Sarah M. Ketelaar

A Clinically Integrated Post-Graduate Training Programme in Evidence-Based Medicine versus ‘No Intervention’ for Improving Disability Evaluations: A Cluster Randomised Clinical Trial

Background Although several studies have shown that teaching EBM is effective in improving knowledge, at present, there is no convincing evidence that teaching EBM also changes professional behaviour in practice. Therefore, the primary aim of this study was to evaluate the effectiveness of a clinically integrated post-graduate training programme in EBM on evidence-based disability evaluation. Methods and Findings In a cluster randomised controlled trial, fifty-four case-based learning groups consisting of 132 physicians and 1680 patients were randomly assigned to the intervention or control groups. A clinically integrated, post-graduate, 5-day training programme in evidence-based medicine, consisting of (home) assignments, peer teaching, interactive training in searching databases, lectures and brainstorming sessions was provided to the intervention group. The control group received no training. The primary outcome was evidence-based disability evaluation, as indicated by the frequency in use of evidence of sufficient quality in disability evaluation reports. There are no general EBM behaviour outcome measures available. Therefore, we followed general guidelines for constructing performance indicators and defined an a priori cut-off for determination of sufficient quality as recommended for evaluating EB training. Physicians trained in EBM performed more evidence-based disability evaluations compared to physicians in the control group (difference in absolute proportion 9.7%, 95% CI 3.5 to 15.9). The primary outcome differences between groups remained significant after both cluster-adjusted analysis and additional sensitivity analyses accounting for subjects lost to follow-up. Conclusions A EBM programme successfully improved the use of evidence in a non-hospital based medical specialty. Our findings support the general recommendations to use multiple educational methods to change physician behaviour. In addition, it appeared important that the professional context of the intervention was very supportive in the sense that searches in databases, using and applying guidelines and other forms of evidence are considered standard practice and are encouraged by colleagues and management.

Comparative cost-effectiveness of two interventions to promote work functioning by targeting mental health complaints among nurses: Pragmatic cluster randomised trial

BACKGROUND The specific job demands of working in a hospital may place nurses at elevated risk for developing distress, anxiety and depression. Screening followed by referral to early interventions may reduce the incidence of these health problems and promote work functioning. OBJECTIVE To evaluate the comparative cost-effectiveness of two strategies to promote work functioning among nurses by reducing symptoms of mental health complaints. Three conditions were compared: the control condition consisted of online screening for mental health problems without feedback about the screening results. The occupational physician condition consisted of screening, feedback and referral to the occupational physician for screen-positive nurses. The third condition included screening, feedback, and referral to e-mental health. DESIGN The study was designed as an economic evaluation alongside a pragmatic cluster randomised controlled trial with randomisation at hospital-ward level. SETTING AND PARTICIPANTS The study included 617 nurses in one academic medical centre in the Netherlands. METHODS Treatment response was defined as an improvement on the Nurses Work Functioning Questionnaire of at least 40% between baseline and follow-up. Total per-participant costs encompassed intervention costs, direct medical and non-medical costs, and indirect costs stemming from lost productivity due to absenteeism and presenteeism. All costs were indexed for the year 2011. RESULTS At 6 months follow-up, significant improvement in work functioning occurred in 20%, 24% and 16% of the participating nurses in the control condition, the occupational physician condition and the e-mental health condition, respectively. In these conditions the total average annualised costs were €1752, €1266 and €1375 per nurse. The median incremental cost-effectiveness ratio for the occupational physician condition versus the control condition was dominant, suggesting cost savings of €5049 per treatment responder. The incremental cost-effectiveness ratio for the e-mental health condition versus the control condition was estimated at €4054 (added costs) per treatment responder. Sensitivity analyses attested to the robustness of these findings. CONCLUSIONS The occupational physician condition resulted in greater treatment responses for less costs relative to the control condition and can therefore be recommended. The e-mental health condition produced less treatment response than the control condition and cannot be recommended as an intervention to improve work functioning among nurses.

Protecting and promoting mental health of nurses in the hospital setting: Is it cost-effective from an employer's perspective?

