Dry mouth in patients with a life-limiting condition or frailty: a study protocol for two intervention studies and a nested qualitative sub-study (the Dry mOuth Project, DROP).

BACKGROUND: Despite its prevalent and impactful nature, dry mouth remains an underexposed and undertreated symptom in patients with a life-limiting condition or frailty. The main contributing factors are a lack of awareness and knowledge amongst both healthcare professionals and patients, and a scarcity of effective, evidence-based interventions. In the DRy mOuth Project (DROP), we address these factors by investigating both a non-pharmacological and a pharmacological intervention: a nurse-led patient education program and locally applied pilocarpine. METHODS: This intervention-based research project consists of two parallel studies. The non-pharmacological study is a cluster non-randomized controlled trial in 228 palliative nursing home and hospital patients, investigating the effect of structured use of guidelines and of patient education on dry mouth symptoms. This intervention, a nurse-led patient education program (the Mouth Education Program, MEP), will be compared to care as usual, the control. The pharmacological study is a double-blind placebo-controlled randomized trial that examines the effect of locally applied pilocarpine drops in 120 patients with dry mouth symptoms. Both studies use the same mixed-methods study design, in which the primary outcome is the clinical response to the intervention at 4 weeks, as measured by a dry mouth severity score (numeric rating scale from 0 to 10). Other outcomes, as measured by questionnaires over a 12-week follow-up period, include durability of the effect, impact on quality of life and, adherence and acceptability of the intervention. In addition, the feasibility and cost-effectiveness are evaluated by means of questionnaires and focus groups with healthcare professionals, and interviews with patients. DISCUSSION: This study investigates the effectiveness and feasibility of two interventions for dry mouth symptoms in patients with life-limiting conditions or frailty. Due to the large-scale and mixed-method nature of the study, this study will also improve our understanding of dry mouth and its relating factors and of the patients' and healthcare professionals' experiences with symptoms, care and guidelines of dry mouth, including any perceived barriers and facilitators. TRIAL REGISTRATION: NCT05964959 & NCT05506137.

Assessment of patient symptom burden and information needs helps tailoring palliative care consultations: An observational study.

OBJECTIVE: The objective of this study is to study (1) the relationship between patient-reported symptom burden and information needs in hospital-based palliative care and (2) differences in patient-reported needs during the disease trajectory. METHODS: Observational study: patient-reported symptom burden and information needs were collected via a conversation guide comprising assessment scales for 12 symptoms (0-10), the question which symptom has priority to be solved and a question prompt list on 75 palliative care-related items (35 topics, 40 questions). Non-parametric tests assessed associations. RESULTS: Conversation guides were used by 266 patients. Median age was 65 years (IQ-range, 57-72), 49% were male and 96% had cancer. Patients reported highest burden for Fatigue (median = 7) and Loss of appetite (median = 6) and prioritised Pain (26%), Fatigue (9%) and Shortness of breath (9%). Patients wanted information about 1-38 (median = 14) items, mostly Fatigue (68%), Possibilities to manage future symptoms (68%) and Possible future symptoms (67%). Patients also wanted information about symptoms for which they reported low burden. Patients in the symptom-directed phase needed more information about hospice care. CONCLUSION: Symptom burden and information needs are related. Patients often also want information about non-prioritised symptoms and other palliative care domains. Tailored information-provision includes inviting patients to also discuss topics they did not consider themselves.

A simple risk score list can be used to predict the occurrence of delirium in patients admitted to inpatient hospice care: A medical record study.

OBJECTIVE: This study aimed to examine whether the 10-item Risk Score List (RSL) accurately predicts delirium in patients admitted to inpatient hospice care and whether this instrument can be simplified. Determining the risk for developing delirium can help to treat these patients in a timely manner. METHODS: This was a retrospective medical record study in patients who died in 2019 or 2020 in three hospices. Predictive values were examined using Cox regression analysis, crosstabs, and C-statistic. RESULTS: In total, 240 patients were included. Median age at admission was 78 (IQR 70-84) years. Primary diagnosis most often was cancer (n = 186, 78%); 173 (72%) patients had an increased risk of delirium according to RSL, of whom 120 (69%) developed delirium. Overall, 147 (61%) patients developed delirium. The RSL significantly predicted future delirium (HR 3.25, CI 1.87-5.65, p < 0.01) and had a sensitivity of 85%, a specificity of 43%, positive predictive value of 62%, negative predictive value of 73%, and a C-statistic of 0.64. Simplifying the RSL to four items still significantly predicted future delirium, with similar predictive values. CONCLUSION: Delirium occurs in more than half of patients admitted to hospice care. The RSL can be simplified to four items, without compromising on predictive accuracy.

