A Federated Database for Obesity Research: An IMI-SOPHIA Study.

Obesity is considered by many as a lifestyle choice rather than a chronic progressive disease. The Innovative Medicines Initiative (IMI) SOPHIA (Stratification of Obesity Phenotypes to Optimize Future Obesity Therapy) project is part of a momentum shift aiming to provide better tools for the stratification of people with obesity according to disease risk and treatment response. One of the challenges to achieving these goals is that many clinical cohorts are siloed, limiting the potential of combined data for biomarker discovery. In SOPHIA, we have addressed this challenge by setting up a federated database building on open-source DataSHIELD technology. The database currently federates 16 cohorts that are accessible via a central gateway. The database is multi-modal, including research studies, clinical trials, and routine health data, and is accessed using the R statistical programming environment where statistical and machine learning analyses can be performed at a distance without any disclosure of patient-level data. We demonstrate the use of the database by providing a proof-of-concept analysis, performing a federated linear model of BMI and systolic blood pressure, pooling all data from 16 studies virtually without any analyst seeing individual patient-level data. This analysis provided similar point estimates compared to a meta-analysis of the 16 individual studies. Our approach provides a benchmark for reproducible, safe federated analyses across multiple study types provided by multiple stakeholders.

In Full Bloom.

A daughter realizes her mother, a former geriatric nurse, is experiencing dementia.

Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy.

Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.

Stress-Induced Immunomodulation in Low and High Reactive Sheep.

The objective of this study was to investigate the relationship between stress and temperament on the humoral immune response of ewes. Eighty ewes were allocated to one of four treatment groups in a 2 × 2 factorial design (n = 20 ewes/treatment): low (LR) and high (HR) reactive ewes were either exposed to no stress (CON) or were visually isolated (STRESS). Ewes remained in treatment pens for 23 h: heart rate was measured continuously, and saliva samples were collected prior to testing and at 0.5 h and 23 h for measurement of cortisol, CarLA IgA and total IgA concentrations. After the first 0.5 h, heart rate was elevated, and cortisol concentrations tended to be higher, whereas CarLa IgA concentrations were lower in STRESS than CON ewes. Similarly, after 23 h, cortisol concentrations remained elevated and CarLA IgA concentrations remained lower in STRESS than CON ewes. Interestingly, total IgA concentrations were not influenced by a 0.5 h or 23 h stressor. Overall, CarLA IgA concentrations were lower in HR than LR ewes at 0.5 h, but there was no significant stress × temperament interaction. Therefore, stress appears to have an immunosuppressive effect on CarLA IgA but not total IgA concentrations in ewes.

'I thought it would keep them all quiet'. Women's experiences of breastfeeding as illusions of compliance: an interpretive phenomenological study.

AIMS: To explore the experiences of breastfeeding women. BACKGROUND: There is a plethora of data demonstrating that human breast milk provides complete nutrition for human infants. While the rate of initiation of breastfeeding in the United Kingdom has shown a steady increase in the last 25 years, rates of exclusive breastfeeding in the early weeks and months over the same time period have shown only marginal increases. This study was designed to extend current knowledge around breastfeeding experiences, decisions and behaviours. DESIGN: Qualitative, interpretive phenomenological approach. METHODS: Data were collected between July 2009-January 2010 through in-depth interviews with 22 women from a city in the East Midlands where the prevalence of breastfeeding has showed a decreasing trend. Data were collected between 3-6 months after the birth of their youngest baby. FINDINGS: Analysis of data uncovered a key theme: illusions of compliance. The findings revealed that women's breastfeeding behaviours were socially mediated. They adopted a good mother image by conforming to the moral obligation to breastfeed immediately after their babies were born. Those women who struggled to establish breastfeeding tried to hide their difficulties rather than admit that they were not coping. CONCLUSION: This study provides insights into women's infant feeding decisions and behaviours, building on understandings of 'good mothering' in the wider literature. Importantly we highlight some of the previously unknown strategies that women employed to portray themselves as calm, coping and in control when in reality they were struggling and not enjoying breastfeeding.

