How to improve newly qualified midwives' transition-into-practice. A Delphi study.

BACKGROUND: In the Netherlands, newly qualified midwives start work as registered midwives without any formal transition support. Research shows that newly qualified midwives do not feel sufficiently confident and competent in their work during the period following graduation. This could impact the quality of care provided by newly registered midwives. The aim of this study is to seek consensus with stakeholders concerning viable components of support for newly qualified midwives working in midwifery care in the Netherlands. METHODS: A Delphi study was conducted among maternity care stakeholders in the Netherlands. During two rounds, sixteen statements derived from a theoretical framework of organizational socialization theory and previous studies were assessed (round 1, n = 56; round 2, n = 52). Stakeholders (N = 61) were invited and completed an online questionnaire that included spaces for opinions and remarks. RESULTS: Stakeholders agreed about an introductory support period for newly qualified midwives, involving performance feedback and regional-level backup from fellow midwives during shifts. They further agreed on the responsibilities of established professionals that they should support newcomers in practice and provide mentoring or group coaching, although they face organizational barriers for supporting newcomers. CONCLUSIONS: Stakeholders found consensus upon several components of support at the workplace. In addition, a stable work environment seemed less important in their opinion while previous research suggests otherwise. Practice organisations need to improve the employment conditions and support for newly qualified midwives to ensure the quality of midwifery care is guaranteed.

Midwives' occupational wellbeing and its determinants. A cross-sectional study among newly qualified and experienced Dutch midwives.

OBJECTIVE: Internationally, about 40 percent of midwives report symptoms of burnout, with young and inexperienced midwives being most vulnerable. There is a lack of recent research on burnout among Dutch midwives. The aim of this study was to examine the occupational wellbeing and its determinants of newly qualified and inexperienced midwives in the Netherlands. The majority of practicing Dutch midwives are aged under 40, which could lead to premature turnover. DESIGN: A cross-sectional study was conducted using an online questionnaire that consisted of validated scales measuring job demands, job and personal resources, burnout symptoms and work engagement. The Job Demands-Resources model was used as a theoretical model. SETTING AND PARTICIPANTS: We recruited Dutch midwives who were actually working in midwifery practice. A total of N=896 midwives participated in this study, representing 28 percent of practicing Dutch midwives. MEASUREMENTS AND FINDINGS: Data were analysed using regression analysis. Seven percent of Dutch midwives reported burnout symptoms and 19 percent scored high on exhaustion. Determinants of burnout were all measured job demands, except for experience level. Almost 40 percent of midwives showed high work engagement; newly qualified midwives had the highest odds of high work engagement. Master's or PhD-level qualifications and employment status were associated with high work engagement. All measured resources were associated with high work engagement. KEY CONCLUSIONS: A relatively small percentage of Dutch midwives reported burnout symptoms, the work engagement of Dutch midwives was very high. However, a relatively large number reported symptoms of exhaustion, which is concerning because of the risk of increasing cynicism levels leading to burnout. In contrast to previous international research findings, being young and having less working experience was not related to burnout symptoms of Dutch newly qualified midwives. IMPLICATIONS FOR PRACTICE: The recognition of job and personal resources for midwives' occupational wellbeing must be considered for a sustainable midwifery workforce. Midwifery Academies need to develop personal resources of their students that will help them in future practice.

Midwives' perceptions of the performance- and transition into practice of newly qualified midwives, a focus group study.

PROBLEM: Newly qualified midwives in the Netherlands perceive the adaptation to new responsibilities as difficult due to the autonomous nature of- and required accountability for the work they face in practice. BACKGROUND: All Dutch newly qualified midwives are accountable for their work from the moment of registration while usually working solistically. AIM: This paper explores the perceptions of experienced midwives regarding: (1) the performance- and transition into practice of newly qualified midwives, and (2) their supporting role in this transition. METHODS: The design of this study is qualitative with focus groups. Experienced midwives' perceptions were explored by means of seven semi-structured focus groups (N = 46 participants) with two meetings for each focus group. FINDINGS: Community-based and hospital-based midwives perceived newly qualified midwives as colleagues who did not oversee all their tasks and responsibilities. They perceived newly qualified midwives as less committed to the practice organisation. Support in community-based practices was informally organised with a lack of orientation. In the hospital-based setting, midwives offered an introduction period in a practical setting, which was formally organised with tasks and responsibilities. Experienced midwives recognised the need to support newly qualified midwives; however, in practice, they faced barriers. DISCUSSION: The differences in experienced midwives' expectations of newly qualified midwives and reality seemed to depend on the newly qualified midwives' temporary working contracts and -context, rather than the generational differences that experienced midwives mentioned. Dutch midwives prioritised their work with pregnant individuals and the organisation of their practice above supporting newly qualified midwives.

