The psychiatric-mental health nurse practitioner as coordinating practitioner in the Netherlands: A multiple case study.

BACKGROUND: Psychiatric-mental health nurse practitioners (PMHNPs) in the Netherlands have been allowed to perform the role of coordinating practitioner (CP) since 2018. This role is reserved for mental health care specialists who are trained and qualified at the master's degree level. Earlier studies have not addressed how PMHNPs perform that role and what mechanisms and contextual factors determine their performance. This understanding could help optimize their performance in this role and promote effective deployment of PMHNPs in mental health care. PURPOSE: To understand how PMHNPs perform this role and what mechanisms and contextual factors underlie that performance. METHODOLOGY: A multiple case study involving PMHNPs who work in various settings as CPs. Data were collected and analyzed using the realistic evaluation approach. RESULTS: We identified four mechanisms related to the performance of PMHNPs in the role of CP: (1) autonomous performance; (2) unique expertise; (3) accessibility, availability, and professional involvement; and (4) additional roles. The extent to which these mechanisms are present is largely determined by organizational factors, team factors, and individual factors. CONCLUSIONS: Psychiatric-mental health nurse practitioners are seeking to identify and interpret the role of CP. This study helps to elucidate the mechanism of role performance by PMHNPs and what they should focus on to deliver effective and patient-centered mental health care. IMPLICATIONS: Policymakers, health care professionals, and educators should consider the mechanisms and contextual factors to facilitate and support PMHNPs' employment and training in the role of CP.

The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study.

BACKGROUND: Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands. METHODS: We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs. RESULTS: Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care. CONCLUSIONS: This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

Facilitators for developing an interprofessional learning culture in nursing homes: a scoping review.

BACKGROUND: Healthcare professionals in nursing homes face complex care demands and nursing staff shortages. As a result, nursing homes are transforming into home-like personalised facilities that deliver person-centred care. These challenges and changes require an interprofessional learning culture in nursing homes, but there is little understanding of the facilitators that contribute to developing such a culture. This scoping review aims to identify those facilitators. METHODS: A scoping review was performed in accordance with the JBI Manual for Evidence Synthesis (2020). The search was carried out in 2020-2021 in seven international databases (PubMed, Cochrane Library, CINAHL, Medline, Embase, PsycINFO and Web of Science). Two researchers independently extracted reported facilitators that contribute to an interprofessional learning culture in nursing homes. Then the researchers inductively clustered the extracted facilitators into categories. RESULTS: In total, 5,747 studies were identified. After removing duplicates and screening titles, abstracts and full texts, 13 studies that matched the inclusion criteria were included in this scoping review. We identified 40 facilitators and clustered them into eight categories: (1) shared language, (2) shared goals, (3) clear tasks and responsibilities, (4) learning and sharing knowledge, (5) work approaches, (6) facilitating and supporting change and creativity by the frontline manager, (7) an open attitude, and (8) a safe, respectful and transparent environment. CONCLUSION: We found facilitators that could be used to discuss the current interprofessional learning culture in nursing homes and identify where improvements are required. Further research is needed to discover how to operationalise facilitators that develop an interprofessional learning culture in nursing homes and to gain insights into what works, for whom, to what extent and in what context.

Developing an interprofessional learning and working culture to improve person-centred care in nursing homes: a realist action research protocol.

INTRODUCTION: Healthcare is changing due to the ageing of the general population, complex care demands and growing attention to person-centred care. To deal with these changes and provide the best possible person-centred care, the different professionals in nursing homes should all collaborate intensively. However, most professionals work within the field of their own expertise and share very little knowledge, experiences and insights. A lack of an interprofessional learning and working culture also prevents professionals with different expertise from working and learning intensively together to achieve high-quality person-centred care. There is a gap of knowledge about how to develop such a culture. Our aim is to provide insights into what actions, in what context and to what extent can contribute to an impactful development of an interprofessional learning and working culture. METHODS AND ANALYSIS: The realist action research design will be applied. It consists of three iterative steps: plan, act and observe, and reflect. First, we will formulate the theory about interprofessional learning and working culture and measure this culture by means of interviews, focus groups and questionnaires. Second, we will apply the nine principles of Practice Development to coach professionals from six Dutch nursing homes to improve their interprofessional learning and working culture. Finally, we will evaluate the impact of the changed attitudes and skills on healthcare practice. ETHICS AND DISSEMINATION: Approval for the project was given by the Hogeschool van Arnhem en Nijmegen (HAN) Research Ethics Committee, the Netherlands, registration number EACO 164.12/19. All organisations, professionals and residents/family members will be informed verbally and by letter about the study and asked for informed consent. The results will be presented in peer-reviewed scientific journals, professional journals and at symposia and conferences. The findings will be transferred to an online toolbox and e-learning modules for graduated professionals and students.