'Practising under your own Pin'- a description of the transition experiences of newly qualified midwives.

AIM: Transition experiences of newly qualified midwives were examined in depth during the third phase of a UK evaluation study of midwifery education. BACKGROUND: The fitness to practise and the retention of newly qualified nursing and midwifery graduates are pressing concerns for health care managers. The advantages of preceptorship are reported in the literature but the content and timing of schemes remain unclear. METHODS: A semi-structured diary was kept for up to 6 months by 35 newly qualified midwives in 18 work sites covering all countries in the UK. The preceptor and supervisor of midwives for each newly qualified midwife completed short questionnaires about their preceptee's performance, and a further sub-sample of newly qualified midwives and preceptors participated in a semi-structured interview. Data were analysed to elicit aspects of newly qualified midwives transition experiences. RESULTS: Findings confirm that structured preceptorship schemes are not widely available. Newly qualified midwives primarily obtained transition support from members of the midwifery team. CONCLUSION: Although perceived as competent, there is no demarcation point in becoming confident to practise as a registered practitioner. Implications for managers include the importance of a supportive culture within clinical teams for successful transition and the introduction of structured preceptorship schemes facilitated by appropriate rotation patterns.

The MINT project--an evaluation of the impact of midwife teachers on the outcomes of pre-registration midwifery education in the UK.

OBJECTIVE: to explore the contribution of midwife teachers in preparing student midwives for competent practice. DESIGN: a three phase design using qualitative and quantitative approaches. Phase one involved UK wide on-line questionnaire surveys, phase two was a case study method in six UK approved education institutions and phase three was a diary study with newly qualified midwives. PARTICIPANTS: phase one included all UK Lead Midwives for Education (LMEs), midwife teachers and Local Supervising Authority Midwifery Officers; phase two participants were three year and shortened programme student midwives, midwife teachers, LMEs and programme leads from each of the four countries; and phase three included a sample of newly qualified midwives graduating from the case study sites and their preceptors and supervisors of midwives. FINDINGS: midwife teachers were valued for their unique and crucial role in supporting the application of knowledge to midwifery practice. Visibility and credibility were two key concepts that can explain the unique contribution of midwife teachers. These concepts included being able to support skills acquisition, understanding of contemporary midwifery practice, having a role in practice contexts and able to offer personal support. Visibility of teachers in practice was vital for students and mentors to assist students put their learning into practice and monitor learning and assessment decisions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: given the complexity of midwifery education a team approach is essential in ensuring the effectiveness of these programmes. This requires a sufficient differentiation of midwife teacher roles to deliver the pre-registration curriculum. A set of resource quality indicators is proposed to support midwife teacher teams achieving sufficient clinical and academic expertise to deliver effective education programmes.

Final year students' perceptions of learning to be a midwife in six British universities.

Midwifery education in the UK has been delivered through the University sector since the mid-1990s, with the requirement to create safe, effective clinicians who are equipped to engage with research and evidence based practice. This paper presents an in-depth analysis of focus group data from 120 senior midwifery students at six British universities to explore the experience of learning to be a midwife. Thematic analysis of the data suggests the following themes pertain to the experience of a number of students: 'teach yourself midwifery', knowing it all, right way of doing things, the importance of physical skills. These themes suggest a dissonance for some students between the andragogical methods of learning espoused by universities, and the expectations of students, who express the belief that there is a fixed and finite body of knowledge, without which they feel disempowered, anxious and ill-prepared for clinical practice. This paper argues that there are unresolved tensions between the perceived demands of practice environments and regulatory bodies and the philosophical stance of universities. For some students the concept of a broad discursive education is a distraction from training in discrete clinical skills.