Improving mental health of student and novice nurses to prevent dropout: A systematic review.

AIMS: To provide: (a) an overview of interventions aimed at improving mental health of student or novice nurses; and (b) an evaluation of their effectiveness on dropout-related outcomes. DESIGN: Systematic review. DATA SOURCES: Research papers published between January 1971-February 2019 were identified from the following databases: Embase, Medline, PsycInfo, CINAHL, ERIC, the Cochrane Library, Web of Science, and Google Scholar. REVIEW METHODS: We followed the procedures recommended by the Editorial Board of the Cochrane Collaboration Back Review Group. We included peer-reviewed articles with a quantitative research design, examining interventions aimed at improving mental health of student and novice nurses and their effect on dropout-related outcomes. The large variation in studies prohibited statistical pooling and a synthesis without meta-analysis of studies was performed. RESULTS: We identified 21 studies with three areas of focus: managing stress or stressors (N = 4); facilitating the transition to nursing practice (N = 14); and a combined approach (N = 3). Five studies showed a statistically significant effect on dropout-related outcomes. The overall risk of bias was high. CONCLUSION: A wide range of interventions are available, but the evidence for their effectiveness is limited. There is a need for high-quality studies in this field, preferably with a randomized controlled design.

Correction to: development of foraging skills in two orangutan populations: needing to learn or needing to grow?

[This corrects the article DOI: 10.1186/s12983-016-0178-5.].

Handedness in gestural and manipulative actions in male hunter-gatherer Aka pygmies from Central African Republic.

OBJECTIVES: All human populations display a right-biased handedness. Nonetheless, if studies on western populations are plenty, investigations of traditional populations living at subsistence levels are rare. Yet, understanding the geographical variation of phenotypes of handedness is crucial for testing evolutionary hypotheses. We aimed to provide a preliminary investigation of factors affecting handedness in 25 Aka pygmies from Central African Republic when spontaneously gesturing or manipulating food/tools (Nactions = 593). MATERIALS AND METHODS: We recorded spontaneous behaviors and characterized individuals' hand preference using GLMM with descriptive variables as target position, task complexity (unimanual/bimanual), task nature (food/tool manipulation, gesture), and task physical/cognitive constraints (precision or power for manipulative actions and informative content for gestures). RESULTS: Individuals were lateralized to the right (93%, N = 15) when manipulating food/tools but not when gesturing. Hand preference was affected by target position but not by task complexity. While nonexplicitly informative gestures were more biased to the right compared to explicitly informative ones, no differences were found within food/tool manipulation (power or precision vs. none). DISCUSSION: Although we do not intend to assume generalizable results due to our reduced sample, our observations provide additional information on handedness in a contemporary traditional society. Especially, the study mainly evidenced considerable cultural effects in gestures while also supporting theories considering active tool manipulation as one of the overriding factor in human handedness evolution.

Physical and mental determinants of dropout and retention among nursing students: protocol of the SPRiNG cohort study.

BACKGROUND: The shortage of nursing professionals is of growing concern. The causes of this include the demanding physical and mental workload, leading to a dropout of nurses that may start during their education. However, it is unclear to what extent nursing students already perceive a physical and mental workload leading to health problems during their nursing education and placement, and to what extent these health problems cause students to dropout from nursing education. Very few prospective cohort studies have investigated protective and risk factors in relation to dropout and retention among nursing students. METHODS: Three cohorts of third-year nursing students will be followed for 2.5 years. Students will be enrolled from the Bachelor of Nursing program of the Rotterdam University of Applied Sciences. At baseline, students will receive a self-administered questionnaire. Primary outcome is dropout from nursing education and dropout from the nursing profession. Data on dropout from nursing education will be retrieved from the student administration on a yearly basis. Dropout from the nursing profession will be measured one year after graduation, using the self-reported questionnaire. Secondary outcomes are presenteeism and sick leave (during internship/work). In addition to student characteristics, the questionnaire asks about physical and mental internship/work characteristics, personal and behavioral factors, and experienced physical and mental burden.Main aims of this study are to determine: 1) the prevalence and incidence rates of dropout, 2) the protective and risk factors, and early indicators of dropout, and 3) the interaction between these factors and the indicators. DISCUSSION: Data analysis of a large, prospective cohort study with regard to determinants of dropout and retention of nursing students and newly graduated nurses is in progress. Findings emerging from this study can be used to develop a predictive model to identify the first indicators of dropout from nursing education and nursing profession, for which targeted interventions can be deployed.

