Reasons why Dutch novice nurses leave nursing: A qualitative approach.

Shortages in the nursing profession are increasing. It is, therefore, imperative to understand why novice nurses are leaving the profession. This qualitative study explores Dutch novice nurses' motives for leaving the profession. Individual semi-structured interviews were held with seventeen former novice nurses who had decided to leave nursing within two years after graduation. Data was collected and analysed following the principles of Thematic Analysis, leading to six themes; 1) Lack of challenge; ambitious to progress further in management or research roles. 2) Lack of passion; no feeling of passion for patient care. 3) Lack of perceived competence; not feeling "up to the challenge". 4) Lack of job satisfaction due to heavy workload; work-life imbalance and inability to deliver high-quality care. 5) Lack of work capacity due to non-work-related health conditions; unmet requirements for job or work environment adjustment. 6) Lack of feeling of belonging; suffering from a negative attitude of colleagues to one another. To prevent novice nurse professional turnover, measures such as capacity building, supervisor support and a tailored personal development plan could be taken. To make novice nurses feel safe and reassured, support from colleagues and supervisors is important. Such measures require thoughtful implementation and evaluation.

The effect of omitting an early population-based vision screen in the Netherlands: A micro-simulation model approach.

Objective To estimate the effect of omitting an individual screen from a child vision screening programme on the detection of amblyopia in the Netherlands. A previous study (Rotterdam Amblyopia Screening Effectiveness Study) suggested that the three screens carried out between 6 and 24 months contributed little. Methods We developed a micro-simulation model that approximated the birth-cohort data from the previous study, in which 2964 children had completed follow-up at age 7, and 100 amblyopia cases were detected. Detailed data on screens, referrals, and orthoptic follow-up, including the cause of amblyopia, were available. The model predicted the number of amblyopia cases detected for each screen and for the entire screening programme, and the effect of omitting screens. Incidence curves for all types of amblyopia caused by strabismus, refractive anomalies or by both were estimated by approximation of the observational data, in conjunction with experts' estimations and the literature. Results We calculated mean actual sensitivity per screen per type of amblyopia, and the effect per screen. Screening at 24 months was found to be least effective. The impact on the screening programme, estimated by summing the effectiveness per screen, omitting the 24-month screen, was a reduction of 3.4% (57 vs. 59 cases) in the number of detected cases of amblyopia at age 5. Conclusion The effectiveness of the Dutch vision screening programme would hardly be affected by omission of the 24-month screening examination. A disinvestment study is warranted.

Impact of transition from analog screening mammography to digital screening mammography on screening outcome in The Netherlands: a population-based study.

BACKGROUND: Full-field digital mammography (FFDM) has replaced screen-film mammography (SFM) in most breast screening programs. We analyzed the impact of this replacement on the screening outcome. PATIENTS AND METHODS: The study population consisted of a consecutive series of 60 770 analog and 63 182 digital screens. During a 1-year follow-up, we collected breast imaging reports, biopsy results and surgical reports of all the referred women. RESULTS: The referral rate and the cancer detection rate at FFDM were, respectively, 3.0% and 6,6‰, compared with 1.5% (P < 0.001) and 4.9‰ (P < 0.001) at SFM. Positive predictive values of referral and percutaneous biopsies were lower at FFDM, respectively, 21.9% versus 31.6% (P < 0.001) and 42.9% versus 62.8% (P < 0.001). Per 1000 screened women, there was a significant increase with FFDM versus SFM in the detection rate of low- and intermediate-grade ductal carcinoma in situ (DCIS) (+0.7), invasive T1a-c cancers (+0.9), invasive ductal cancers (+0.9), low-grade (+1.1), node-negative invasive cancers (+1.2), estrogen-receptor or progesterone-receptor-positive invasive cancers (respectively, +0.9 and +1.1) and Her2/Neu-negative (+0.8) invasive cancers. Mastectomy rates were stable at 1.1 per 1,000 screens. CONCLUSIONS: FFDM significantly increased the referral rate and cancer detection rate, at the expense of a lower positive predictive value of referral and biopsy. Extra tumors detected at FFDM were mostly low-intermediate grade DCIS and smaller invasive tumors, of more favorable tumor characteristics. Mastectomy rates were not increased in the FFDM population, while increased over-diagnosis cannot be excluded.

Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome.

We prospectively determined the variability in radiologists' interpretation of screening mammograms and assessed the influence of type and number of readers on screening outcome. Twenty-one screening mammography radiographers and eight screening radiologists participated. A total of 106,093 screening mammograms were double-read by two radiographers and, in turn, by two radiologists. Initially, radiologists were blinded to the referral opinion of the radiographers. A woman was referred if she was considered positive at radiologist double-reading with consensus interpretation or referred after radiologist review of positive cases at radiographer double-reading. During 2-year follow-up, clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result from any reader. Single radiologist reading (I) resulted in a mean cancer detection rate of 4.64 per 1000 screens (95% confidence intervals (CI)=4.23-5.05) with individual variations from 3.44 (95% CI=2.30-4.58) to 5.04 (95% CI=3.81-6.27), and a sensitivity of 63.9% (95% CI=60.5-67.3), ranging from 51.5% (95% CI=39.6-63.3) to 75.0% (95% CI=65.3-84.7). Sensitivity at non-blinded, radiologist double-reading (II), radiologist double-reading followed by radiologist review of positive cases at radiographer double-reading (III), triple reading by one radiologist and two radiographers with referral of all positive readings (IV) and quadruple reading by two radiologists and two radiographers with referral of all positive readings (V) were as follows: 68.6% (95% CI=65.3-71.9) (II); 73.2% (95% CI=70.1-76.4) (III); 75.2% (95% CI=72.1-78.2) (IV), and 76.9% (95% CI=73.9-79.9) (V). We conclude that screener performance significantly varied at single-reading. Double-reading increased sensitivity by a relative 7.3%. When there is a shortage of screening radiologists, triple reading by one radiologist and two radiographers may replace radiologist double-reading.

[Evaluation of visual acuity in a historical cohort of 137 patients treated for amblyopia by occlusion 30-35 years ago]. / Visusevaluierung in einer historischen Kohorte von 137 okkludierten Patienten, 30-35 Jahre nach Ende der Okklusionsbehandlung.

BACKGROUND: Opinions differ on the course of the visual acuity in the amblyopic eye after cessation of occlusion therapy. This study evaluated visual acuity in a historical cohort treated for amblyopia with occlusion therapy 30-35 years ago. MATERIALS AND METHODS: Between 1968 and 1975, 1250 patients had been treated by the orthoptist in the Waterland Hospital in Purmerend, The Netherlands. Of these, 471 received occlusion treatment for amblyopia (prevalence 5.0%, after comparison with the local birth rate). We were able to contact 203 of these patients, 137 were orthoptically re-examined in 2003. We correlated the current visual acuity with the cause of amblyopia, the age at start and end of treatment, the visual acuity at start and end of treatment, fixation, binocular vision and refractive errors. RESULTS: Mean age at the start of treatment was 5.4 +/- 1.9 years, 7.4 +/- 1.7 years at the end and 37 +/- 2.7 years at follow-up. Current visual acuity in the amblyopic eye was correlated with a low visual acuity at the start (p < 0.0001) and end (p < 0.0001) of occlusion therapy, an eccentric fixation (p < 0.0001), and the cause of amblyopia (p = 0.005). At the end of the treatment, patients with a strabismic amblyopia (n = 98) had a visual acuity in the amblyopic eye of 0.29 logMAR +/- 0.3, and in 2003 0.27 +/- 0.3 logMAR. In patients with an anisometropic amblyopia (> 1 D, n = 16) visual acuity had decreased from 0.17 +/- 0.23 logMAR to 0.21 logMAR +/- 0.23. In patients with both strabismic and anisometropic amblyopia (n = 23), visual acuity had decreased from 0.52 logMAR +/- 0.54 to 0.65 logMAR +/- 0.54. Overall, acuity had decreased in 54 patients (39%) after cessation of treatment. Of these, 18 patients had an acuity decrease to less than 50% of their acuity at the end of treatment. In 15 of these 18 patients anisohypermetropia had increased. CONCLUSIONS: A decrease in visual acuity after cessation of occlusion therapy occurred in patients with a combined cause of amblyopia or with an increase in anisohypermetropia.