OBJECTIVES Nurses are at elevated risk of burnout, anxiety and depressive disorders, and may then become less productive. This begs the question if a preventive intervention in the work setting might be cost-saving from a business perspective. MATERIAL AND METHODS A cost-benefit analysis was conducted to evaluate the balance between the costs of a preventive intervention among nurses at elevated risk of mental health complaints and the cost offsets stemming from improved productivity. This evaluation was conducted alongside a cluster-randomized trial in a Dutch academic hospital. The control condition consisted of screening without feedback and unrestricted access to usual care (N = 206). In the experimental condition screen-positive nurses received personalized feedback and referral to the occupational physician (N = 207). RESULTS Subtracting intervention costs from the cost offsets due to reduced absenteeism and presenteeism resulted in net-savings of 244 euros per nurse when only absenteeism is regarded, and 651 euros when presenteeism is also taken into account. This corresponds to a return-on-investment of 5 euros up to 11 euros for every euro invested. CONCLUSIONS Within half a year, the cost of offering the preventive intervention was more than recouped. Offering the preventive intervention represents a favorable business case as seen from the employers perspective.

Improved quality and more attractive work by applying EBM in disability evaluations: a qualitative survey

BackgroundThe uptake of evidence in practice by physicians, even if they are trained in the systematic method of evidence-based medicine (EBM), remains difficult to improve. The aim of this study was to explore perceptions and experiences of physicians doing disability evaluations regarding motivators and preconditions for the implementation of EBM in daily practice.MethodsThis qualitative study was nested in a cluster randomized controlled trial (Trial registration NTR1767; 20-apr-2009) evaluating the effects of training in EBM. The 45 physicians that participated received a comprehensive 6-months training program in EBM of which the last course day included audio-recorded interviews in groups. During these interviews participating physicians discussed perceptions and experiences regarding EBM application in daily practice. In an iterative process we searched for common motivators or preconditions for the implementation of EBM.ResultsThree main concepts or themes emerged after analyzing the transcriptions of the discussions: 1) improved quality of physicians’ actions, such as clients benefiting from the application of EBM; 2) improved work attractiveness of physicians; and 3) preconditions that have to be met in order to work in an evidence-based manner including professional competence, facilitating material conditions and organizational support and demands.ConclusionsPhysicians trained in EBM are motivated to use EBM because they perceive it as a factor improving the quality of their work and making their work more attractive. In addition to personal investments and gains, organizational support should further facilitate the uptake of evidence in practice.

Is change in health behavior of Dutch medical students related to change in their ideas on how a physician's lifestyle influences their patient's lifestyle?

Abstract Background: A change of medical students’ health behavior over time may be related to a change in their opinion regarding the relationship between physicians’ own health behavior and effective healthy lifestyle counseling in patients. Objective: To investigate Dutch medical students’ (1) change of health behavior over time, (2) change of opinion over time regarding the relationship between a physician’s own health behavior and effective healthy lifestyle counseling in patients, and (3) the relationship between these aspects. Method: All medical students from two Dutch medical schools were invited to fill out an online questionnaire in 2010. Respondents of 2010 were invited for 2011. Health behavior was assessed with five aspects: drinking behavior, smoking, eating habits, sleeping behavior, and sexual behavior. Their opinion regarding the relationship between their own health behavior and effective healthy lifestyle counseling in patients was assessed with one statement. Results: At baseline, 2016 medical students (41%) participated, and at 1 year follow-up 1078 medical students (53%) participated. Fourteen percent adopted healthier behavior over time, and 12% adopted unhealthier behavior. Twelve percent positively changed their opinion, and 13% negatively changed their opinion. Participants who adopted unhealthier behavior were more inclined to also have negatively changed their opinion than participants who adopted healthier behavior (statistically nonsignificant difference, p=0.38). Conclusions: No significant relationship was found between a change in health behavior of Dutch medical students and a change of their opinion regarding the relationship between physicians’ own healthy lifestyle and their ability to effectively influence patients to adhere to a healthy lifestyle.

