Curricular Quality Improvement in Midwifery: Simulating Unexpected Perinatal Loss.

INTRODUCTION: Caring for families experiencing perinatal loss is a fundamental component of midwifery practice, but little attention is paid to perinatal palliative care in midwifery curricula. Lack of educational preparation and self-care resources negatively impacts midwifery students and health care teams caring for families experiencing stillbirth. PROCESS: A private, urban university conducted a curricular quality improvement project to integrate perinatal palliative care into the midwifery curriculum using a high-fidelity, branching simulation pedagogy. Simulation objectives were developed from curricular gap analyses and the Core Competencies for Basic Midwifery Practice. Development of the Unexpected Perinatal Loss Simulation was guided by the International Nursing Association for Clinical Simulation and Learning Outcomes and Objectives and Design Standards. The Unexpected Perinatal Loss Simulation was revised based on qualitative data from student focus groups and expert content validation. OUTCOMES: Qualitative data yielded 4 key domains: presimulation, simulation skills, prior experience/personal reflections, and recommendations. Simulation procedures and scenario content were revised, after which 8 expert clinicians in the fields of midwifery, palliative care, and psychiatry validated the scenario content using the Lynn method. Two items did not meet the content validity index (CVI) threshold of 0.78, necessitating review by stakeholders; however, the overall scenario CVI threshold was met (0.82). DISCUSSION: Through this project, faculty integrated perinatal palliative care into the midwifery program using a novel approach of high-fidelity, branching simulation, structured debriefing, and an introductory self-care skills workshop. Potential clinical impact includes skillful perinatal palliative care with effective communication skills to mitigate how families experience and remember a traumatic loss and facilitate the grieving process. Students voiced insights into how they would process loss and seek support to mitigate their own grief as future midwives.

Vaccine hesitancy in prenatal women and mothers of newborns: Results of an interventional study.

INTRODUCTION: The purpose of this study was to determine the effectiveness of a web-based, vaccine resource-directed, interactive communication intervention for vaccine-hesitant prenatal women and mothers of newborns/infants to make informed decisions based on scientific evidence about vaccinating themselves and their newborns/infants, respectively. METHODS: A prospective quasi-experimental design was used to determine the effectiveness of the intervention for vaccine-hesitant prenatal women (stage 1) and for mothers of newborns (stage 2). A survey was administered to prenatal women to determine attitudes about vaccines for themselves during pregnancy. A survey on parental attitudes about vaccination for their children was administered to mothers of newborns. The surveys were administered to determine levels of vaccine acceptance. Vaccine acceptors and vaccine-hesitant individuals were included in the study as control and intervention group participants, respectively; vaccine refusers were eliminated from the study. RESULTS: Among prenatal vaccine-hesitant women, 82% had full prenatal vaccination coverage after receiving the intervention (χ2 = 7.2, P = .02). The majority of mothers of newborns/infants (74%) fully immunized their infants. DISCUSSION: The interventions for prenatal vaccine-hesitant women were effective in changing their status from hesitant to acceptors. The mothers of newborns/infants who were initially hesitant had vaccination rates that exceeded the comparison group comprised of vaccine acceptors.

Structure, Process, and Outcomes of Liberian National Nursing and Midwifery Curricular Revisions.

Background: The Republic of Liberia has had major disruptions to the education of its health care cadres. Post Ebola, the Resilient and Responsive Health Systems (RRHS) initiative began a new era of capacity building with the support of PEPFAR and HRSA. Nursing and Midwifery serve as the largest healthcare cadres in Liberia. The national nursing and midwifery curricula were overdue for the regulated review and revisions. Methods: The Science of Improvement was used as the framework to accomplish this multilateral activity. The Institute for Healthcare Improvement's (IHI) stages of improvement included: 1) Forming the team, 2) Setting the aims, 3) Establishing measures, 4) Selecting measures, 5) Testing changes, 6) Implementing changes, and 7) Spreading changes. These stages served as the blueprint for the structures and processes put into place to accomplish this national activity. Findings: The RN, Bridging, and BScM curricula all had redundant content that did not reflect teaching pedagogy and health priorities in Liberia. Courses were eliminated or reconfigured and new courses were created. Development of Nursing and Midwifery Curricular Taskforces were not as successful as was hoped. Two large stakeholder meetings ensured that this was the curricula of the Liberian faculty, deans and directors, and clinical partners. Monitoring and evaluation tools have been adopted by the Liberian Board for Nursing and Midwifery to serve as another improvement to check that the new curricula are being implemented and to identify gaps that may require future cycles of change for continued quality and improvement. Conclusions: Developing trust among the multilateral partners was critical to the success of this activity. Networks have been expanded, and a proposed pilot with the Ghana Board of Nursing and Midwifery and the US academic partner will examine the feasibility of implementing electronic licensing examinations for nurses and midwives.

