Women's decision satisfaction and psychological distress following early breast cancer treatment: a treatment decision support role for nurses.

This prospective cross-sectional study investigated Australian women's (n = 104) decision satisfaction with cancer treatment decision for early breast cancer as well as their psychological distress 3-4 months following surgery. Women's satisfaction was surveyed using the Treatment Decision Satisfaction Questionnaire, and the Brief Symptom Inventory-18 was used to measure psychological distress. Women who were living alone, who worked as professionals and who were not involved in the decision-making process by their doctors were less likely to be satisfied with their decision process, outcome and their overall treatment decision. Following treatment, 26.0% of women were distressed; 18.3% experienced anxiety; 19.2% somatization; and 27.9% depression. Women who experienced somatization were more likely to be dissatisfied with the treatment decision (P = 0.003) as were those who reported psychological distress (P = 0.020). Women who were involved in choosing their treatment were more satisfied with their decision. Many women experienced distress following breast cancer treatment and might have required referral for psychological assessment, management and long-term support. Women who experienced distress were more likely to be dissatisfied with the treatment decision (or vice versa).

From 'postnatal depression' to 'perinatal anxiety and depression': key points of the National Perinatal Depression Plan for nurses and midwives in Australian primary health care settings.

BACKGROUND: Perinatal anxiety and depression constitute one of the long term major public health issues in Australia and for too long they has been bundled under the over-arching term of 'postnatal depression'. However, the generation, funding, and implementation of the National Perinatal Depression Plan (NPDP) (Australian Government Department of Health and Ageing, 2008), across all Australian States and Territories, are proving to be wide-reaching and influential. Not only does the NDPD move from the umbrella term of 'postnatal depression' to establish the reality of perinatal anxiety and depression which women can experience from conception to the first year of the infant's life but also all States and Territories have made Individual Investment Plans for the implementation of the NPDP. IMPLEMENTATION: In these Investment Plans, each State and Territory will address the following three major goals of the NPDP differently and mainly within a primary health care setting: (1) Psychosocial assessment in addition to screening of women antenatally and postnatally; (2) Education of health professionals about the complexity of perinatal depression and the need for early assessment and intervention; (3) Development of quality pathways of care for follow-up support and care of women who are depressed and who are assessed as being at the risk for depression. IMPLICATIONS FOR NURSES AND MIDWIVES: General nurses, maternal child health nurses, midwives, and mental health nurses are spread throughout primary health care settings. Three essential aspects of the NPDP are pertinent to their practice: (1) the Edinburgh Postnatal Depression Scale (EPDS); the 2008 beyondblue National Action Plan for Perinatal Mental Health (NAP); and the Draft beyondblue Clinical Practice Guidelines for depression and related disorders - anxiety, bipolar disorder, and puerperal psychosis - in the perinatal period (March 2010). The author addresses these three aspects of the NPDP by citing two personal accounts by women who have experienced perinatal anxiety and depression; these accounts are available in the public domain.

The interface of mental and emotional health and pregnancy in urban indigenous women: Research in progress.

Research among indigenous women in Australia has shown that a number of lifestyle factors are associated with poor obstetric outcomes; however, little evidence appears in the literature about the role of social stressors and mental health among indigenous women. The not-for-profit organization beyondblue established a "Depression Initiative" in Australia. As part of this they provided funding to the Townsville Aboriginal and Torres Strait Islander Health Service in the "Mums and Babies" clinic. The aim of this was to establish a project to (a) describe the mental health and level of social stressors among antenatal indigenous women and (b) assess the impact of social stressors and mental health on perinatal outcome. A purposive sample of 92 indigenous women was carried out. Culturally appropriate research instruments were developed through consultations with indigenous women's reference groups. The participants reported a range of psychosocial stressors during the pregnancy or within the last 12 months. Significant, positive correlations emerged between the participants' Edinburgh Postnatal Depression Scale (EPDS; J. Cox, J. Holden, & R. Sagovsky, 1987) score and the mothers' history of child abuse and a history of exposure to domestic violence. A more conservative cutoff point for the EPDS (>9 vs. >12) led to 28 versus 17% of women being identified as "at risk" for depression. Maternal depression and stress during pregnancy and early parenthood are now recognized as having multiple negative sequelae for the fetus and infant, especially in early brain development and self-regulation of stress and emotions. Because of the cumulative cultural losses experienced by Australian indigenous women, there is a reduced buffer to psychosocial stressors during pregnancy; thus, it is important for health professionals to monitor the women's emotional and mental well-being.