Development of foraging skills in two orangutan populations: needing to learn or needing to grow?

BACKGROUND: Orangutans have one of the slowest-paced life histories of all mammals. Whereas life-history theory suggests that the time to reach adulthood is constrained by the time needed to reach adult body size, the needing-to-learn hypothesis instead suggests that it is limited by the time needed to acquire adult-level skills. To test between these two hypotheses, we compared the development of foraging skills and growth trajectories of immature wild orangutans in two populations: at Tuanan (Pongo pygmaeus wurmbii), Borneo, and Suaq Balimbing (Pongo abelii), Sumatra. We collected behavioral data on diet repertoire, feeding rates and ranging competence during focal follows, and estimated growth through non-invasive laser photogrammetry. RESULTS: We found that adult-like diet repertoires are attained around the age of weaning and that female immatures increase their repertoire size faster than their male peers. Adult-level feeding rates of easy techniques are reached just after weaning, but several years later for more difficult techniques, albeit always before adulthood (i.e. age at first reproduction). Independent immatures had faster feeding rates for easy to process items than their mothers, with male immatures achieving faster feeding rates earlier in development relative to females. Sumatran immatures reach adult-level feeding rates 2-3 years later than their Bornean peers, in line with their higher dietary complexity and later weaning. The range-use competence of independently ranging and weaned immatures is similar to that of adult females. Body size measurements showed, immatures grow until female age of first reproduction. CONCLUSIONS: In conclusion, unlike in humans, orangutan foraging skills are in place prior to reproduction. Growth trajectories suggest that energetic constraints, rather than skills, best explain the length of immaturity. However, skill competence for dietary independence is reached later where the adult niche is more complex, which is consistent with the relatively later weaning age with increasing brain size found generally in primates, and apes in particular.

Self-management support from the perspective of patients with a chronic condition: a thematic synthesis of qualitative studies.

BACKGROUND: Receiving adequate support seems to be crucial to the success of self-management. Although different empirical studies separately examined patients' preferences for self-management support (SMS), an overview is lacking. OBJECTIVE: The aim of this qualitative review was to identify patients' needs with respect to SMS and to explore by whom this support is preferably provided. SEARCH STRATEGY: Qualitative studies were identified from Embase, MEDLINE OvidSP, Web of science, PubMed publisher, Cochrane central, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. INCLUSION CRITERIA: Articles needed to meet all of the following criteria: (i) focuses on self-management, (ii) concerns adult patients with rheumatic diseases (rheumatoid arthritis and fibromyalgia), a variant of cancer or chronic kidney disease, (iii) explores support needs from the patients' perspective, (iv) uses qualitative methods and (v) published in English. DATA EXTRACTION AND SYNTHESIS: A thematic synthesis, developed by Thomas and Harden, was conducted of the 37 included studies. MAIN RESULTS: Chronic patients need instrumental support, psychosocial support and relational support from health-care professionals, family/friends and fellow patients to manage the chronic condition. Relational support is at the centre of the support needs and fuels all other types of support. DISCUSSION AND CONCLUSIONS: Patients do not self-manage on their own. Patients expect health-care professionals to fulfil a comprehensive role. Support needs can be knitted together only when patients and professionals work together on the basis of collaborative partnership. Dynamics in support needs make it important to regularly assess patient needs.

Rapid milk group classification by 1H NMR analysis of Le and H epitopes in human milk oligosaccharide donor samples.

