based CRM training in 2010. During the training, new ideas for safety initiatives were documented as concrete plans of action. All plans were categorized as individual (for example, "Always ask a colleague to double-check your medication"), team, or organizational. Two months before and three months after the CRM training, all ICU employees were asked to fill out a set of questionnaires. Results Management support for patient safety before the training was a positive determinant of the number of perceived facilitators. A significant relationship was found between the perceived barriers and facilitators after CRM training and Taking Action. More barriers were negatively associated, while more facilitators were positively associated, with Taking Action. When assessed separately, none of the readiness factors were significantly associated with taking action, while when assessed together, the readiness factors were positive related to Taking Action. Discussion To overcome the barriers and profit from the facilitators, they should be considered during the training and in regular CRM meetings afterward.

Background: Although communicating effectively with patients receiving palliative care can be difficult, it may contribute to maintaining or enhancing patients’ quality of life. Little is known about the effect of training general practitioners in palliative care–specific communication. We hypothesized that palliative care patients of general practitioners exposed to the ‘Availability, Current issues and Anticipation’ communication training programme would report better outcomes than patients of control general practitioners. Aim: To evaluate the effectiveness of the Availability, Current issues and Anticipation training programme for general practitioners on patient-reported outcomes. Design: In a controlled trial, general practitioners followed the Availability, Current issues and Anticipation programme or were part of the control group. Patients receiving palliative care of participating general practitioners completed the Palliative Care Outcome Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative, the Rest & Peace Scale, the Patient Satisfaction Questionnaire–III and the Availability, Current issues and Anticipation Scale, at baseline and 12 months follow-up. We analysed differences between groups using linear mixed models. Trial registration: ISRCTN56722368. Setting/participants: General practitioners who attended a 2-year Palliative Care Training Course in the Netherlands. Results: Questionnaire data were available for 145 patients (89 in intervention and 56 in control group). We found no significant differences over time between the intervention and control groups in any of the five outcome measures. Ceiling effects were observed for the Rest & Peace Scale, Patient Satisfaction Questionnaire–III and Availability, Current issues and Anticipation Scale. Conclusion: General practitioner participation in the Availability, Current issues and Anticipation training programme did not have a measurable effect on any of the outcomes investigated. Patients reported high levels of satisfaction with general practitioner care, regardless of group assignment. Future research might focus on general practitioners without special interest in palliative care.

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder (OCD), and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient's autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient's and the therapist's perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist's approach, who used motivational interventions with a view to appealing to the patient's responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions.

For the first time, 8 patients with psoriatic arthritis (PsA) participated as full delegates at the 2013 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). Patients were invited to provide their perspective for different sessions of the conference program. Before the conference, the patient delegates had a separate meeting to familiarize themselves with the conference program and to gain a better understanding of the vision and objectives of GRAPPA. During the conference, the patient group discussed options for increased involvement in research projects. Herein we summarize the presentations on patient participation in research, the experiences of the patient group, and plans to enhance the patient perspective in psoriasis and PsA research.

Grote verschillen in arbeidssatisfactie onder bedrijfsartsen waren de aanleiding voor het uitvoeren van een kwalitatief onderzoek naar wat bedrijfsartsen motiveert in hun werk (satisfiers) en wat hen frustreert (dissatisfiers). Daarbij is speciaal aandacht besteed aan de betekenis van de werksetting. Er zijn elf focusgroepinterviews afgenomen waarbij 87 bedrijfsartsen waren betrokken. In dit artikel wordt verslag gedaan van de satisfiers. In een volgend artikel gaan we in op de dissatisfiers.

