Acuity-Based Staffing in Labor and Delivery Using Electronic Health Record Data.

BACKGROUND: Planning safe and effective nurse staffing can be challenging for nurse leaders of labor and delivery units due to the dynamic nature of birth and unpredictable fluctuations in census and acuity. The electronic health record (EHR) has a vast source of patient data that can be used to retrospectively review patient needs and nurse staffing gaps that can serve as a basis for prospective planning for nurse staffing. PURPOSE: This quality improvement project was initiated with the goal of developing real-time and longitudinal reports to quantify hourly nurse staffing needs based on patient census, acuity, and required clinical interventions from data that are contained with the EHR. The plan was to determine trends and nurse staffing needs for each 24-hour period every day of the week and identify ongoing staffing patterns to meet the Association of Women's Health, Obstetric, and Neonatal Nurses' (AWHONN) staffing guidelines. METHODS: The obstetric nursing leadership team worked with the information technology specialists and developed an algorithm that identifies patient acuity level, indicated clinical interventions, and outlines necessary staffing requirements to provide safe high-quality care. Various reports were built in the EHR to inform the nursing leadership team about nurse staffing on a real-time and historical basis. RESULTS: The reports provided quantitative data that supported a budgetary increase in nurse staffing and a more flexible nurse staffing scheduling system to meet the needs of the patients. The project was successfully implemented in all four of the hospital system maternity units. CLINICAL IMPLICATIONS: Use of EHR in labor and delivery units is nearly universal. Working with the information technology specialists to integrate nurse staffing data into the EHR is one way to align nurse staffing with the AWHONN nurse staffing standards in real-time and for projections of nurse staffing needs based on unit historical patient data.

Mixed methods research - the best of both worlds?

INTRODUCTION: There has been a bias towards quantitative research approaches within manual therapy, which may have resulted in a narrow understanding of manual therapy practice. The aim of this Masterclass is to make a contribution to the expansion of methodologies used in manual therapy enquiry by discussing mixed methods research (MMR), a methodology which utilises both qualitative and quantitative methods within a single study in order to provide more comprehensive insights. PURPOSE: To review rationales for MMR, as well as some of the common design options and potential difficulties. The paper also discusses theoretical frameworks that have been used to underpin qualitative and quantitative research, and ongoing debates about the possibility of combining them. IMPLICATIONS: Complexities associated with health and manual therapy cannot always be investigated satisfactorily by using a single research method. Some issues require a more comprehensive understanding, which may be provided by combining the strengths of quantitative and qualitative methods in a mixed methods study.

A new model of father support to promote breastfeeding.

Research shows that fathers can have a considerable influence on a mother's decision to initiate and continue with breastfeeding. Despite this, many health professionals and broader care services (including maternity services) fail to engage meaningfully and systematically with fathers in supporting breastfeeding. Although the importance of the father's role in supporting breastfeeding has been known for some time, little is known about the nature of this support. No clear delineation of which behaviours and attributes constitute father support, or differentiate it from other kinds of support, is provided in the current literature base. The purpose of this study was to analyse empirically the concept of 'father support' in relation to maternity services and broader health settings. It aimed to clarify the meaning of 'father support' to enable comprehension and application in practice, education and research. As a result, we present a new model of father support to promote breastfeeding, and focus specifically on some of the practical implications for health practitioners in supporting breastfeeding couples.

Engaging and supporting fathers to promote breast feeding: a concept analysis.