Normal Physiologic Birth Continuing Professional Development: From a National Health Priority to Expanded Capacity.

Background: The Republic of Liberia has experienced many barriers to maintaining the quality of its healthcare workforce. The Resilient and Responsive Health Systems (RRHS) Initiative supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has responded to Liberian identified health priorities. Liberia's maternal morbidity and mortality rates continue to rank among the highest in the world. Recent country regulations have put forth required continuing professional development (CPD) for all licensed healthcare workers for re-licensure. Methods: The Model for Improvement was the guiding framework for this CPD to improve midwifery and nursing competencies in assisting birthing women. Two novel activities were used in the CPD. We tested the formal CPD application and approval process as this is a recent regulatory body policy. We also included the use of simulation and its processes as a pedagogical method. Over a two-year period, we developed a two-day CPD module, using didactic training and clinical simulation, for Liberian midwives. We then piloted the module in Liberia, training a group of 21 participants, including midwives and nurses, including pre- and post-test surveys as well as observational evaluation of participant skills. Findings: There were no significant changes in knowledge acquisition noted in the post-test. Small tests of change were implemented during the program, supporting the stages of the Model of Improvement. Observation of skill acquisition was done; however, using a formal observation checklist, such as an Observed Structured Clinical Evaluation (OSCE), would add more robust findings. The CPD and follow-up activity highlighted the need for human and financial support to maintain the simulation kits and to create sustainability for future trainings. Videotaping the didactic and simulation two-day continuing professional development train-the-trainer workshop expands the sustainability beyond newly prepared trainers. Simultaneous with this CPD, the Liberian Board for Nursing and Midwifery (LBNM) worked with a partner to create a CPD portal. The CPD partners created modules from the videos and have uploaded these modules to the LBNM's new CPD portal. Conclusions: Using a quality improvement model as a framework for developing and implementing CPDs provides a clear structure and supports the dynamic interactions in learning and clinical care. It is too soon to determine measurable health outcomes resulting from this project. Anecdotal feedback from clinicians and leaders was not directly related to the content of the CPD; however, it does demonstrate an increased awareness of examining changes in practice to support expanded health outcomes. Further research to examine methods and processes to determine the quality and safety outcomes of CPD trainings is necessary.

Integrating Oral Health Curricula into Midwifery Graduate Programs: Results of a US Survey.

INTRODUCTION: Midwives are a significant segment of the US maternal and primary health care workforce and play a pivotal role in addressing women's oral health care needs during pregnancy and throughout their life span. The purpose of this research was to assess oral health curricular integration in midwifery programs and examine factors that influence integration and satisfaction with graduates' level of oral health competence. METHODS: A cross-sectional, national survey of midwifery programs was conducted using an electronically distributed 19-item, self-administered questionnaire completed by the Directors of Midwifery Education. Data analysis included univariate and bivariate statistics. RESULTS: All of the responding midwifery programs (N = 33) were educating their graduates about oral health; however, less than a quarter (22.6%) of program directors were satisfied with their graduates' competency. Significant factors promoting integration were routine teaching by a dental professional and a formal relationship with a dental school, dental residency, or dental hygiene program. Programs with 4 or more hours of oral health curriculum were more likely to have a faculty oral health champion, use simulation in evaluation of their learners, and include interprofessional oral health education. DISCUSSION: With adequate oral health education, midwives are ideally positioned to integrate oral health in pregnancy care as well as well woman care throughout the life span, thereby expanding access to oral health care.