Preparedness of newly qualified midwives to deliver clinical care: an evaluation of pre-registration midwifery education through an analysis of key events.

OBJECTIVE: this study was part of a larger project commissioned to ascertain whether midwife teachers bring a unique contribution to the preparation of midwives for practice. The aim of this phase was to determine whether the student midwives' educational programme had equipped them to practise competently after entry to the professional register. DESIGN: this was a prospective, longitudinal qualitative study, using participant diaries to collect data. SETTING: data were collected from newly qualified midwives during the initial six months after they commenced their first post as a qualified midwife. PARTICIPANTS: the potential participants were all student midwives who were completing their education at one of six Universities (three in England, one in Scotland, one in Wales and one in Northern Ireland). Diary data were submitted by 35 newly qualified midwives; 28 were graduates of the three year programme and seven of the shortened programme. MEASUREMENTS AND FINDINGS: diary entries were analysed using thematic analysis (Braun and Clarke, 2006), with a focus on identification of key events in the working lives of the newly qualified midwives. A total of 263 key events were identified, under three main themes: (1) impact of the event on confidence, (2) gaps in knowledge or experience and (3) articulated frustration, conflict or distress. KEY CONCLUSIONS: essentially, pre-registration education, delivered largely by midwife teachers and supported by clinical mentors, has been shown to equip newly qualified midwives to work effectively as autonomous practitioners caring for mothers and babies. While newly qualified midwives are able to cope with a range of challenging clinical situations in a safe manner, they lack confidence in key areas. Positive reinforcement by supportive colleagues plays a significant role in enabling them to develop as practitioners. IMPLICATIONS FOR PRACTICE: whilst acknowledging the importance of normality in childbearing there is a need within the curriculum to enable midwives to recognise and respond to complex care situations by providing theory, simulations and practice experience.

Supporting the midwifery practice-based curriculum: the role of the link lecturer.

BACKGROUND: It is essential that Approved Education Institutions (AEIs) support practice learning to the education standards required by the Nursing and Midwifery Council (NMC, 2009). Evaluating whether midwife lecturers bring a unique contribution to the outcomes of preregistration midwifery education programmes was investigated through a national research project (Fraser et al., 2011). The study task addressed in this paper was to establish which roles and responsibilities of lecturers have most impact on student learning and capability as midwives and provide best support for mentors' teaching and assessment decisions. METHODS: Data were collected through United Kingdom (UK) wide survey of Lead Midwives for Education, midwife lecturers and questionnaires and focus groups of student midwives from six case study sites. An activity analysis tool was completed by lecturers in these sites, as well as individual interviews with LMEs and Programme Leads. FINDINGS: The nature of midwife lecturers' engagement with practice is variable and is determined by the particular organisation model used. There is an overall agreement that midwife lecturers have a vital role in supporting the practice based curriculum. Key findings highlight the link lecturer role in supporting students, participating in assessments, supporting mentors and maintaining clinical credibility. Enhancements and deterrents to undertaking the link role are also outlined. These findings are relevant to health care programmes worldwide where clinical practice is an essential component. IMPLICATIONS: contribution to knowledge development about models to support and enhance practice-based learning.

'SINK or SWIM': the experience of newly qualified midwives in England.

OBJECTIVE: To explore newly qualified midwives' and preceptors' view of the preceptorship period. DESIGN: Qualitative design utilising focus groups as a means of collecting data. SETTING: Hospital trusts partnered with three Universities in England. PARTICIPANTS: In total there were 62 participants; 40 newly qualified midwives, 20 preceptors and two practice development midwives participated in focus group interviews. FINDINGS: The findings suggested that newly qualified midwives and preceptors found it difficult to meet due to time constraints and either working different shifts or in different clinical areas. In addition three main themes emerged in relation to what affected effective preceptorship. The most important areas to improve the preceptorship period were to appoint midwives responsible for the organisation and support of newly qualified midwives. In addition, each new midwife should have a programme tailored to their needs which avoids repetitive learning. CONCLUSIONS: The transition period causes anxiety for newly qualified midwives, especially when there is a long delay between qualification and taking up their first post. There appears to be some confusion over induction and preceptorship paperwork. The majority of midwives described their initial experience of working as a qualified midwife as 'SINK or SWIM'.