Regional variations in childbirth interventions and their correlations with adverse outcomes, birthplace and care provider: A nationwide explorative study.

BACKGROUND: Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics. METHODS: In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks' gestation in 2010-2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman's rank correlations. FINDINGS: Intrapartum referral rates varied between 55-68% (nulliparous) and 20-32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6-16% (nulliparous) and 16-31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14-42% (nulliparous) and 3-13% (multiparous) and in obstetrician-led births from 46-67% and 14-28% respectively. Rates of postpartum oxytocin varied between 59-88% (nulliparous) and 50-85% (multiparous) and artificial rupture of membranes between 43-52% and 54-61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin. CONCLUSIONS: Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.

Continuity of care is an important and distinct aspect of childbirth experience: findings of a survey evaluating experienced continuity of care, experienced quality of care and women's perception of labor.

BACKGROUND: To compare experienced continuity of care among women who received midwife-led versus obstetrician-led care. Secondly, to compare experienced continuity of care with a. experienced quality of care during labor and b. perception of labor. METHODS: We conducted a questionnaire survey in a region in the Netherlands in 2014 among 790 women after they gave birth. To measure experienced continuity of care, the Nijmegen Continuity Questionnaire was used. Quality of care during labor was measured with the Pregnancy and Childbirth Questionnaire, and to measure perception of labor we used the Childbirth Perception Scale. RESULTS: Three hundred twenty five women consented to participate (41%). Of these, 187 women completed the relevant questions in the online questionnaire. 136 (73%) women were in midwife-led care at the onset of labor, 15 (8%) were in obstetrician-led care throughout pregnancy and 36 (19%) were referred to obstetrician-led care during pregnancy. Experienced personal and team continuity of care during pregnancy were higher for women in midwife-led care compared to those in obstetrician-led care at the onset of labor. Experienced continuity of care was moderately correlated with experienced quality of care although not significantly so in all subgroups. A weak negative correlation was found between experienced personal continuity of care by the midwife and perception of labor. CONCLUSION: This study suggests that experienced continuity of care depends on the care context and is significantly higher for women who are in midwife-led compared to obstetrician-led care during labor. It will be a challenge to maintain the high level of experienced continuity of care in an integrated maternity care system. Experienced continuity of care seems to be a distinctive concept that should not be confused with experienced quality of care or perception of labor and should be considered as a complementary aspect of quality of care.

From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home.

BACKGROUND: Implementation fidelity, the degree to which a care program is implemented as intended, can influence program impact. Since results of trials that aim to implement comprehensive care programs for frail, older people have been conflicting, assessing implementation fidelity alongside these trials is essential to differentiate between flaws inherent to the program and implementation issues. This study demonstrates how a theory-based assessment of fidelity can increase insight in the implementation process of a complex intervention in primary elderly care. METHODS: The Geriatric Care Model was implemented among 35 primary care practices in the Netherlands. During home visits, practice nurses conducted a comprehensive geriatric assessment and wrote a tailored care plan. Multidisciplinary team consultations were organized with the aim to enhance the coordination between professionals caring for a single patient with complex needs. To assess fidelity, we identified 5 key intervention components and formulated corresponding research questions using Carroll's framework for fidelity. Adherence (coverage, frequency, duration, content) was assessed per intervention component during and at the end of the intervention period. Two moderating factors (participant responsiveness and facilitation strategies) were assessed at the end of the intervention. RESULTS: Adherence to the geriatric assessments and care plans was high, but decreased over time. Adherence to multidisciplinary consultations was initially poor, but increased over time. We found that individual differences in adherence between practice nurses and primary care physicians were moderate, while differences in participant responsiveness (satisfaction, involvement) were more distinct. Nurses deviated from protocol due to contextual factors and personal work routines. CONCLUSIONS: Adherence to the Geriatric Care Model was high for most of the essential intervention components. Study limitations include the limited number of assessed moderating factors. We argue that a longitudinal investigation of adherence per intervention component is essential for a complete understanding of the implementation process, but that such investigations may be complicated by practical and methodological challenges. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR). TRIAL NUMBER: 2160 .