OBJECTIVE: Empirical evidence demonstrates that fathers have a strong influence on a mother's decision to initiate and continue breast feeding. However, no clear delineation of what behaviours and attributes constitute father support or differentiate it from other kinds of support is provided in the current literature. The purpose of this study was to analyse the concept of 'father support' in relation to maternity services and broader health settings, thereby clarifying meaning to enable comprehension and application in practice, education, and research. DESIGN: A concept analysis combining the evolutionary model of concept development with the inter-related theoretical, fieldwork and analytical phases of the hybrid model of concept development. SETTING: Children's Centres in East and West Sussex in Southern England. PARTICIPANTS: Repeated qualitative research over two phases with 16 parents of breast fed infants through seven focus groups and five telephone interviews. MEASUREMENTS AND FINDINGS: CINAHL, PsycINFO, AMED, MEDLINE, OVID and EMBASE databases were searched for articles published in English between 1999 and 2013 using the keywords breast feeding, father, and support. Seven same-sex focus groups and five individual interviews were also conducted over two research phases with the parents of breast fed infants to expand and exemplify, and then validate the analysis of the literature search. Five main attributes of father support in relation to breast feeding were identified: (1) knowledge about breast feeding; (2) positive attitude to breast feeding; (3) involvement in the decision-making process; (4) practical support; and (5) emotional support. Multiple antecedents and consequences to these attributes were also identified. KEY CONCLUSION: This study has contributed to clarifying the meaning of father support in relation to breast feeding and provides an important starting point for the development of a theoretical and practical model of optimal breast feeding that takes into account father support. IMPLICATIONS FOR PRACTICE: Identification of attributes, antecedents, and consequences of father support may assist practitioners to reflect on current working practices and service delivery models, and offer important educational opportunities for the training of student midwives and other health professionals.

Ciprofloxacin-induced phototoxicity in an adult cystic fibrosis population.

The incidence of phototoxicity as a side effect of ciprofloxacin appears to be increased in patients with cystic fibrosis compared to the general population (approximately 2.4%). We used an interview-based questionnaire to determine the incidence of such phototoxic skin reactions in cystic fibrosis patients. Results from 105 respondents revealed the incidence of ciprofloxacin-induced phototoxicity in the adult cystic fibrosis population in Northern Ireland to be 48.4% with only 66% of the patients recalling being given sun care information beforehand. We concluded that the incidence of phototoxicity is increased in patients with cystic fibrosis and that it is important for all to receive good sun care information prior to taking ciprofloxacin given the high risk of developing phototoxic rash.

Prolonged jaundice in neonates.

Jaundice is common in neonates and is often the reason for a parent to consult a community midwife or health visitor. It is known that up to 40 per cent of breastfed infants are jaundiced at 14 days of age and a proportion of these infants are referred to paediatric services for assessment and blood investigations. Most often the investigations reveal a high bilirubin level but otherwise normal liver function results, leading to a diagnosis of breastfeeding jaundice, with no treatment required other than reassurance to the parents and monitoring. A recent clinical audit is presented which evaluates current clinical practice and the results reflect breast feeding as the main reason for prolonged jaundice. This is followed by some guidance for the community health practitioners with the aim of reducing referral of otherwise well neonates with jaundice and reducing invasive investigations.

Using virtual reality to provide health care information to people with intellectual disabilities: acceptability, usability, and potential utility.