Effect of permeable biofilm on micro- and macro-scale flow and transport in bioclogged pores.

Simulations of coupled flow around and inside biofilms in pores were conducted to study the effect of porous biofilm on micro- and macro-scale flow and transport. The simulations solved the Navier-Stokes equations coupled with the Brinkman equation representing flow in the pore space and biofilm, respectively, and the advection-diffusion equation. Biofilm structure and distribution were obtained from confocal microscope images. The bulk permeability (k) of bioclogged porous media depends on biofilm permeability (kbr) following a sigmoidal curve on a log-log scale. The upper and lower limits of the curve are the k of biofilm-free media and of bioclogged media with impermeable biofilms, respectively. On the basis of this, a model is developed that predicts k based solely on kbr and biofilm volume ratio. The simulations show that kbr has a significant impact on the shear stress distribution, and thus potentially affects biofilm erosion and detachment. The sensitivity of flow fields to kbr directly translated to effects on the transport fields by affecting the relative distribution of where advection and diffusion dominated. Both kbr and biofilm volume ratio affect the shape of breakthrough curves.

Systematic analysis of micromixers to minimize biofouling on reverse osmosis membranes.

Micromixers, UV-curable epoxy traces printed on the surface of a reverse osmosis membrane, were tested on a cross-flow system to determine their success at reducing biofouling. Biofouling was quantified by measuring the rate of permeate flux decline and the median bacteria concentration on the surface of the membrane (as determined by fluorescence intensity counts due to nucleic acid stains as measured by hyperspectral imaging). The micromixers do not appear to significantly increase the pressure needed to maintain the same initial permeate flux and salt rejection. Chevrons helped prevent biofouling of the membranes in comparison with blank membranes. The chevron design controlled where the bacteria adhered to the membrane surface. However, blank membranes with spacers had a lower rate of permeate flux decline than the membranes with chevrons despite having greater bacteria concentrations on their surfaces. With better optimization of the micromixer design, the micromixers could be used to control where the bacteria will adhere to the surface and create a more biofouling resistant membrane that will help to drive down the cost of water treatment.

Predictors of relapse in bipolar disorder: A review.

INTRODUCTION: Bipolar disorder is the sixth leading cause of disability in the United States. Moreover, repeated episodes and non-responsiveness to treatment continue to present a significant problem, and little is known about the factors that may precipitate relapse. This article reviews the available literature on predictors of bipolar relapse. METHODS: We conducted a literature search on Medline from 1996 to March 2006, using the keywords "relapse," "recurrence," "compliance," "adherence," "life events," "kindling," and "predictors" combined with the term "bipolar disorder(s)." References from the resulting articles also supplemented the initial search. Thirty-eight articles were included in the analysis. RESULTS: Predictors of episodes include stressful life events, increased number of previous episodes, decreased interval between episodes, and persistence of affective symptoms and episodes. Factors associated with longer survival times include psychotherapy, social support, and medication adherence. CONCLUSIONS: Our review suggests several reliable predictors of bipolar episodes. Knowledge of these factors has significant clinical implications and could aid in treatment and prevention strategies. However, further research is clearly needed to address the limitations of the existing research and to increase our understanding of predictors of relapse, with the intent of improving quality of life and preventing episodes in patients with bipolar disorder.

Colloid dispersion in a uniform-aperture fracture.

This research investigates the dispersion of colloids through fracture systems by exploring experimentally and numerically the transport and dispersion of 1.0-, 0.11-, and 0.043-mum diameter fluorescent carboxylate-modified microspheres and chloride at various flow rates through variable-length, synthetic Plexiglas fractures (flow cells). A dimensionless number describing each experiment is varied by changing the colloid size, flow rate, and fracture length. Surface characteristics of the microspheres and Plexiglas favor repulsive interactions, thereby minimizing the chance of colloid filtration and remobilization. Full recovery of the colloids is typically observed, thereby supporting the assumption of negligible colloid filtration. In comparison to chloride transport, there is increased tailing for colloid plumes traveling through the flow cell. This increased tailing is attributed to Taylor dispersion phenomena (dispersion due to an advection gradient). In the synthetic fractures investigated here, colloid dispersion due to the velocity gradient is evident, but fully developed Taylor conditions are not realized. A particle-tracking algorithm is run inversely to estimate the effective dispersion rate for the colloid plume in each experiment as a function of the experimental parameters (flow rate, fracture length, and colloid size). Results suggest that the log of the effective dispersion rate of the colloid plume increases linearly with the log of the dimensionless number comprising experimental parameters.