Cost-effectiveness of different reading and referral strategies in mammography screening in the Netherlands.

In mammography screening with double reading, different strategies can be used when the readers give discordant recommendations for referral. We investigated whether the results of the Dutch breast cancer screening programme can be optimised by replacing the standard referral strategy by consensus. Twenty-six screening radiologists independently and blinded to outcome read a test set consisting of previous screening mammograms of 250 cases (screen-detected and interval cancers) and 250 controls. Their referral recommendations were paired and, in case of discrepancy, re-read according to three referral strategies: (1) decision by one of the readers; (2) arbitration by a third reader; (3) referral if both readers agree (consensus). Data allowed studying other referral strategies, including referral if any reader suggests, as well. Double reading with referral if any reader suggests resulted in a 1.03 times higher sensitivity (76.6%) and a 1.31 times higher referral rate (1.26%) than double reading with consensus. To estimate the cost-effectiveness, the outcomes were used in a microsimulation model. Even if double reading with referral if any reader suggests results in four times as high referral rates and an accompanying increase of biopsies or other invasive procedures, the cost-effectiveness of 4,190 Euros per life-year gained may well be in the range of acceptable cost-effectiveness for Dutch health care programmes.

Mammography screening in the Netherlands: delay in the diagnosis of breast cancer after breast cancer screening.

In a prospective study we determined the frequency and causes of delay in the diagnosis of breast cancer after suspicious screening mammography. We included all women aged 50-75 years who underwent biennial screening mammography in the southern breast cancer screening region of the Netherlands between 1 January 1996 and 1 January 2002. Clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result with a minimum of 2-year follow-up. Of 153 969 mammographic screening examinations, 1615 (1.05%) were positive screens. Breast cancer was diagnosed in 770 (47.9%) of 1607 women for whom follow-up information was available, yielding a cancer detection rate of 5.0 per 1000 women screened. Breast cancer was diagnosed within 3 months following a positive screen in 722 cases (93.8%). The diagnostic delay was 4-6, 7-12 and 13-24 months, respectively, in 11 (1.4%), 24 (3.1%) and nine (1.2%) patients. In four other patients (0.5%), breast cancer was diagnosed after a repeat positive screen, resulting in a diagnostic delay of 25-27 months. Reasons for a diagnostic delay >3 months were erroneous mammographic interpretation of suspicious lesions as benign or probably benign lesions (33 cases), benign biopsies from a malignant lesion (10), and omission to biopsy or remove a lesion that was suspicious at breast imaging (4) or core biopsy (1). We conclude that there is room for improvement in the workup of patients with a positive screening mammography, as seen from data in this screening region. To improve the workup, we suggest that other breast cancer screening programmes also identify delay in breast cancer diagnosis after a positive screen.

Cost-effectiveness of stereotactic large-core needle biopsy for nonpalpable breast lesions compared to open-breast biopsy.