Primary care treatment guidelines for skin infections in Europe: congruence with antimicrobial resistance found in commensal Staphylococcus aureus in the community.

BACKGROUND: Over 90% of antibiotics for human use in Europe are prescribed in primary care. We assessed the congruence between primary care treatment guidelines for skin infections and commensal Staphylococcus aureus (S. aureus) antimicrobial resistance levels in community-dwelling persons. METHODS: The prevalence of antimicrobial resistance in S. aureus was analysed by taking nose swabs from healthy primary care patients in nine European countries (total N = 32,032). Primary care treatment guidelines for bacterial skin infections were interpreted with respect to these antimicrobial resistance patterns. First- and second-choice recommendations were assessed and considered congruent if resistance to the antibiotic did not exceed 20%. RESULTS: We included primary care treatment guidelines for impetigo, cellulitis, folliculitis and furuncle. Treatment recommendations in all countries were consistent: most of the first-choice recommendations were beta-lactams, both for children and adults. Antimicrobial resistance levels were low, except for penicillin (on average 73% resistance). Considerable variation in antimicrobial resistance levels was found between countries, with Sweden displaying the lowest levels and Spain the highest. In some countries resistance to penicillin and azithromycin was significantly higher in children (4-17 years) compared with adults. CONCLUSIONS: Most of the first- and second-choice recommendations in the treatment guidelines for skin infections were congruent with commensal S. aureus antimicrobial resistance patterns in the community, except for two recommendations for penicillin. Given the variation in antimicrobial resistance levels between countries, age groups and health care settings, national data regarding antimicrobial resistance in the community should be taken into account when updating or developing primary care treatment guidelines.

Knowledge and acceptability of Chlamydia trachomatis screening among pregnant women and their partners; a cross-sectional study.

BACKGROUND: Chlamydia trachomatis infections in pregnancy can cause maternal disease, adverse pregnancy outcomes and neonatal disease, which is why chlamydia screening during pregnancy has been advocated. The effectiveness of a screening program depends on the knowledge of health care professionals, women and partners and the acceptability for screening of the target population. We assessed the knowledge of chlamydia infection among pregnant women and their partners in the Netherlands, their attitudes towards testing, and their experiences of being offered a chlamydia test. In addition, we evaluated the association between participants' background characteristics and knowledge of chlamydia. METHODS: Pregnant women aged ≤ 30 years and their partners (regardless of their age) attending one of the participating primary midwifery care practices in the Netherlands were invited to participate. All participants completed a questionnaire, pregnant women provided a vaginal swab and partners provided a urine sample to test for C. trachomatis. RESULTS: In total, 383 pregnant women and 282 partners participated in the study of whom 1.9% women and 2.6% partners tested chlamydia positive. Participants had high levels of awareness (92.8%) of chlamydial infection. They were knowledgeable about the risk of chlamydia infection; median knowledge score was 9.0 out of 12.0. Lower knowledge scores were found among partners (p-value <0.001), younger aged (p-value 0.02), non-western origin (p-value <0.001), low educational level (p-value <0.001), and no history of sexually transmitted infections (p-value <0.001). In total, 78% of respondents indicated that when pregnant women are tested for chlamydia, their partners should also be tested; 54% believed that all women should routinely be tested. Pregnant women more often indicated than partners that testing partners for chlamydial infection was not necessary (p-value <0.001). The majority of pregnant women (56.2%) and partners (59.2%) felt satisfied by being offered the test during antenatal care. CONCLUSION: Pregnant women and their partners were knowledgeable about chlamydial infection, found testing, both pregnant women and their partners, for chlamydia acceptable and not stigmatizing.

Design of the INTEGRATE study: effectiveness and cost-effectiveness of a cardiometabolic risk assessment and treatment program integrated in primary care.