Human milk oligosaccharides (HMOs) are a major constituent of human breast milk and play an important role in reducing the risk of infections in infants. The structures of these HMOs show similarities with blood group antigens in protein glycosylation, in particular in relation to fucosylation in Lewis blood group-type epitopes, matching the maternal pattern. Previously, based on the Secretor and Lewis blood group system, four milk groups have been defined, i.e. Lewis-positive Secretors, Lewis-positive non-Secretors, Lewis-negative Secretors and Lewis-negative non-Secretors. Here, a rapid one-dimensional (1)H nuclear magnetic resonance (NMR) analysis method is presented that identifies the presence/absence of (α1-2)-, (α1-3)- and (α1-4)-linked fucose residues in HMO samples, affording the essential information to attribute different HMO samples to a specific milk group. The developed method is based on the NMR structural-reporter-group concept earlier established for glycoprotein glycans. Further evaluation of the data obtained from the analysis of 36 HMO samples shows that within each of the four milk groups the relative levels of the different fucosylation epitopes can greatly vary. The data also allow a separation of the Lewis-positive Secretor milk group into two sub-groups.

Association between Inappropriate End-of-Life Cancer Care and Specialist Palliative Care: A Retrospective Observational Study in Two Acute Care Hospitals.

A substantial number of patients with life-threatening illnesses like cancer receive inappropriate end-of-life care. Improving their quality of end-of-life care is a priority for patients and their families and for public health. To investigate the association between provision, timing, and initial setting of hospital-based specialist palliative care and potentially inappropriate end-of-life care for patients with cancer in two acute care hospitals in the Netherlands, we conducted a retrospective observational study using hospital administrative databases. All adults diagnosed with or treated for cancer in the year preceding their death in 2018 or 2019 were included. The main exposure was hospital-based specialist palliative care initiated >30 days before death. The outcome measures in the last 30 days of life were six quality indicators for inappropriate end-of-life care (≥2 ED-visits, ≥2 hospital admissions, >14 days hospitalization, ICU-admission, chemotherapy, hospital death). We identified 2603 deceased patients, of whom 14% (n = 359) received specialist palliative care >30 days before death (exposure group). Overall, 27% (n = 690) received potentially inappropriate end-of-life care: 19% in the exposure group, versus 28% in the non-exposure group (p < 0.001). The exposure group was 45% less likely to receive potentially inappropriate end-of-life care (AOR 0.55; 95% CI 0.41 to 0.73). Early (>90 days) and late (≤90 and >30 days) initiation of specialist palliative care, as well as outpatient and inpatient initiation, were all associated with less potentially inappropriate end-of-life care (AOR 0.49; 0.62; 0.32; 0.64, respectively). Thus, timely access to hospital-based specialist palliative care is associated with less potentially inappropriate end-of-life care for patients with cancer. The outpatient initiation of specialist palliative care seems to enhance this result.

Interventions that support novice nurses' transition into practice: A realist review.

BACKGROUND: Many transition-to-practice programs have been developed to support novice nurses during their first years into practice. These programs report improvements in retention, wellbeing and clinical competence, but the driving mechanisms of these interventions remain largely unclear. OBJECTIVE: To identify how transition-to-practice programs for novice nurses work and in what contexts they work successfully. METHODS: A realist review was conducted. Eligibility criteria included intervention studies aimed at novice nurses in their first two years of practice that reported outcomes on organizational or individual nurse level. The underlying theory of included transition-to-practice programs was extracted, and relevant contextual factors, mechanisms and outcomes were explored and synthesized into context-mechanism-outcome (CMO) configurations. The search was limited to studies between 2000 and 2023. RESULTS: A total of 32 studies were included, evaluating 30 different transition-to-practice programs with a wide range of intervention components including stress management, clinical education, professional and peer support, and ward rotations. Transition-to-practice programs were often designed without a theoretical foundation. Driving mechanisms behind the programs pertained to psychological, professional, and social development. Contextual factors that activated the mechanisms were enabling conditions for mentors and novice nurses, selection and motivation of novice nurses and organizational culture. CONCLUSIONS: Current transition-to-practice programs primarily focus on the individual and professional development of nurses. However, transition to practice can benefit from a systemic approach that includes development initiatives on the organizational level. REGISTRATION: PROSPERO ID CRD42021268080, August 15, 2021. TWEETABLE ABSTRACT: Context and mechanisms determine successful implementation of transition to practice programs for novice nurses. @transitiontopractice @nurseworkforce.