Developing an Evidence-Based Nursing Culture in Nursing Homes: An Action Research Study.

Background: Nursing homes face challenges caused by increasing numbers of older adults with multimorbidity and the demand for quality of care. Developing an evidence-based nursing (EBN) culture is a promising strategy to face these challenges. Therefore, the aim of this study was to develop an EBN culture in nursing homes and gain insight into the influencing factors. Methods: An action research study was conducted with 12 nursing teams in 4 Dutch nursing homes, using the Practice Development approach to develop an EBN culture. The teams (mostly certified nurse assistants) were coached by internal facilitators (bachelor's or master's degree nurses) and external facilitators (nursing teachers). Data were gathered at baseline and after 15 months using questionnaires and individual and focus group interviews. Results: With varying degrees, most nursing teams implemented elements (related to values, attitudes, and behaviors) of an EBN culture with appropriate leadership, advocacy, and training. The team members became open to new insights and asked critical questions. During the project, participants learned how EBN could be incorporated into daily practice, for example, by keeping it small, discussing information from professional journals, and using creative methods such as quizzes. Influencing factors of an EBN culture were: (a) support of managers, (b) inspiring facilitators close to the team, and (c) stable teams with driving forces and student nurses. Conclusions: Integrating EBN into daily practice in creative and motivating ways contributes to the development of an EBN culture in nursing homes. To facilitate this, managers should support teams in the process and content of EBN, and internal facilitators should collaborate with driving forces on the teams.

Perceptions of interprofessional collaboration in education of dentists and dental hygienists and the impact on dental practice in the Netherlands: A qualitative study.

INTRODUCTION: The purpose of this study was to evaluate the perceptions of dentists and dental hygienists regarding their own and each other's roles in interprofessional collaboration following a clinical interprofessional educational programme (CIEP) as part of their graduate programme at Radboud university medical center (Radboudumc) and HAN University of Applied Sciences (HAN UAS), Nijmegen, the Netherlands, respectively. Perceptions were obtained at the end of their study (2014) and two years after their graduation (2016). METHODS: A qualitative study was conducted using a questionnaire with open-ended questions. Sixty-two dentists and thirty-eight dental hygienists were invited. Theory-based analyses were applied in combination with principles of Grounded Theory to analyse and synthesise the collected data from the open-ended questions. RESULTS: At baseline, 100% responded. At follow-up, thirty-two dentists (51.6%) and twenty-six dental hygienists (68.4%) responded; twenty-seven dentists (43.5%) and eighteen dental hygienists (47.4%) were included. Many similarities were found between baseline and follow-up regarding perceptions of each other's expertise and responsibility, learning from and with each other, and the behaviour of students and the "novice" professionals in interprofessional collaboration. Both dentists and dental hygienists experienced the CIEP as useful for interprofessional collaboration. The "novice" dentists and dental hygienists indicated that in dental practices interprofessional collaboration was less common. CONCLUSION: The CIEP resulted in more understanding amongst dentists and dental hygienists with regard to interprofessional roles, but in practice the "novice" dentists and dental hygienists face difficulties in applying the interprofessional roles.

Skill mix change between physicians, nurse practitioners, physician assistants, and nurses in nursing homes: A qualitative study.

Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses.

The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing.

AIM: This study determined the effect of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs) on non-adherence to guidelines on medication prescribing. METHODS: A multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with MDs (PA/MD model), with wards on which only MDs provide medical care (MD model). A set of 17 quality indicators to measure non-adherence to guidelines on medication prescribing by PAs and MDs was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in case of use of NSAID or prevention of obstipation in case of use of opioids. These indicators were expressed in proportions by dividing the number of patients in which the prescriber did not adhere to a guideline, by all patients that were applicable. Multivariable regression analysis was performed in order to adjust for potential confounders. RESULTS: 1021 patients from 17 hospital wards in the 'PA/MD model' group and 1286 patients from 17 hospital wards in the 'MD model' group were included. Two of the 17 quality indicators showed significantly less non-adherence to guidelines for the PA/MD model; the indicators concerning prescribing gastric protection in case of use of NSAID in combination with corticosteroids (OR 0.42, 95% CI 0.19-0.90) and in case of use of NSAID in patients older than 70 years (OR 0.47, 95% 0.23-0.95). For none of the other quality indicators for prescribing of medication a difference between the MD model and the PA/MD model was found. CONCLUSION: This study suggests that the non-adherence to guidelines on medication prescribing on wards with the PA/MD model does not differ from wards with traditional house staffing by MDs only. Further research is needed to determine quality, efficiency and safety of prescribing behavior of PAs.