BACKGROUND: The increasing prevalence of cardiometabolic disease (CMD) in combination with an ageing population is a major public health problem. Early detection and management of individuals at risk for CMD is required to prevent future health problems with associated costs. General practice is the optimal health care setting to accomplish this goal. Prevention programs for identification and treatment of patients with an increased risk for CMD in primary care have been proven feasible. However, the effectiveness and cost-effectiveness have yet to be demonstrated. The 'Personalized Prevention Approach for CardioMetabolic Risk' (PPA CMR) is such a prevention program. The objective of the INTEGRATE study is to investigate the effectiveness and cost-effectiveness of PPA CMR, as well as to establish determinants for participation and compliance. METHODS: The INTEGRATE study is designed as a stepped-wedge randomized controlled trial with a waiting list control group. In approximately 40 general practices, all enlisted patients without CMD aged 45-70 years, are invited to participate in PPA CMR. After an online risk estimation, patients with a score above risk threshold are invited to the GP for additional measurements, detailed risk profiling and tailored treatment of risk factors through medication and/or lifestyle counseling. At baseline and after twelve months of follow-up lifestyle, health and work status of all participants are established with online questionnaires. Additionally after twelve months, we will determine health care utilization, costs of PPA CMR and compliance. Primary endpoints are the number of newly detected patients with CMD and changes in individual risk factors between the intervention and waiting list control group. Medical data will be extracted from the GPs' electronic medical records. In order to assess factors related to participation, we will send questionnaires to non-participants and assess characteristics of participating practices. For all participants, additional demographic characteristics will be available through Statistics Netherlands. DISCUSSION: The INTEGRATE study will provide insight into the effectiveness and cost-effectiveness of PPA CMR as well as determinants for participation and compliance, which represents essential information to guide further large-scale implementation of primary prevention programs for CMD. TRIAL REGISTRATION NUMBER: NTR4277, The Netherlands National Trial Register, 26-11-2013.

Maternal cytomegalovirus infection prevention: the role of Dutch primary care midwives.

OBJECTIVE: to assess the knowledge of cytomegalovirus (CMV) infection among Dutch primary care midwives, and clinical approaches to informing women about CMV. DESIGN: cross-sectional study, using self-administered questionnaires. PARTICIPANTS: 330 Dutch primary care midwives. SETTING: primary midwifery care practices across the Netherlands. MAIN OUTCOME: Midwives' knowledge of CMV transmission routes and maternal symptoms, and clinical practice behaviours regarding CMV, the information typically provided or reasons for not informing pregnant women about CMV. FINDINGS: the overall median knowledge score was 8.0 out of a maximum possible score of 13.0. Of all participants, 10.6% reported always informing pregnant women about CMV infection prevention and 41.0% reported never informing pregnant women. The main reason indicated for not informing pregnant women was lack of knowledge about preventive methods (45.7%). CONCLUSION: Dutch primary care midwives have limited knowledge of CMV infection. Improvement in providing education to pregnant women about strategies to prevent CMV is necessary.

General practitioners' perceptions of their role in cancer follow-up care: a qualitative study in the Netherlands.

BACKGROUND: In the last few decades there has been a considerable increase in the number of cancer survivors. Health policy makers would like to see cancer follow-up care moved from secondary to primary care. METHOD: Between 2008 and 2010, a qualitative study among primary health care professionals was performed to get more insight into the way they care for cancer survivors. Analysed was whether a coordinating role in cancer survivorship care would fit in with the practical logic underlying the way the general practitioners work. RESULTS: In their everyday work, general practitioners are used to provide care in a reactive way. Based on this habitus, they classify their patients into 'not special' and 'special' ones. Since general practitioners label cancer survivors as 'not special,' they expect these patients to take the initiative to ask for help and present their complaints in a clear and complete way. Their habitus as a gatekeeper implies that they are reticent about referring patients to other primary health care professionals. In regard to 'not special' patients, such as cancer survivors, general practitioners appear to build on the patients' own strengths. CONCLUSION: The emphasis on a wait-and-see attitude in contemporary Dutch general practice, as well as the general practitioners' role as a gatekeeper are at odds with the proactive and holistic approach inherent to a coordinating role in cancer follow-up. Therefore, we assume that it will be difficult for general practitioners to shape a pivotal role in this care.

Chlamydia trachomatis infection during pregnancy: knowledge, test practices, and attitudes of Dutch midwives.