Urinary incontinence after surgery for pelvic organ prolapse.

AIMS: This study focused on the changes in urinary incontinence (UI) rates pre- and postoperatively and identified risk factors which predict the presence of symptoms of urgency urinary incontinence (UUI) or stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) without concomitant or previous anti-incontinence surgery. METHODS: All consecutive women who underwent POP surgery without concomitant or previous anti-incontinence surgery in the years 2004-2010 were included. Assessments were performed preoperatively and at 1-year follow-up, including pelvic organ prolapse quantification score and a standardized urogynecological questionnaire (Urogenital Distress Inventory, UDI). Primary outcome of this study was stress and/or urgency UI postoperatively. Furthermore, this study measured the improvement or worsening of UI following surgery using the UDI. Univariable- and multivariable logistic regression with forward selection procedure was used to identify the risk factors. RESULTS: Nine hundred seven patients were included. De novo SUI appeared in 22% and de novo UUI occurred in 21% of the women. At 1-year 42% were cured for UUI and 39% were recovered from SUI by POP surgery alone. The best predictor for the occurrence of postoperative SUI or UUI was the presence of preoperative SUI or UUI. BMI and chronic obstructive pulmonary disease (COPD) were identified as independent risk factors for postoperative SUI. A recurrence in the anterior compartment protected against SUI postoperatively. CONCLUSIONS: Preoperative SUI or UUI is the most important predictor of SUI and UUI postoperatively. BMI and COPD were identified as important risk factors for SUI.

Randomized controlled study of pain education in patients receiving radiotherapy for painful bone metastases.

BACKGROUND: Although short-course radiotherapy is an effective treatment for patients with painful bone metastases, pain is not always sufficiently controlled. We therefore investigated the additional effect of a nurse-led pain education program on pain control and quality of life (QoL). PATIENTS AND METHODS: In this multicenter study, patients with solid tumor bone metastases and a worst pain intensity of ≥5 on a 0-10 numeric rating scale (NRS) were randomized between care as usual (control-group) and care as usual plus the Pain Education Program (PEP-group). PEP consisted of a structured interview and personalized education with follow-up phone calls. Patients completed the Brief Pain Inventory, EORTC QLQ-C15-PAL and BM22 at week 0, 1, 4, 8 and 12. The primary outcome was pain control, defined as the number of patients whose worst pain intensity was <5 on a 0-10 NRS after 12 weeks. Secondary outcomes were time to reach control of pain (NRS < 5), mean worst pain and average pain, and QoL at weeks 1, 4, 8 and 12. RESULTS: Of 308 included patients, 182 (92 PEP-group) completed 12 weeks follow-up. At 12 weeks, more patients in the PEP-group (71%) compared to the control-group (52%) reported pain control (P =.008). In the PEP-group, pain control was reached earlier than in the control-group (median 29 days versus 56 days; P =.003). Mean worst and average pain decreased in both groups but decreased more in the PEP-group. QoL did not differ between the groups. CONCLUSION: The addition of PEP to care as usual for patients treated with radiotherapy for painful bone metastases resulted in less pain and faster pain control.

The role of terrestriality in promoting primate technology.

"Complex technology" has often been considered a hallmark of human evolution. However, recent findings show that wild monkeys are also capable of habitual tool use. Here we suggest that terrestriality may have been of crucial importance for the innovation, acquisition, and maintenance of "complex" technological skills in primates. Here we define complex technological skills as tool-use variants that include at least two tool elements (for example, hammer and anvil), flexibility in manufacture or use (that is, tool properties are adjusted to the task at hand), and that skills are acquired in part by social learning. Four lines of evidence provide support for the terrestriality effect. First, the only monkey populations exhibiting habitual tool use seem to be particularly terrestrial. Second, semi-terrestrial chimpanzees have more complex tool variants in their repertoire than does their arboreal Asian relative, the orangutan. Third, tool variants of chimpanzees used in a terrestrial setting tend to be more complex than those used exclusively in arboreal contexts. Fourth, the higher frequency in tool use among captive versus wild primates of the same species may be attributed in part to a terrestriality effect. We conclude that whereas extractive foraging, intelligence, and social tolerance are necessary for the emergence of habitual tool use, terrestriality seems to be crucial for acquiring and maintaining complex tool variants, particularly expressions of cumulative technology, within a population. Hence, comparative evidence among primates supports the hypothesis that the terrestriality premium may have been a major pacemaker of hominin technological evolution.