Contains fulltext : 137446.pdf (Publisher’s version ) (Open Access) OBJECTIVE: this study aims to provide insight into: (a) midwives' views on appropriate antenatal counselling for congenital anomaly tests, and (b) whether these views match clients' preferences regarding antenatal counselling. DESIGN: a comparative (midwives versus clients) questionnaire survey. Cognitive interviews (n=8) were used to validate the internal validity of the midwifery questionnaire results. PARTICIPANTS AND SETTING: 1416 Dutch midwives (response 62%) completed a questionnaire measuring their views on appropriate antenatal counselling for congenital anomaly tests. MEASUREMENTS: we used the 58-item midwives' version of the QUOTE (prenatal), an instrument to assess clients' counselling preferences. Descriptive statistics were used to explore midwives' views on appropriate counselling and how these relate to client preferences as measured previously with the clients' version of the QUOTE (prenatal). FINDINGS: almost all midwives consider the client-midwife relation (100%) and health education (95%) to be (very) important for appropriate antenatal counselling for congenital anomaly tests. Almost half of the midwives consider decision-making support (47%) to be (very) important. These findings are practically congruent with client preferences. Still, clinically relevant differences were found regarding 13 individual items, e.g. more clients than midwives value 'medical information about congenital anomalies' and 'getting advice whether to take prenatal tests or not'. KEY CONCLUSION: like clients, most midwives value a good client-midwife relation and health education as (very) important for antenatal counselling for congenital anomaly tests. Less than half of them value decision-making support. These findings are in contrast with the literature in which decision-making support is seen as the most important part of antenatal counselling for congenital anomaly tests. IMPLICATION FOR PRACTICE: preferably, antenatal counselling for congenital anomaly tests should be consistent with the three-function model of antenatal counselling i.e. maintaining a client-midwife relation, providing health education as well as decision-making support, and tailored to clients' individual preferences. As not all midwives subscribe to these functions, reflection on their views is important. Furthermore, midwives need to bridge their views on appropriate antenatal counselling and client preferences. To do so, midwives may benefit from the Shared Decision Making approach.

To describe factors influencing the QoL of patients with Parkinson's disease (PD), as experienced by patients themselves.A qualitative design was used to investigate which factors influence the QoL of patients with PD as this design allows one to focus sufficiently on (reporting) the experiences of patients and their perspectives.Interviews with patients (n = 27) were organized which formed the input for four focus groups and participants were selected by the Dutch Parkinson Association (PV).The results illustrate that patients mentioned a broad array of issues related to their QoL, including intra- and interpersonal factors, quality of care, societal pressure and communication. Participants developed a model symbolizing a radar wheel to illuminate the complex and dynamic inter-relations between the themes affecting their QoL. How the set of factors actually influences a person's life differs per patient and per situation.The QoL of patients with PD is influenced by many interacting factors related to their health, personal relations, care, communication and society. To improve the QoL and care for persons with PD, all factors should be taken into account. Person-centred care recognizes the uniqueness and capabilities of patients with PD.

Aim To understand whether and how Family Group Conferencing might contribute to the social embedding of clients with mental illness. Background Ensuring the social integration of psychiatric clients is a key aspect of community mental health nursing. Family Group Conferencing has potency to create conditions for clients' social embedding and subsequently can prevent coercive measures. Design A naturalistic qualitative case study on the process of one conference that was part of 41 conferences that had been organized and studied from January 2011–September 2013 in a public mental health care setting in the north of the Netherlands. Methods Semi-structured interviews (N = 20) were conducted with four stakeholder groups (N = 13) involved in a conference on liveability problems in a local neighbourhood wherein a man with schizophrenia resides. Findings To prevent an involuntary admission to a psychiatric ward of a man with schizophrenia, neighbourhood residents requested a family group conference between themselves, the sister of the man and the mental health organization. As a possible conference aggravated psychotic problems, it was decided to organize it without the client. Nine months after the conference, liveability problems in the neighbourhood had been reduced and coercive measures adverted. The conference strengthened the community and resulted in a plan countering liveability problems. Conclusion The case indicates that social embedding of clients with severe psychiatric problems can be strengthened by Family Group Conferencing and that hence coercive measures can be prevented. A shift is required from working with the individual client to a community driven approach.