BACKGROUND: People with intellectual disabilities have poor access to health care, which may be further compromised by a lack of accessible health information. To be effective, health information must be easily understood and remembered. People with intellectual disabilities learn better from multimodal information sources, and virtual reality offers a 3-dimensional (3D) computer-generated environment that can be used for providing information and learning. To date, research into virtual reality experiences for people with intellectual disabilities has been limited to skill-based training and leisure opportunities within the young to mid age ranges. OBJECTIVE: This study assessed the acceptability, usability, and potential utility of a virtual reality experience as a means of providing health care-related information to people with intellectual disabilities. We designed a prototype multimodal experience based on a hospital scenario and situated on an island in the Second Life 3D virtual world. We wanted to know how people of different ages and with varying levels of cognitive function would participate in the customized virtual environment, what they understood from being there, and what they remembered a week later. METHODS: The study drew on qualitative data. We used a participatory research approach that involved working alongside people with intellectual disabilities and their supporters in a community setting. Cognitive function was assessed, using the Matrix Analogies Test and the British Picture Vocabulary Scale, to describe the sample. Participants, supported by facilitators, were video recorded accessing and engaging with the virtual environment. We assessed recall 1 week later, using a specialized interview technique. Data were downloaded into NVivo 8 and analyzed using the framework analysis technique. RESULTS: Study participants were 20 people aged between 20 and 80 years with mild to severe intellectual disabilities. All participants were able to access the environment and voluntarily stayed there for between 23 and 57 minutes. With facilitator support, all participants moved the avatar themselves. Participants engaged with the scenario as if they were actually there, indicating cognitive presence. Some referred back to previous medical experiences, indicating the potential for experiential knowledge to become the foundation of new learning and retention of knowledge. When interviewed, all participants remembered some aspects of the environment. CONCLUSIONS: A sample of adults with intellectual disabilities of all ages, and with varying levels of cognitive function, accessed and enjoyed a virtual-world environment that drew on a health care-related scenario, and remembered aspects of it a week later. The small sample size limits generalizability of findings, but the potential shown for experiential learning to aid retention of knowledge on which consent is based appears promising. Successfully delivering health care-related information in a non-National Health Service setting indicates potential for delivery in institutional, community, or home settings, thereby widening access to the information.

When the womb is no longer safe: chorioamnionitis.

Intrauterine infections are a leading cause of preterm birth, cerebral palsy and neonatal sepsis. This article investigates current ideas about prevention, diagnosis and treatment from a midwifery point of view.

Engaging and supporting fathers to promote breastfeeding: a new role for Health Visitors?

BACKGROUND: Health visitors have a central role in delivering and leading on the new UK government targets on breastfeeding as part of the strategy to reduce health inequalities. This article explores fathers' views and proposes that health visitors are best placed to engage with fathers in supporting the initiation and continuance of breastfeeding. AIM: To conduct initial pilot scoping of fathers' views on breastfeeding in order to provide insights into possible interventions which could contribute to increasing rates of exclusive breastfeeding. METHODS: Eight individual in-depth interviews were conducted with fathers (aged 28-47) from different socio-economic groupings living in Brighton and Hove (UK). Data were collected as part of a larger social marketing project focussing on increasing rates of exclusive breastfeeding in Brighton and Hove. Fathers were recruited through their partners whom had been interviewed previously about breastfeeding. Interviews were digitally recorded, transcribed, and analysed using a 'framework' approach. FINDINGS: Data reveal that fathers are interested in breastfeeding and want to be involved more broadly in preparation for, and supporting of, breastfeeding. Fathers reported requiring more relevant and accessible information about the benefits of breastfeeding as well as details concerning some of the practical issues involved in supporting their partner's breastfeeding. DISCUSSION AND CONCLUSION: Although in our study fathers reported wanting to be involved in supporting breastfeeding, it is likely that current discourses about men and fathers as well as more practical worries and concerns may prevent some health visitors and other health professionals from involving them in meaningful ways. Whilst our study is limited in its scope and more research is needed, our data indicates that fathers are potentially a missing part of the jigsaw in terms of breastfeeding support.

Shaking and rattling: developing a child obesity prevention program using a faith-based community approach.

This article describes the creation of a faith-based, community action research intervention aimed at reducing childhood obesity among a vulnerable population. Of particular concern to the community was the prevalence of obesity among its minority children. Engaging parents in a childhood obesity initiative through faith-based organizations (churches, community organizations with a common religious focus) was a method to provide a research intervention. It is important for researchers to be culturally competent, employ community-based participatory research methods, carefully plan interventions that have clear outcome criteria, and build evaluation of the process into every step of the research.

Effective and robust plasmid topology analysis and the subsequent characterization of the plasmid isoforms thereby observed.