"There are guiding hands and there are controlling hands": student midwives experience of mentorship in the UK.

OBJECTIVE: to explore student midwives' experience and views on the role of the mentor in practice, and to survey perceptions of the qualities required for mentorship. DESIGN: qualitative longitudinal cohort study using focus groups. SETTING: an academic division of midwifery at a university in the East Midlands region of the UK. PARTICIPANTS: 58 women enrolled in a three-year midwifery education programme at the university. MEASUREMENTS: the focus groups were conducted with two cohorts of midwifery students at four time points during their three-year education programme. FINDINGS: the themes that emerged from the data were: qualities of good mentors; relationships; expectations of mentors; role models; and mentorship experience. CONCLUSIONS: mentors are used as role models by the students in both positive and negative ways. The relationship that the student has with a mentor is fundamental to their confidence in practice, although there is an appreciation that sometimes there are problems with personality clashes. Expectations of the mentor are a major issue for student midwives, and this can be affected by the length of time they have worked with a mentor. There was general consensus about the qualities of a good mentor.

Investigating multitasking in high-functioning adolescents with autism spectrum disorders using the Virtual Errands Task.

Using a modified version of the Virtual Errands Task (VET; McGeorge et al. in Presence-Teleop Virtual Environ 10(4):375-383, 2001), we investigated the executive ability of multitasking in 18 high-functioning adolescents with ASD and 18 typically developing adolescents. The VET requires multitasking (Law et al. in Acta Psychol 122(1):27-44, 2006) because there is a limited amount of time in which to complete the errands. ANCOVA revealed that the ASD group completed fewer tasks, broke more rules and rigidly followed the task list in the order of presentation. Our findings suggest that executive problems of planning inflexibility, inhibition, as well as difficulties with prospective memory (remembering to carry out intentions) may lie behind multitasking difficulties in ASD.

Practice improvement, breastfeeding duration and health visitors.

The primary purpose of practice improvement is to improve clinical practice through changing the behaviour of healthcare professionals. Breastfeeding is a key public health issue, conferring benefits associated with both infant and maternal health, yet breastfeeding rates in the U.K. and Ireland are among the lowest in Western Europe. In this paper, the ways in which practice improvement can be utilised to enhance both efficiency and effectiveness are described, using a case study of the potential contribution of health visitors to increasing breastfeeding duration in primary care in order to illustrate this in clinical practice.

Perceptions of motherhood: The effect of experience and knowledge on midwifery students.

OBJECTIVE: to explore the factors that influence student midwives' constructs of childbearing, before and during their undergraduate midwifery programme. DESIGN: a naturalistic, qualitative study. SETTING: a university in the East Midlands, UK. PARTICIPANTS: 58 women registered on a 3-year midwifery education programme. MEASUREMENTS: focus groups were conducted at programme commencement and at 9-12 monthly intervals with two cohorts of midwifery students who were separated into groups of mothers and non-mothers (32 focus groups in total). This paper draws on data from the nine focus groups held at the start of the students' programme. FINDINGS: the main themes that emerged from the data were in relation to image during pregnancy, expectations/experiences of childbirth and parenting. In particular, students believed that pregnancy and childbirth should be special. They suggested that a lack of knowledge about sexuality and choice options affected women's ability to be in control. Although normality was the students' expectation of childbirth, they also assumed that hospital birth was the norm. They were unsure whether the baby's father was the best birth partner. Their mothers were suggested as likely to be more supportive, but there was lack of agreement regarding whether they were the best parenting role models. Students also said that there was a lack of positive images of breast feeding. The overall motivation to become midwives was 'to make a difference'. CONCLUSIONS: students need to be facilitated early in their programme to explore their belief systems and constructs of childbearing critically so that they are equipped to support parents to have a positive experience, whether childbirth is normal or complex, and so that they can cope with any dissonance between their own expectations and the uncertainties and realities of practice.