PMO-module psychische gezondheid verbetert werkfunctioneren in de zorg

SamenvattingOmdat psychische klachten relatief veel voorkomen bij werknemers in de zorg en deze het functioneren in werk kunnen belemmeren, is voor verpleegkundigen en paramedici een module voor preventief medisch onderzoek (PMO) gericht op psychische gezondheid ontwikkeld. Het effect op het werkfunctioneren is onderzocht in een clustergerandomiseerd gecontroleerde studie. Een bedrijfsartsstrategie (online screening op verminderd werkfunctioneren en psychische klachten, digitale individuele feedback en een uitnodiging voor een preventief bedrijfsartsconsult) had een positief effect op werkfunctioneren ten opzichte van een controlegroep in de groep positief gescreenden. Een e-mental health strategie (dezelfde screening en individuele feedback gevolgd door advies-op-maat en het aanbod om een of meerdere zelfhulpinternetcursussen te volgen) had geen significant effect, mogelijk vanwege lage deelname aan de internetcursussen. Implementatie van de bedrijfsartsstrategie lijkt goed mogelijk.SummaryMental Vital i ty @ Work: a mental health module for Workers’ Health Surveillance can improve work functioningMental health complaints are relatively common in healthcare employees and can adversely affect their work functioning. Early interventions can prevent a worsening of complaints. Therefore, a mental health module for Workers’ Health Surveillance (WHS) was developed for nurses and allied health professionals. The effect on work functioning was studied 3 and 6 months after intervention. In the Mental Vitality@Work study two WHS strategies and a control group were compared in a cluster-randomised controlled trial. Both strategies started with online screening on impaired work functioning and mental health of nurses and allied health professionals at a Dutch academic medical centre (n=1,731), followed by personalised online feedback. In the more traditional ‘Occupational Physician (OP)-strategy’ employees who screened positive were then invited for a preventive consultation with an OP. The second strategy was an ‘e-mental health (EMH-) strategy’ in which employees were given tailored advice and the option to follow one or more self-help internet courses.The participants were positive about the mental health module. Work functioning improved in all three groups, but the OP strategy had a positive effect on work functioning compared to a control group. After 3 and 6 months significantly more participants in the OP group showed a relevant improvement in work functioning compared with the control group. Compared to the control group the EMH group did not show a significant effect, possibly because of low participation in the courses on offer. There was no significant difference in the improvement of work functioning between the OP group and the EMH group over time. After 3 months more participants showed a relevant improvement in the OP group (46%) than the EMH group (30%), but this was not a significant difference (p=0.07).Answering the questionnaire about work functioning and mental health can possibly raise awareness about work functioning and mental health. The OP strategy for mental health could lead to an even larger improvement of work functioning. Implementa tion of the OP strategy seems viable.

Exploring novice nurses’ needs regarding their work-related health: a qualitative study

PurposeTo investigate Dutch novice nurses’ experiences and needs regarding occupational health support to prevent work-related health problems and to keep them well-functioning.MethodsA qualitative interview study was conducted with six nursing students and eight newly qualified nurses. The interviews covered three topics: experiences with the link between work and health, received occupational health support, and occupational health support needs. Data were analysed using a grounded theory approach.ResultsParticipants reported experiences with work-related health problems early in their career and described experiences with how health problems lead to suboptimal work functioning. Occupational health support needs included knowledge and psychosocial support during nursing education, e.g. through paying attention to dealing with shift work, or career counselling. Also, they reported a need for knowledge and psychosocial support at the start of their clinical placement or new job in the hospital, e.g. information from occupational health services or having a mentor. Furthermore, they reported that occupational health support requires a more general place at work through offering knowledge, e.g. tailored advice on proper lifting position; psychosocial support, e.g. positive team atmosphere; and physical support, e.g. suitable preventive measures.ConclusionsOccupational health support for novice nurses is important, since they already experience work-related health problems and suboptimal work functioning due to health problems early in their career and while still in training to be a nurse. Novice nurses should be given more knowledge and support to help them stay healthy and well-functioning in their work. This is a joint responsibility of nurse educators, the employer and occupational health services.