Skill mix change between general practitioners, nurse practitioners, physician assistants and nurses in primary healthcare for older people: a qualitative study.

BACKGROUND: More and more older adults desire to and are enabled to grow old in their own home, regardless of their physical and mental capabilities. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older people lacks prestige among medical students and few medical students are interested in a career in care for older people. Innovative solutions are needed to reduce the demand for GPs, to guarantee quality of healthcare and to contain costs. A solution might be found in skill mix change by introducing nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs). The aim of this study was to describe how skill mix change is organised in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people. METHODS: In total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n = 9), NPs (n = 10), PAs (n = 5) and RNs (n = 10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction. RESULTS: In most cases, healthcare for older people was only a small part of the tasks of NPs, PAs and RNs; they did not solely focus on older people. The tasks they performed and their responsibilities in healthcare for older people differed between, as well as within, professions. Although the interviewees debated the usefulness of proactive structural screening on frailty in the older population, when implemented, it was also unclear who should perform the geriatric assessment. Interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs. CONCLUSIONS: The roles and responsibilities of NPs, PAs and RNs for the care of older people living at home are still not established. Nonetheless, these examples show the potential of these professionals. The establishment of a clear vision on primary healthcare for older people, including the organisation of proactive healthcare, is necessary to optimise the impact of skill mix change.

Impact of practice, provider and patient characteristics on delivering screening and brief advice for heavy drinking in primary healthcare: Secondary analyses of data from the ODHIN five-country cluster randomized factorial trial.

BACKGROUND: The implementation of primary healthcare-based screening and advice that is effective in reducing heavy drinking can be enhanced with training. OBJECTIVES: Undertaking secondary analysis of the five-country ODHIN study, we test: the extent to which practice, provider and patient characteristics affect the likelihood of patients being screened and advised; the extent to which such characteristics moderate the impact of training in increasing screening and advice; and the extent to which training mitigates any differences due to such characteristics found at baseline. METHODS: A cluster randomized factorial trial involving 120 practices, 746 providers and 46 546 screened patients from Catalonia, England, the Netherlands, Poland, and Sweden. Practices were randomized to receive training or not to receive training. The primary outcome measures were the proportion of adult patients screened, and the proportion of screen-positive patients advised. RESULTS: Nurses tended to screen more patients than doctors (OR = 3.1; 95%CI: 1.9, 4.9). Screen-positive patients were more likely to be advised by doctors than by nurses (OR = 2.3; 95%CI: 1.4, 4.1), and more liable to be advised the higher their risk status (OR = 1.9; 95%CI: 1.3, 2.7). Training increased screening and advice giving, with its impact largely unrelated to practice, provider or patient characteristics. Training diminished the differences between doctors and nurses and between patients with low or high-risk status. CONCLUSIONS: Training primary healthcare providers diminishes the negative impacts that some practice, provider and patient characteristics have on the likelihood of patients being screened and advised. Trial registration ClinicalTrials.gov. Trial identifier: NCT01501552.

The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study.

BACKGROUND: Medical care for admitted patients in hospitals is increasingly reallocated to physician assistants (PAs). There is limited evidence about the consequences for the quality and safety of care. This study aimed to determine the effects of substitution of inpatient care from medical doctors (MDs) to PAs on patients' length of stay (LOS), quality and safety of care, and patient experiences with the provided care. METHODS: In a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model). Thirty-four wards were recruited across the Netherlands. Patients were followed from admission till one month after discharge. Primary outcome measure was patients' LOS. Secondary outcomes concerned eleven indicators for quality and safety of inpatient care and patients' experiences with the provided care. RESULTS: Data on 2,307 patients from 34 hospital wards was available. The involvement of PAs was not significantly associated with LOS (ß 1.20, 95%CI 0.99-1.40, p = .062). None of the indicators for quality and safety of care were different between study arms. However, the involvement of PAs was associated with better experiences of patients (ß 0.49, 95% CI 0.22-0.76, p = .001). CONCLUSIONS: This study did not find differences regarding LOS and quality of care between wards on which PAs, in collaboration with MDs, provided medical care for the admitted patients, and wards on which only MDs provided medical care. Employing PAs seems to be safe and seems to lead to better patient experiences. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01835444.