A study exploring UK midwives' knowledge and attitudes towards caring for women who have been sexually abused.

OBJECTIVE: to investigate midwives' knowledge and attitudes in relation to caring for women who have been sexually abused. DESIGN: survey using a postal questionnaire. The questionnaire looked at midwives' knowledge and attitudes towards a range of aspects of sexuality and childbirth. The area of caring for women who have been sexually abused was one aspect of this study. The questionnaire included fixed response and open-ended questions. Quantitative data were analysed using chi2-test, logistic regression, Mann-Whitney U-test, Kruskal Wallis test and Mantel-Haenszel test. Qualitative data were analysed using a modified constant comparative approach as described by Morse and Field [1995. Qualitative research methods for health professionals, second edn. Sage Publications, London]. SETTING: four National Health Service trusts within the East and West Midlands. PARTICIPANTS: 489 community and hospital-based midwives. FINDINGS: 372 midwives returned their questionnaire giving a 76% response rate. The majority of midwives in the sample group did not feel adequately prepared to deal with a disclosure of sexual abuse (n=207, 56%), with a further 109 (29%) midwives being 'unsure' if they could deal with such a disclosure. Community midwives rated themselves as more able to deal with disclosures of sexual abuse compared with hospital-based midwives (chi2=4.044, df=1, p=0.044). The analysis of the in-depth responses to the open-ended questions showed that a small number of midwives were very knowledgeable about the topic of sexual abuse and had experience in dealing with these situations. In contrast, it emerged that the majority of midwives had little if any education in this area and felt unable to deal effectively with disclosures of sexual abuse. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the finding that the majority of midwives did not feel adequately prepared to deal with disclosures of sexual abuse may have implications for the quality of care received by survivors of sexual abuse. It is possible that midwives who have been inadequately prepared for dealing with such disclosures may give inappropriate advice, and may inadvertently compound the feelings of powerlessness that women have experienced. Aspects of sexuality and, in particular, caring for women who have been sexually abused should be included in all pre-registration curricula, and post-registration education should include this topic to either update midwives or introduce these topics to qualified midwives. As the incidence of sexual abuse is high and may potentially affect a significant number of childbearing women, it is recommended that further good-quality research should be conducted in this area.

What are the essential competencies required of a midwife at the point of registration?

OBJECTIVE: to identify the essential competencies required of a midwife at the point of registration. DESIGN: qualitative, descriptive, extended case study and depth interviews. SETTING: pre-registration midwifery education in England. PARTICIPANTS: 39 qualifying midwives, their assessors, midwives and midwife teachers across six higher education institutions, and 20 experienced midwives at two sites. FINDINGS: essential competencies were identified relating to (1) being a safe practitioner; (2) having the right attitude; and (3) being an effective communicator. In order to be a safe practitioner, it was proposed that a midwife must have a reasonable degree of self-sufficiency, use up-to-date knowledge in practice, and have self and professional awareness. It was suggested that having the right attitude involves being motivated, being committed to midwifery and being caring and kind. Participants highlighted the importance of effective communication so that midwives can relate to and work in partnership with women and provide truly informed choice. Essential communication skills include active listening, providing appropriate information and flexibility. KEY CONCLUSIONS: the most important requirement at registration is that a midwife is safe and will practise safely. However, this capability to be safe is further mediated by attitudes and communication skills. IMPLICATIONS FOR PRACTICE: models of midwifery competence should always include personal attributes and effective communication in addition to the competencies required to be able to practise safely, and there should be an explicit focus in curriculum content, skills training and assessment on attitudes and communication.