Securing the oral tradition: reflective positioning and professional conversations in midwifery education.

We postulate that positioning is a powerful tool in guiding and transforming student professional learning and practice development. In our experiences with students enrolled in he Graduate Diploma of Midwifery, we determined that positioning elaborates individual scholarship and identity formation of the learner midwife in practice settings. Positioning Theory, developed by Harré and other authorities, is a psycho-sociological 'ontology' or concept of how individuals metaphorically position or locate themselves, and others, within institutions and societies. Three key components of positioning theory include 'position', 'speech act' and 'storylines', developing from the everyday social interactions of professional conversations. Reflective positioning can be applied as an analytical tool for the moment-to-moment exchanges inherent in practice related conversations, occurring between midwives and midwifery students. These moment-to-moment interactions of professional conversations can be used by students to complete or fill their learning gaps. Positioning therefore, provides a novel, contemporary theoretical framework to 'unpack' or understand the complexity of midwifery practice and yet is complementary with reflective practice. Excerpts are used to demonstrate reflective positioning applications by students. Midwives are encouraged by health services and by the University to provide student support through a 'preceptorship' program to supervise, work with and assess students for competence in midwifery practices. We claim that reflective positioning by students within professional conversations with their preceptor/midwives, are the construction sites for learning and where identity formation of each student as a future midwife is both shaped and transformed. Both academics and managers of health services need to embrace the value of workplace conversations, the sites of rich oral traditions of nursing and midwifery. Thus, in seeking claim to our rich oral traditions, all students will benefit from engagement in reflective positioning to promote their professional learning and practice development.

Postnatal mental health of women giving birth in Australia 2002-2004: findings from the beyondblue National Postnatal Depression Program.

OBJECTIVES: To describe the postnatal mental health status of women giving birth in Australia 2002-2004 at 6-8 weeks postpartum. METHOD: Women were recruited from 43 health services across Australia. Women completed a demographic questionnaire and an Edinburgh Postnatal Depression Scale (EPDS) in pregnancy; the latter was repeated at 6-8 weeks following childbirth. RESULTS: A total of 12 361 postnatal women (53.8% of all postnatal women surveyed) completed questionnaires as part of a depression screening programme; 15.5% of women screened had a postnatal EPDS>9 and 7.5% of women had an EPDS>12 at 6-8 weeks following childbirth. There was significant variation between States in the percentage of women scoring as being potentially depressed. The highest percentage of women scoring EPDS>12 were in Queensland and South Australia (both 10.2%) while Western Australia had the lowest point prevalence (5.6%). Women recruited from private health services in Western Australia had a significantly lower prevalence of elevated EPDS scores than those women recruited from the public health service (EPDS >12: 3.6% vs 6.4%, p=0.026); differences in the prevalence of elevated EPDS scores were not significant between public and private in Australian Capital Territory (EPDS>12: 7.6% vs 5.8%, p=0.48), where income and education was significantly higher than other States for both groups. CONCLUSIONS: Postnatal depressive symptoms affect a significant number of women giving birth in Australia, and the point prevalence on the EPDS may be higher for women in the public sector, associated with lower incomes and educational levels. Maternity services--particularly those serving women with these risk factors--need to consider how they identify and manage the emotional health needs of women in their care. Specific State-related issues, such as availability of specialist perinatal mental health services and liaison between treating health professionals, also need to be considered.

National program for depression associated with childbirth: the Australian experience.