The involvement of physician assistants in inpatient care in hospitals in the Netherlands: a cost-effectiveness analysis.

OBJECTIVE: To investigate the cost-effectiveness of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs). DESIGN: Cost-effectiveness analysis embedded within a multicentre, matched-controlled study. The traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which, besides MDs, PAs are also employed (PA/MD model). SETTING: 34 hospital wards across the Netherlands. PARTICIPANTS: 2292 patients were followed from admission until 1 month after discharge. Patients receiving daycare, terminally ill patients and children were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: All direct healthcare costs from day of admission until 1 month after discharge. Health outcome concerned quality-adjusted life years (QALYs), which was measured with the EuroQol five dimensions questionnaire (EQ-5D). RESULTS: We found no significant difference for QALY gain (+0.02, 95% CI -0.01 to 0.05) when comparing the PA/MD model with the MD model. Total costs per patient did not significantly differ between the groups (+€568, 95% CI -€254 to €1391, p=0.175). Regarding the costs per item, a difference of €309 per patient (95% CI €29 to €588, p=0.030) was found in favour of the MD model regarding length of stay. Personnel costs per patient for the provider who is primarily responsible for medical care on the ward were lower on the wards in the PA/MD model (-€11, 95% CI -€16 to -€6, p<0.01). CONCLUSIONS: This study suggests that the cost-effectiveness on wards managed by PAs, in collaboration with MDs, is similar to the care on wards with traditional house staffing. The involvement of PAs may reduce personnel costs, but not overall healthcare costs. TRIAL REGISTRATION NUMBER: NCT01835444.

Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: protocol for a realist evaluation case study.

INTRODUCTION: In developed countries, substituting physicians with nurse practitioners, physician assistants and nurses (physician substitution) occurs in nursing homes as an answer to the challenges related to the ageing population and the shortage of staff, as well as to guarantee the quality of nursing home care. However, there is great diversity in how physician substitution in nursing homes is modelled and it is unknown how it can best contribute to the quality of healthcare. This study aims to gain insight into how physician substitution is modelled and whether it contributes to perceived quality of healthcare. Second, this study aims to provide insight into the elements of physician substitution that contribute to quality of healthcare. METHODS AND ANALYSIS: This study will use a multiple-case study design that draws upon realist evaluation principles. The realist evaluation is based on four concepts for explaining and understanding interventions: context, mechanism, outcome and context-mechanism-outcome configuration. The following steps will be taken: (1) developing a theory, (2) conducting seven case studies, (3) analysing outcome patterns after each case and a cross-case analysis at the end and (4) revising the initial theory. ETHICS AND DISSEMINATION: The research ethics committee of the region Arnhem Nijmegen in the Netherlands concluded that this study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (WMO) (registration number 2015/1914). Before the start of the study, the Board of Directors of the nursing home organisations will be informed verbally and by letter and will also be asked for informed consent. In addition, all participants will be informed verbally and by letter and will be asked for informed consent. Findings will be disseminated by publication in a peer-reviewed journal, international and national conferences, national professional associations and policy partners in national government.

Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the ageing population: a systematic literature review.

AIMS: To evaluate the effects of substituting nurse practitioners, physician assistants or nurses for physicians in long-term care facilities and primary healthcare for the ageing population (primary aim) and to describe what influences the implementation (secondary aim). BACKGROUND: Healthcare for the ageing population is undergoing major changes and physicians face heavy workloads. A solution to guarantee quality and contain costs might be to substitute nurse practitioners, physician assistants or nurses for physicians. DESIGN: A systematic literature review. DATA SOURCES: PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL, Web of Science; searched January 1995-August 2015. REVIEW METHODS: Study selection, data extraction and quality appraisal were conducted independently by two reviewers. Outcomes collected: patient outcomes, care provider outcomes, process of care outcomes, resource use outcomes, costs and descriptions of the implementation. Data synthesis consisted of a narrative summary. RESULTS: Two studies used a randomized design and eight studies used other comparative designs. The evidence of the two randomized controlled trials showed no effect on approximately half of the outcomes and a positive effect on the other half of the outcomes. Results of eight other comparative study designs point towards the same direction. The implementation was influenced by factors on a social, organizational and individual level. CONCLUSION: Physician substitution in healthcare for the ageing population may achieve at least as good patient outcomes and process of care outcomes compared with care provided by physicians. Evidence about resource use and costs is too limited to draw conclusions.