This paper demonstrates that the introduction of large-core needle biopsy (LCNB) replacing needle-localised breast biopsy (NLBB) for nonpalpable (screen-detected) breast lesions could result in substantial cost savings at the expense of a possible slight increase in breast cancer mortality. The cost-effectiveness of LCNB and NLBB was estimated using a microsimulation model. The sensitivity of LCNB (0.97) and resource use and costs of LCNB and NLBB were derived from a multicentre consecutive cohort study among 973 women who consented in getting LCNB and NLBB, if LCNB was negative. Sensitivity analyses were performed. Replacing NLBB with LCNB would result in approximately six more breast cancer deaths per year (in a target population of 2.1 million women), or in 1000 extra life-years lost from breast cancer (effect over 100 years). The total costs of management of breast cancer (3% discounted) are estimated at pound 4676 million with NLBB; introducing LCNB would save pound 13 million. The incremental cost-effectiveness ratio of continued NLBB vs LCNB would be pound 12 482 per additional life-year gained (3% discounted); incremental costs range from pound -21 687 (low threshold for breast biopsy) to pound 74 378 (high sensitivity of LCNB).

Nationwide breast cancer screening programme fully implemented in The Netherlands.

The period 1990-1997 saw the implementation of a nationwide breast cancer screening programme in the Netherlands, which provided biennial mammography for all women aged 50-69 years (50-75 years at present). The National Evaluation Team monitors the programme annually collecting regional data on screening outcomes; regional cancer registries provide data on interval cancers and on breast cancers in unscreened women by linkage of cancer registry data to data on screened women. Of 4 million women invited, 78.5% attended for screening. Screening resulted in 13.1 referrals, 9.2 biopsies and 6.1 breast cancers detected per 1000 women screened initially (6.9, 4.5 and 3.5 per 1000 in subsequently screened women, respectively). Within the first 2 years following screening 0.95 interval cancers per 1000 women-years were diagnosed. The stage distribution of screen-detected cancers was more favourable than that of interval cancers and of those diagnosed in unscreened women. The results are largely consistent with expectations. Results may nonetheless be further improved, particularly the detection rate in subsequent screens.

A nationwide study of decisions to forego life-prolonging treatment in Dutch medical practice.

BACKGROUND: Decisions to withhold or withdraw life-prolonging treatment in terminally ill patients are common in some areas of medical practice. Information about the frequency and background of these decisions is generally limited to specific clinical settings. This article describes the practice of withholding or withdrawing life-prolonging treatment in the Netherlands. METHODS: Questionnaires were sent to the attending physicians of a stratified sample of 6060 of all 43002 cases of death in the Netherlands from August 1 through November 30, 1995. The questions concerned the treatments foregone, the patient characteristics, and the decision-making process. The response rate was 77%. RESULTS: A nontreatment decision was made in 30% (95% confidence interval, 28%-31%) of all deaths in the Netherlands in 1995; this is an increase compared with 28% (95% confidence interval, 26%-29%) in 1990; in 20% of all deaths, this decision was the most important end-of-life decision. Artificial nutrition or hydration and antibiotics were the treatments most frequently foregone, each accounting for 25% of cases in which a nontreatment decision was made. Nursing-home physicians withheld or withdrew treatment more often than clinical specialists or general practitioners in 52%, 35%, and 17% of all deaths they were involved with, respectively. Of the patients in whom a nontreatment decision was the most important end-of-life decision, 26% were competent; of those, 93% were involved in the decision making. In 17% of patients, the nontreatment decision was made without being discussed with the patient or the patient's relatives and without knowledge of the patient's wishes. Life was shortened by an estimated 24 hours or less in 42% and 1 month or more in 8% of patients. CONCLUSIONS: Decisions to forego life-prolonging treatment are frequently made end-of-life decisions in the Netherlands and may be increasing. Most of these decisions do not involve high-technology treatments, and the consequences, in terms of shortening of life, are relatively small.

Clinical problems with the performance of euthanasia and physician-assisted suicide in The Netherlands.

BACKGROUND AND METHODS: The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in The Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death. RESULTS: In 114 cases, the physician's intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5). CONCLUSIONS: There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In The Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient's inability to take the medication or because of problems with the completion of physician-assisted suicide.

Drugs used in physician-assisted death.