BACKGROUND: Chlamydia trachomatis infection in pregnancy may lead to adverse pregnancy outcomes. In the Netherlands, testing for C. trachomatis is based on risk assessment. We assessed midwives' knowledge, test practices, assessment of risk behavior, and attitudes regarding testing for C. trachomatis infection during pregnancy. We evaluated the association between midwives' characteristics and their knowledge of C. trachomatis infection in terms of symptomatology and outcomes. METHODS: This was a cross-sectional study among primary care midwives in the Netherlands. Between September and November 2011, midwives from all Dutch primary care midwifery practices were invited to complete a questionnaire about C. trachomatis infection. RESULTS: Of the 518 midwives invited to participate in this study, 331 (63.9%) responded. The overall median knowledge score for questions about symptomatology and outcomes was 10 out of a maximum score of 15. The median knowledge score was higher among midwives in urban areas. In total, 239 (72.2%) midwives reported testing pregnant women for C. trachomatis. The primary reason for testing was a request by the woman herself (96.2%), followed by symptoms of infection (89.1%), risk behavior (59.3%), and risk factors for infection (7.3%). Almost 25% of midwives showed positive attitudes towards universal screening for C. trachomatis. CONCLUSIONS: Midwives were knowledgeable about symptoms of infection, but less about outcomes. Midwives test pregnant women for C. trachomatis mainly on the women's request. Otherwise, testing is based on symptoms of infection rather than on known risk factors. This may contribute to under-diagnosis and under-treatment, leading to maternal, perinatal, and neonatal morbidity.

Do pregnant women contact their general practitioner? A register-based comparison of healthcare utilisation of pregnant and non-pregnant women in general practice.

BACKGROUND: Midwives and obstetricians are the key providers of care during pregnancy and postpartum. Information about the consultations with a general practitioner (GP) during this period is generally lacking.The aim of this study is to compare consultation rates, diagnoses and GP management of pregnant women with those of non-pregnant women. METHODS: Data were retrieved from the Netherlands Information Network of General Practice (LINH), a nationally representative register. This register holds longitudinal data on consultations, prescriptions and the referrals of all patients listed at 84 practices in the Netherlands in 2007-2009, including 15,123 pregnant women and 102,564 non-pregnant women in the same age-range (15 to 45 years). We compared consultation rates (including all contacts with the practice), diagnoses (ICPC-1 coded), medication prescriptions (coded according to the Anatomical Therapeutic Chemical classification system), and rate and type of referrals from the start of the pregnancy until six weeks postpartum (336 days). RESULTS: Pregnant women contacted their GP on average 3.6 times, compared to 2.2 times for non-pregnant women. The most frequently recorded diagnoses for pregnant women were 'pregnancy' and 'cystitis/urinary infection', and 'cystitis/urinary infection' and 'general disease not otherwise specified' for non-pregnant women. The mean number of prescribed medications was lower in pregnant women (2.1 against 4.4). For pregnant women, the most frequent referral indication concerned obstetric care, for non-pregnant women this concerned physiotherapy. CONCLUSIONS: GP consultation rates in pregnancy and postpartum shows that GPs are important providers of care for pregnant women. Therefore, the involvement of GPs in collaborative care during pregnancy and postpartum should be reinforced.

How unique is continuity of care? A review of continuity and related concepts.

BACKGROUND: The concept of 'continuity of care' has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear. OBJECTIVE: In order to clarify the confusion of tongues and to identify core values of these patient-centred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management. METHODS: We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary. RESULTS: Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient's perspective. CONCLUSIONS: The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.

Patients with a psychiatric disorder in general practice: determinants of general practitioners' psychological diagnosis.

BACKGROUND: Although psychiatric disorders are highly prevalent in the community, many patients with a psychiatric morbidity remain unidentified as such in primary care. OBJECTIVE: The aim of this study was to analyze which clinical and sociodemographic characteristics of patients with psychiatric morbidity are related to general practitioners' (GPs) diagnosis of mental illness. METHODS: A 1-year naturalistic survey of primary care contacts of patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of affective disorder, anxiety disorder or alcohol abuse was carried out. RESULTS: Of the patients with a DSM-IV diagnosis, 10% did not visit their GP at all during 1 year, 40% visited their GP but were only diagnosed as having somatic diagnoses and 50% were given a psychological or social diagnosis at least once during 1 year. Affective disorders are more frequently diagnosed than anxiety disorders or alcohol abuse. The chances of psychological GP diagnosis increase with the number of GP contacts. CONCLUSIONS: GPs appear to have few indications to help them distinguish patients with a psychiatric morbidity from others, as long as the patients themselves do not express more explicit clues to their condition. Public mental health education and a better public relations policy are badly needed.