Routine screening was introduced as a joint research/public-health initiative across 43 health services in Australia, funded by beyondblue, the National Australian Depression Initiative. This program included assessing risk factors and prevalence of depression in perinatal women. Other objectives included increasing awareness of the condition, training of relevant staff, and assessing the feasibility of a screening program. Women were screened antenatally and postnatally with a demographic questionnaire and the Edinburgh Postnatal Depression Scale. A subgroup of women and health professionals was surveyed. Over 40,000 women participated directly in the program. Data and issues for specific groups are presented. There was a high level of acceptability to women and health professionals involved. Screening is acceptable and feasible as part of the mental-health management of perinatal women. It needs to be supplemented with information for women and education and support for staff.

Prenatal depression: a randomized controlled trial in the emotional health of primiparous women.

The prevalence of postnatal depression (10%-15%) renders it a major public health problem not only for the depressed mother but also for the infant, who may suffer from behavioral disturbances and cognitive delays in later years. This study aimed at evaluating an educational intervention to alleviate postnatal depression and at generally measuring the prenatal and postnatal mood of primiparous women. A prospective, randomized controlled trial of an education intervention to reduce postnatal depression was conducted at three sites in Australia enrolling a total of 184 primiparous women. The intervention consisted of an information booklet on postnatal depression and an audiotape of one woman's journey through clinical postnatal depression. Mood was assessed once prenatally (12-28 weeks) and twice postnatally (8-12 weeks and 16-24 weeks) using the Scale for Assessment of Depression and Schizophrenia modified for pregnant and postnatal women (SADS-M). Demographic and social support data were also collected at enrollment. Comparisons between the control group and the intervention group revealed no differences; the educational intervention did not show any effect when women's mood was measured by the SADS-M. Overall, a general, significant, steady decrease of depressive tendencies was observed when the two postnatal assessments were compared to the prenatal measurements. Women were less depressed postnatally than prenatally. This overall improvement of mood was significant in most SADS-M items. The exceptions were discouragement, anxiety, anger, and irritability, which did not reach significance. Additional multivariate analyses revealed no relevant influence of social support or demographic variables on the changes in mood. The main results that the education intervention had no effect and women, overall, were more depressed prenatally than postnatally contributes further evidence to the view that the prenatal period is a separate entity from the postnatal period, with distinctive psychoneuro-endocrine pathways and, thus, suggesting different profiles of women's experience. This evidence indicates the necessity to screen, refer, and manage prenatal maternal mood as an entity in its own right, rather than as a window on the postnatal period.

Australian women's prediagnostic decision-making styles, relating to treatment choices for early breast cancer treatment.

Women diagnosed with early breast cancer are now asked by their doctors to choose from a range of options for their preferred medical treatment plan. Little information is known about women's treatment decision-making and therefore nurses do not have evidence to guide this decision support. The aim of this descriptive survey was to investigate the prediagnostic decision-making behavior of a sample (N = 377) of Australian women, regarding their treatment choices for early breast cancer. The data were collected using the Pre-Decision Portfolio Questionnaire (PDPQ) by Pierce (1996), which includes the Michigan Assessment of Decision Styles (MADS). Of 366 participating women, 19.9% strongly agreed to all three items of the MADS factor Deferring Responsibility; 0.3% strongly agreed to all four factors of Avoidance; 32.7% strongly agreed on all four items of Information Seeking; and 63.4% strongly agreed to all five items of Deliberation. Women showed a variety of preferred decision styles, depending on age, education, occupation and employment status. Only 36% of women indicated it was critically important to "get the treatment over as soon as possible;" 55% to "participate in selecting treatment;" and 53% to "read a lot of information:" The understanding of factors that are important to women when they are making decisions for medical treatment is a mandatory step in designing customized evidence-based decision support, which can be delivered by nurses to help women during this distressing experience.

To screen or not to screen--that is the question in perinatal depression.

Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. A valid, reliable, economical screening tool (the Edinburgh Postnatal Depression Scale, EPDS) is available. Arguments against screening pertain largely to lack of evidence about the acceptability of routine use of the EPDS during pregnancy and the postnatal period, and inadequate evidence regarding outcomes and cost-effectiveness. To address these concerns, the National Postnatal Depression Prevention and Early Intervention Program will evaluate outcomes of screening in terms of acceptability, cost-effectiveness, access and satisfaction with management in up to 100 000 women.