Epidemiological studies, case reports, and recommendations concerning the drugs used in physician-assisted death are reviewed in this paper. Using a MEDLINE and Cancerlit search, we found a total of 20 relevant publications. Recent research, mainly from the Netherlands, has shown that high doses of barbiturates are usually effective for physician-assisted suicide, while a combination of a barbiturate and a derivative of curare are effective for euthanasia. Opioids are less reliable drugs for physician-assisted death because of the unpredictable duration of the dying process even after high doses. The same applies to benzodiazepines. The most frequent undesired effect is an unexpectedly long dying process due to impaired uptake of the drugs. Although the evidence base is incomplete, the Dutch recommendations issued in 1994 and renewed in 1998 do not seem inappropriate.

Physician-assisted death in psychiatric practice in the Netherlands.

BACKGROUND: In 1994 the Dutch Supreme Court ruled that in exceptional instances, physician-assisted suicide might be justifiable for patients with unbearable mental suffering but no physical illness. We studied physician-assisted suicide and euthanasia in psychiatric practice in the Netherlands. METHODS: In 1996, we sent questionnaires to 673 Dutch psychiatrists - about half of all such specialists in the country - and received 552 responses from the 667 who met the study criteria (response rate, 83 percent). We estimated the annual frequencies of requests for physician-assisted suicide by psychiatrists and actual instances of assistance. RESULTS: Of the respondents, 205 (37 percent) had at least once received an explicit, persistent request for physician-assisted suicide and 12 had complied. We estimate there are 320 requests a year in psychiatric practice and 2 to 5 assisted suicides. Excluding those who had ever assisted, 345 of the respondents (64 percent) thought physician-assisted suicide because of a mental disorder could be acceptable, including 241 who said they could conceive of instances in which they themselves would be willing to assist. The most frequent reasons for refusing were the belief that the patient had a treatable mental disorder, opposition to assisted suicide in principle, and doubt that the suffering was unbearable or hopeless. Most, but not all, patients who had been assisted by their psychiatrists in suicide had both a mental disorder and a serious physical illness, often in a terminal phase. Thirty percent of the respondents had been consulted at least once by a physician in another specialty about a patient's request for assisted death. The annual number of such consultations was estimated at 310, about 3 percent of the estimated 9700 requests for euthanasia or physician-assisted suicide in medical practice. CONCLUSIONS: Explicit requests for physician-assisted suicide are not uncommon in psychiatric practice in the Netherlands, but these requests are rarely granted. Psychiatric consultation for medical patients who request physician-assisted death is relatively rare.

[Frequency of decisions to forgo (artificial) administration of food and fluids at life's end]. / Frequentie van het afzien van (kunstmatige) toediening van voeding en vocht aan het levenseinde.

OBJECTIVE: To determine the frequency and characteristics of decisions to forgo (artificial) feeding and hydration with hastening of death as a possible result. DESIGN: Retrospective, descriptive study. SETTING: The Netherlands. METHODS: Data were collected from questionnaires mailed to physicians attending 6060 deaths identified from death certificates dating from August through November 1995 (response rate: 77%). RESULTS: Decisions to forgo feeding and hydration preceded 8% of all deaths studied; for deaths attended by nursing home physicians this percentage was 23%, for deaths attended by general practitioners and specialists it was 4%. In 68% of all these death cases, the patients had been 80 years of age or over, and 76% of them had been partly or completely incompetent. The non-treatment decision had been discussed with relatives in 82% of all cases, and in 89% of the death cases attended by nursing home physicians. These patients had had (possibly) life-shortening medication less frequently than other patients for whom a medical decision concerning the end of life had been made. CONCLUSION: Decisions to forgo (artificial) feeding and hydration were made relatively often by nursing home physicians, and rarely by general practitioners and specialists. These decisions were usually but not always made after discussion with relatives. There were no indications that these decisions entailed a great deal of suffering for the patients.