Within the biopharmaceutical industry, recombinant plasmid DNA is used both as a raw material (e.g. in lentiviral and AAV vector production) as well as an active ingredient (e.g. in DNA vaccines). Consequently, many analytical laboratories are routinely involved with plasmid DNA topoisoform qualitative analysis and quantification. In order to reliably determine plasmid topology, one must ensure that the methodology employed can reliably, precisely and accurately measure qualitatively and quantitatively all topological isoforms. Presented here are an anion-exchange high-performance liquid chromatography (AEC) and an agarose gel electrophoresis (AGE)-based method developed for this purpose. The strategies undertaken to overcome the respective typical problems of limited linear range of quantitation (for AGE) and isoform resolution (for AEC) are described. Also presented is a subsequent direct comparison (for assay precision/accuracy) of these two methods, as well as a package of species characterization [by chloroquine-AGE, enzymatic digestion, multi-angle laser light-scattering (MALLS) and electron microscopy] undertaken to confirm the identity of a minor supercoiled dimeric concatamer observed by both approaches.

Helping health and social care professionals to develop an 'inequalities imagination': a model for use in education and practice.

BACKGROUND: The 'inequalities imagination model' originated from our own research, and led to findings and recommendations regarding clinical and education issues. This article focuses on the creation of the model which, we suggest, could be used to facilitate the development of an 'inequalities imagination' in health and social care professionals. AIM: To describe and critically analyse the thinking that led to the concept of an 'inequalities imagination' and provide the framework for the theoretical model. METHODOLOGICAL APPROACH: Influencing concepts from the fields of social work, sociology, nursing and midwifery, and debates around antidiscriminatory and antioppressive practice, cultural safety, cultural competence and individualized care are analysed. INEQUALITIES IMAGINATION MODEL: Ideas generated from an analysis of the concepts of antidiscriminatory/anti-oppressive practice and from the research data led us to conceptualize a flexible model that incorporated issues of individual and structural agency and a broad definition of disadvantage. The literature review underpinning the theoretical framework means that the model has the potential to be truly interdisciplinary. CONCLUSIONS: Professional educators face a difficult task in preparing practitioners to work with clients in ways that take account of differences in background and lifestyle and which respect human rights and dignity. The model makes explicit a process that enables practitioners to think about their current practice and move towards a greater understanding and awareness of the way they work with disadvantaged clients, and ways in which they prepare others to do so. We suggest that professionals develop an 'inequalities imagination' in order to enhance equality of care. The development of an 'inequalities imagination' helps practitioners to bridge the gap between the challenges they face in day-to-day practice and what they need to achieve to aspire to provide equality of care to all.

Recent landscape history from a Co. Down lake deposit.

A radiocarbon-dated pollen diagram from a lake deposit at a lowland site in Co. Down, Northern Ireland showed mixed agriculture had been continuous over much of the last two millennia. The introduction of cereal cultivation at between the 3rd and 5th centuries A.D. is earlier than usual at sites with heavy soils in Ireland. There was no palynological evidence to support the historical view that there had been substantial woodland clearance in the area during the 17th century. Landscape enclosure by hedges, starting in the 18th century, was detectable in the fossil pollen record. The pollen evidence for flax cultivation showed that this was relatively recent. Throughout the diagram the continual presence of Ulmus pollen demonstrated that, in contradiction of the historic view, the taxon was extant in the area throughout the period A.D. 600 to A.D. 1700.

The use of sieving during standard pollen pre-treatment of samples of fossil deposits to enhance the concentration of large pollen grains.

Small pollen grains and fine particles of the organic matrix in samples of a coarse detritus mud and a blanket peal deposit were removed by sieving through 30µ polyester mesh after digestion with KOH and acetolysis during standard pollen pre-treatment. The technique enhanced the number of large pollen grains m the sample. There was also an increase in the range of taxa which produce huge grains. The method provided a means of estimating the ratio of any scarce large pollen grain to the total grain sum in samples prepared by standard methods of pre-treatment.