Conflict or connection? A feasibility study on the implementation of a training based on connecting communication in a nursing curriculum.

BACKGROUND: Nursing students frequently experience offensive behaviour and communication problems with patients, clinical supervisors, and nursing and faculty staff. A communication training was developed based on connecting communication to prevent and manage conflict, and build interpersonal trust-based relationships. OBJECTIVES: Feasibility study to evaluate the acceptability, demand, implementation, integration, and limited efficacy of a training based on connecting communication within a nursing curriculum. DESIGN: Mixed method design. PARTICIPANTS: Third-year nursing students (n = 24). SETTING: A Dutch Bachelor of Nursing degree programme in Rotterdam. METHODS: Between November 2019 and March 2020, data were collected from students and trainers, using quantitative and qualitative methods. Feasibility aspects, including limited efficacy testing, were measured with pre- and post-training surveys. Descriptive statistical analyses and (non)parametric tests were used to analyse feasibility aspects and baseline and follow-up scores for empathy, self-compassion, and exposure to violence. In addition, reflection reports of students and two paired interviews with the two trainers were analysed using qualitative content analysis with a deductive approach. RESULTS: The post-training survey and reflection reports showed a positive assessment of the training on acceptability, demand, and integration. Students rated the training as helpful in improving their communication skills and in dealing with conflict situations. Furthermore, they recommended to implement the training in earlier years of the educational programme. According to the trainers, miscommunication, students' lack of preparation for lessons, and the timing of the training prohibited full participation in the training. The pretest-posttest survey results show statistically significant improved self-compassion (3.77 vs. 4.10; p = 0.03) and decreased self-judgement (4.21 vs. 3.50; p = 0.03). Empathy and exposure to violence did not change. CONCLUSIONS: From the perspective of nursing students and trainers involved, this 10-week training based on connecting communication is feasible to implement in the Bachelor of Nursing degree programme, preferably before clinical placements.

Do physical work factors and musculoskeletal complaints contribute to the intention to leave or actual dropout in student nurses? A prospective cohort study.

BACKGROUND: Little is known, whether physical workload and musculoskeletal complaints (MSCs) have an impact on the intended or actual dropout of nursing students in the later years of their degree program. PURPOSE: Studying the determinants of intention to leave and actual dropout from nursing education. We hypothesized that physical workload and MSCs are positively associated with these outcomes. METHODS: A prospective cohort study among 711 third-year students at a Dutch Bachelor of Nursing degree program. Multivariable backward binary logistic regression was used to examine the association between physical work factors and MSCs, and intention to leave or actual dropout. RESULTS: Intention to leave was 39.9% and actual dropout 3.4%. Of the nursing students, 79% had regular MSCs. The multivariable model for intention to leave showed a significant association with male sex, working at a screen, physical activity, decision latitude, co-worker support, distress and need for recovery. The multivariable model for dropout showed a significant association with living situation (not living with parents), male sex, sick leave during academic year and decision latitude. CONCLUSIONS: Our research shows that the prevalence of MSCs among nursing students is surprisingly high, but is not associated with intention to leave nor with actual dropout.

Technique of anterior colporrhaphy: a Dutch evaluation.

INTRODUCTION AND HYPOTHESIS: To evaluate the variation in techniques of anterior colporrhaphy among members of the Dutch Urogynecologic Society. METHODS: A questionnaire evaluating the technique of anterior colporrhaphy, preoperative and postoperative care, and use of the POP-Q score was sent out by e-mail. RESULTS: One hundred thirty-three completed questionnaires were received. The response rate was 65%. There are large variations in incisions, use of hydrodissection, method of plication, and excision of redundant vaginal epithelium. The urinary catheter was generally removed on day 2 after surgery and the vaginal pack on day 1. Less than half of the respondents used the POP-Q score routinely. CONCLUSIONS: Dutch gynecologists use a variety of surgical techniques to operate on a cystocele. This suggests that there is no widely accepted opinion on the best surgical approach. The lack of differentiation between central and lateral defects is striking and in contrast with the, mostly, American literature.