Evaluation of synchrotron X-ray computerized microtomography for the visualization of transport processes in low-porosity materials.

Synchrotron-source X-ray computerized microtomography (CMT) is evaluated as a method to visualize transport processes. We conclude that CMT is adequate for visualization of transport experiments if the right conditions exist. Namely, 1) not much more than one-order-of-magnitude range in concentration data is needed for the study, 2) the pore space in the samples are greater than approximately 2--50 mum, depending on the sample size and system setup; 3) the sample is fine-grained enough so that a representative elemental volume (REV) can be contained by a 2--10 mm diameter sample, and 4) the transport process is slow enough that significant changes do not occur within the 25--50 min (and possibly less in the future) needed to collect data for one three-dimensional image. Absorption edge difference imaging (AEDI) in association with CMT is introduced as a method to enhance pore-space visualization. We successfully imaged the pore space in a low-porosity granodiorite, diorite and fine-grained granite cores and a higher-porosity soil aggregate sample. We found that the pore space important to transport in the core samples was smaller than what we were able to visualize with CMT. We also made rudimentary associations of minerals with pore-space location.

Characterization of adsorption sites on aggregate soil samples using synchrotron X-ray computerized microtomography.

Synchrotron-source X-ray computerized microtomography (CMT) was used to evaluate the adsorptive properties of aggregate soil samples. A linear relationship between measured mean mass attenuation coefficient (sigma) and mass fraction iron was generated by imaging mineral standards with known iron contents. On the basis of reported stoichiometries of the clay minerals and identifications of iron oxyhydroxides (1), we calculated the mass fraction iron and iron oxyhydroxide in the intergranular material. The mass fractions of iron were estimated to range from 0.17 to 0.22 for measurements made at 18 keV and from 0.18 to 0.21 for measurements made at 26 keV. One aggregate sample also contained regions within the intergranular material with mass fraction iron ranging from 0.29 to 0.31 and from 0.33 to 0.36 for the 18 and 26 keV measurements, respectively. The mass fraction iron oxyhydroxide ranged from 0.18 to 0.35 for the low-iron intergranular material and from 0.40 to 0.59 for the high-iron intergranular material. Using absorption edge difference imaging with CMT, we visualized cesium on the intergranular material, presumably because of adsorption and possible exchange reactions. By characterizing the mass fraction iron, the mass fraction iron oxyhydroxide, and the adsorptive capacity of these soil mineral aggregates, we provide information useful for conceptualization, development, and parametrization of transport models.

Use of X-ray absorption imaging to examine heterogeneous diffusion in fractured crystalline rocks.

Heterogeneous diffusion in different regions of a fractured granodiorite from Japan has been observed and measured through the use of X-ray absorption imaging. These regions include gouge-filled fractures, recrystallized fracture-filling material and hydrothermally altered matrix. With the X-ray absorption imaging technique, porosity, relative concentration, and relative mass of an iodine tracer were imaged in two dimensions with a sub-millimeter pixel size. Because portions of the samples analyzed have relatively low porosity values, imaging errors can potentially impact the results. For this reason, efforts were made to better understand and quantify this error. Based on the X-ray data, pore diffusion coefficients (Dp) for the different regions were estimated assuming a single diffusion rate and a lognormal multirate distribution of Dp. Results show Dp for the gouge-filled fractures are over an order of magnitude greater than those of the recrystallized fracture-filling material, which in turn is approximately two times greater than those for the altered matrix. The recrystallized fracture-filling material was found to exhibit the greatest degree of variability. The results of these experiments also provide evidence that diffusion from advective zones in fractures through the gouge-filled fractures and recrystallized fracture-filling material could increase the pore space available for matrix diffusion. This evidence is important for understanding the performance of potential nuclear waste repositories in crystalline rocks as diffusion is thought to be an important retardation mechanism for radionuclides.