Cost-effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care: Study protocol of the COCON study.

BACKGROUND: Guidelines on urinary incontinence recommend that absorbent products are only used as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy, or for long-term management after all treatment options have been explored. However, these criteria are rarely met and a significant share of long-term product users could still benefit from therapeutic interventions recommended in guidelines for urinary incontinence. Better implementation of these guidelines can potentially result in both health benefits for women and long-term cost savings for society. The aim of the COCON study is to evaluate the (cost-)effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care in comparison with usual care for urinary incontinent women aged 55 years and over who use absorbent products. METHODS: This randomised clinical trial compares usual care with a nurse-led intervention to optimise implementation of guideline-concordant continence care. Women (anticipated N = 160) are recruited in 12 community pharmacies in three Dutch regions, and are eligible for trial entry when they are 55 years and over, community-dwelling and long-term users of absorbent products (≥4 months) reimbursed by health insurance. Measurements are administered at baseline, 3, 6 and 12 months. Primary outcome is severity of urinary incontinence (ICIQ-UI SF); other outcomes include health related quality of life (EQ-5D-5 L), use of absorbent products (in accordance with the recommended criteria in guidelines) (yes/no), and societal costs. Mixed model analysis will be performed to compare (the course) of outcomes between groups. The economic evaluation will be performed from a societal perspective. The implementation process is investigated using the Tailored Implementation for Chronic Diseases (TICD) framework. DISCUSSION: Results will add to current knowledge of the (cost-)effectiveness of nurse-led primary healthcare to improve guideline-concordant care for older women with urinary incontinence. In addition, the results will provide more insight into care needs and health service utilization of this group of women, as well as into use of absorbent products in accordance with the recommended criteria in guidelines. Finally, results will increase our understanding of the intervention's uptake and could provide useful insights for future dissemination and sustenance. TRIAL REGISTRATION: Dutch Trial Register NTR4396, registered 13-January-2014.

Mentor mother support for mothers experiencing intimate partner violence in family practice: A qualitative study of three different perspectives on the facilitators and barriers of implementation.

BACKGROUND: Intimate partner violence (IPV) is highly prevalent and associated with physical and mental health problems. Mentor mother support is a low threshold intervention in family practice consisting of support by non-professionals trained to support mothers experiencing IPV. A mentor mother support study showed reduced exposure to IPV and decreased symptoms of depression. OBJECTIVES: Identify factors determining implementation success of mentor mother support in family practice. METHODS: Individual interviews were conducted with 12 family physicians, 16 abused mothers and three mentor mothers. Four mentor mothers participated in a focus group. Qualitative content analysis was used to analyse the data. RESULTS: The identification and discussion of abuse is hindered by family physicians' attitudes because they considered mothers experiencing IPV as a difficult target group with a responsibility of their own to break out of their violent situation. Some family physicians doubted the partner's violence because he was known as a patient as well. Acceptance of mentor mother support is related to the readiness for change of mothers experiencing IPV. Mentor mothers facilitate acceptance and completion of their support by connecting as a friend who is equal and less threatening than professionals. CONCLUSION: To improve successful implementation of mentor mother support in primary care, we should focus on family physicians' attitudes towards IPV. To change these attitudes, we recommend continuous training of family physicians. By being paraprofessional friends, mentor mothers offer low threshold support that is complementary to professional support and should be embedded more widely in primary care. [Box: see text].

Determinants of the sustained employment of physician assistants in hospitals: a qualitative study.

OBJECTIVES: To identify determinants of the initial employment of physician assistants (PAs) for inpatient care as well as of the sustainability of their employment. DESIGN: We conducted a qualitative study with semistructured interviews with care providers. Interviews continued until data saturation was achieved. All interviews were transcribed verbatim. A framework approach was used for data analysis. Codes were sorted by the themes, bringing similar concepts together. SETTING: This study was conducted between June 2014 and May 2015 within 11 different hospital wards in the Netherlands. The wards varied in medical speciality, as well as in hospital type and the organisational model for inpatient care. PARTICIPANTS: Participant included staff physicians, residents, PAs and nurses. RESULTS: The following themes emerged to be important for the initial employment of PAs and the sustainability of their employment: the innovation, individual factors, professional interactions, incentives and resources, capacity for organisational change and social, political and legal factors. CONCLUSIONS: 10 years after the introduction of PAs, there was little discussion among the adopters about the added value of PAs, but organisational and financial uncertainties played an important role in the decision to employ and continue employment of PAs. Barriers to employ and continue PA employment were mostly a consequence of locally arranged restrictions by hospital management and staff physicians, as barriers regarding national laws, PA education and competencies seemed absent.