Psychosocial work characteristics associated with distress and intention to leave nursing education among students; A one-year follow-up study.

BACKGROUND: Dropout in later years of the nursing degree programme involves lost investment and is a particular problem for both students and educators. Reasons for late dropout seem to be related to the work and learning environment of the clinical placement. OBJECTIVES: The aim of this study was to investigate associations between psychosocial work characteristics and distress and intention to leave nursing education among third-year nursing students. DESIGN: A prospective cohort study. SETTING: A Bachelor of Nursing programme of a University of Applied Sciences in the Netherlands. PARTICIPANTS: 363 third-year nursing students. METHODS: Baseline and one-year follow-up measurements were used from a prospective cohort study. Third-year nursing students were invited annually in May between 2016 and 2018. Psychosocial work characteristics were psychological demands, supervisor and co-worker support, and acts of offensive behaviour. Logistic regression analyses were used to build multivariate models. RESULTS: Frequent exposure to violence (OR = 2.52, 95% CI: 1.29-4.92) was univariately associated with distress. In the multivariate model for distress, psychological demands (OR = 1.63, 95% CI: 1.05-2.52) and frequent exposure to violence (OR = 3.02, 95% CI: 1.48-6.19) were associated with distress. Supervisor support (OR = 0.54, 95% CI: 0.36-0.80) and co-worker support (OR = 0.41, 95% CI: 0.24-0.72) were negatively associated with intention to leave (i.e. were protective) in the univariate model. In the adjusted multivariate model, only co-worker support (OR = 0.50, 95% CI: 0.25-0.97) was a protective factor for an intention to leave. CONCLUSION: Psychological demands and frequent exposure to violence are risk factors for distress, and co-worker support is a protective factor reducing the intention to leave nursing education in the last stage of the programme. Improving the psychosocial working climate of nursing students may reduce the intention to leave at a late stage in nursing education, and hence actual late dropout.

The self-perceived palliative care barriers and educational needs of clinicians working in hospital primary care teams and referral patterns: lessons learned from a single-center survey and cohort study.

BACKGROUND: Within the generalist-plus-specialist palliative care model, palliative care is mainly provided by nurses and physicians of hospital primary care teams. Palliative care consultation teams (PCCTs) support these clinicians in adequately caring for patients with advanced illnesses. Our team started in 2012. The aim of this study was to assess the self-perceived barriers, educational needs and awareness of available palliative care support options among our hospital primary care teams. In addition, palliative care referral patterns were evaluated. METHODS: Single-center mixed methods study. Outcomes of two surveys of primary care team clinicians (2012 and 2016) on barriers to palliative care, educational needs and awareness of palliative care support options were compared (chi-square, Mann-Whitney U tests, qualitative analysis). Palliative care referral characteristics were evaluated (2012-2017), including referral timing (survival since referral) (descriptive statistics, Kaplan-Meier methodology). Predictions of survival at referral were analyzed (weighted Kappa). RESULTS: In 2012 and 2016, the most frequently reported barrier was the late initiation of the palliative care approach. Clinicians reported a need for education on physical symptom management and basic palliative care principles. Awareness of support options increased from 2012 to 2016, including improved familiarity with the PCCT (56% vs. 85%, P<0.001) and positive appraisal of the team (8% vs. 40% gave an 'excellent' rating, P<0.001). The use of national symptom management guidelines also improved (23% vs. 53%, P<0.001). Of 1,404 referrals, 86% were for cancer patients. Referrals increased by 28% (mean) per year. Medical oncology clinicians referred most frequently (27%) and increasingly early in the disease trajectory (survival ≥3 months after referral) (P=0.016). Median survival after referral was 0.9 (range, 0-83.3) months. Referring physicians overestimated survival in 44% of patients (kappa 0.36, 95% CI: 0.30-0.42). CONCLUSIONS: Primary care team clinicians persistently reported needing support with basic palliative care skills. PCCTs should continuously focus on educating primary care teams and promoting the use of guidelines. Because physicians tend to overestimate survival and usually referred patients late for specialist palliative care, consultation teams should support primary care teams to identify, treat and refer patients with palliative care needs in a timely manner.