Solo emergency care by a physician assistant versus an ambulance nurse: a cross-sectional document study.

BACKGROUND: This study compares the assessment, treatment, referral, and follow up contact with the dispatch centre of emergency patients treated by two types of solo emergency care providers in ambulance emergency medical services (EMS) in the Netherlands: the physician assistant (PA), educated in the medical domain, and the ambulance registered nurse (RN), educated in the nursing domain. The hypothesis of this study was that there is no difference in outcome of care between the patients of PAs and RNs. METHODS: In a cross-sectional document study in two EMS regions we included 991 patients, treated by two PAs (n = 493) and 23 RNs (n = 498). The inclusion period was October 2010-December 2012 for region 1 and January 2013-March 2014 for region 2. Emergency care data were drawn from predefined and free text fields in the electronic patient records. Data were analysed using descriptive statistics. We used χ (2) and Mann-Whitney U tests to analyse for differences in outcome of care. Statistical significance was assumed at a level of P <0.05. RESULTS: Patients treated by PAs and RNs were similar with respect to patient characteristics. In general, diagnostic measurements according to the national EMS standard were applied by RNs and by PAs. In line with the medical education, PAs used a medical diagnostic approach (16 %, n = 77) and a systematic physical exam of organ tract systems (31 %, n = 155). PAs and RNs provided similar interventions. Additionally, PAs consulted more often other medical specialists (33 %) than RNs (17 %) (χ (2) = 35.5, P <0.0001). PAs referred less patients to the general practitioner or emergency department (50 %) compared to RNs (73 %) (χ (2) = 52.9, P <0.0001). Patient follow up contact with the dispatch centre within 72 h after completion of the emergency care on scene showed no variation between PAs (5 %) and RNs (4 %). CONCLUSIONS: In line with their medical education, PAs seemed to operate from a more general medical perspective. They used a medical diagnostic approach, consulted more medical specialists, and referred significantly less patients to other health care professionals compared to RNs. While the patients of the PAs did not contact the dispatch centre more often afterwards.

Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial.

AIM: To test if training and support, financial reimbursement and option of referring screen-positive patients to an internet-based method of giving advice (eBI) can increase primary health-care providers' delivery of Alcohol Use Disorders Identification Test (AUDIT)-C-based screening and advice to heavy drinkers. DESIGN: Cluster randomized factorial trial with 12-week implementation and measurement period. SETTING: Primary health-care units (PHCU) in different locations throughout Catalonia, England, the Netherlands, Poland and Sweden. PARTICIPANTS: A total of 120 PHCU, 24 in each of Catalonia, England, the Netherlands, Poland and Sweden. INTERVENTIONS: PHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR) and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI. MEASUREMENTS: The primary outcome measure was the proportion of eligible adult (age 18+ years) patients screened during a 12-week implementation period. Secondary outcome measures were proportion of screen-positive patients advised; and proportion of consulting adult patients given an intervention (screening and advice to screen-positives) during the same 12-week implementation period. FINDINGS: During a 4-week baseline measurement period, the proportion of consulting adult patients who were screened for their alcohol consumption was 0.059 per PHCU (95% CI 0.034 to 0.084). Based on the factorial design, the ratio of the logged proportion screened during the 12-week implementation period was 1.48 (95% CI = 1.13-1.95) in PHCU that received TS versus PHCU that did not receive TS; for FR, the ratio was 2.00 (95% CI = 1.56-2.56). The option of referral to eBI did not lead to a higher proportion of patients screened. The ratio for TS plus FR was 2.34 (95% CI = 1.77-3.10), and the ratio for TS plus FR plus eBI was1.68 (95% CI = 1.11-2.53). CONCLUSIONS: Providing primary health-care units with training, support and financial reimbursement for delivering Alcohol Use Disorders Identification Test-C-based screening and advice to heavy drinkers increases screening for alcohol consumption. Providing primary health-care units with the option of referring screen-positive patients to an internet-based method of giving advice does not appear to increase screening for alcohol consumption.