How specialist palliative care nurses identify patients with existential distress and manage their needs.

BACKGROUND: Existential distress is a term used when patients who are coming towards the end of their lives exhibit profound suffering, related particularly to their thoughts on life and existence. The clinical expression of this phenomenon has not been widely researched, and so specialist palliative care nurses were asked how they identify and manage this patient cohort. AIMS: To explore how palliative-care nurses identify patients with existential distress and manage their needs. METHODS: A qualitative descriptive design with thematic content analysis of transcribed interviews. FINDINGS: Behavioural changes, agitation, social withdrawal and communication difficulties are identified as indicators of possible existential distress. Susceptible patient groups are identified. Nurses acknowledged that caring for patients with existential distress can be emotionally demanding. Being present and building relationships with patients are identified as enabling meaning-making. Sedation for refractory distress is seen as a last resort. CONCLUSION: Early identification of existential distress by carers could enable timely intervention (counselling, psychotherapy and or spiritual guidance) to improve the patients' quality of life in the terminal phase of their illness and avoid intractable or refractory existential distress that may necessitate palliative sedation.

An evaluation of the appropriateness and effectiveness of structured reflection for midwifery students in Ireland.

Midwifery students undertaking the undergraduate midwifery education programme in Ireland participate in facilitated reflective sessions that aim to develop their skills of reflecting on and in clinical practice. This paper presents a qualitative evaluation of the appropriateness and effectiveness of the facilitated reflection sessions for pre and post-registration midwifery students in two large Dublin maternity teaching hospitals. The aim was to evaluate structured reflective practice sessions which sought to assist midwifery students to become competent reflective practitioners. Group reflection sessions were conducted weekly in a clinical practice area at the same time each week over one academic year. After the series of structured reflective sessions, midwifery students and facilitating staff were invited to evaluate the reflective process. This evaluation consisted of a self-completion survey to identify the factors that facilitated and impeded student participation in the sessions. Respondents answered a series of questions about the reflective practice sessions and were also invited to enter qualitative data regarding their subjective experiences of the process in free text boxes. The data were then collated into themes by an independent reviewer. The results of the evaluation clearly indicate that midwifery students and facilitators welcomed the opportunity to engage in group reflection sessions as a form of peer support and as a catalyst for learning from clinical practice. Findings suggest that reflective practice can contribute to the development of skilled, self-aware and engaged practitioners.

Nurses' experiences of leech therapy in plastic and reconstructive surgery.

The aim of this study was to explore nurses' experience of using leech therapy. Leech therapy is useful in promoting revascularisation of skin grafts. Nurse disquiet in their role as leech therapists has been noted. This study explored the experience of Irish nurses. A qualitative design with an interview schedule was used to learn about emotional and practical clinical experiences. Interviews were carried out with seven nurses working with leeches in reconstructive surgery in 2013. These interviews were coded and explored for themes. Results revealed that many nurses feel aversion to the use of leeches. This may be associated with the use of a parasitic organism as treatment in conflict with the nurse's role in cross infection. It was also found that management of a nurse's own and patient's emotional responses is required. In conclusion, preparation for the role of leech therapy beyond the purely practical is necessary, and should explore affective responses of the practitioner and patients.

'Just waiting to be hauled over the coals': home birth midwifery in Ireland.

OBJECTIVE: to describe the context of Irish home birth midwives' practise experience. DESIGN: ethnography derived from participant observation, unstructured interview and documentary analysis. SETTING: women and midwives' homes and meeting places in Ireland. PARTICIPANTS: 21 self-employed community midwives. MEASUREMENTS AND FINDINGS: choice of place of birth is extremely limited in Ireland. Structural and professional supports for home birth and midwifery are lacking. Home birth midwives highly value midwifery professionalism but are professionally isolated. They promote women's birthing autonomy and choice of place of birth. However, they experience and anticipate negative, even punitive, responses from their own and other professions. This ethnography describes a particularly volatile period in Irish home birth midwifery practice. KEY CONCLUSIONS: Irish home birth midwives are professionally isolated which, given wider cultural antagonism to home birth, perfuses their practice with an element of defensiveness. Strong midwifery association is a key pillar of professionalism globally. In Ireland, the lack of a strong professional body undermines autonomous midwifery practice in all settings but particularly in the home. The midwifery philosophy of 'being with woman' appears to run contrary to professionalising discourses where the professional 'knows best'. Contemporary cultural expectations of professionalism such as clinical indemnification and risk averse practice protocols, bring challenges to autonomous midwifery practice. IMPLICATIONS FOR PRACTICE: place and context of birth effects not only the woman's birth experience but the midwife's professional autonomy. Without supports for autonomous midwifery, autonomous birthing is under threat. Place of birth effects birth experience and birth quality, not least because it is that context which also influences, for good or ill, midwifery autonomy.

Educating advanced midwife practitioners: a collaborative venture.

AIM: To describe the collaborative development of an MSc course preparing Ireland's first advanced midwife practitioners. BACKGROUND: Ireland has 55 advanced nurse practitioner posts, but, as yet, no advanced midwife practitioners. METHODS: A consultative, collaborative process involving 38 midwives across Ireland generated the philosophy, aims and content of the course. RESULTS: Participants stated that candidates should be committed to the conceptual uniqueness of midwifery; the advanced midwife practitioner role should be clearly defined and supported by the candidate's sponsors; programme content should emphasize normal midwifery, be practice led, and encourage reflective, evidence-based, women-centred care. CONCLUSION: The collaborative process used to develop this programme ensures that it will meet individual students' needs, thus enhancing the education of Ireland's first advanced midwife practitioners. IMPLICATIONS FOR MIDWIFERY MANAGEMENT: The emphasis on normality rather than specialization is a message that could be assimilated by managers in other countries to the benefit of childbearing women across the world.

Evaluating maternity care: a core set of outcome measures.

BACKGROUND: Comparing the relative effectiveness of interventions on specific outcomes across trials can be problematic due to differences in the choice and definitions of outcome measures used by researchers. We sought to identify a minimum set of outcome measures for evaluating models of maternity care from the perspective of key stakeholders. METHODS: A 3-round, electronic Delphi survey design was used. Setting was multinational, comprising a range of key stakeholders. Participants consisted of a single heterogeneous panel of maternity service users, midwives, obstetricians, pediatricians/neonatologists, family physicians/general practitioners, policy-makers, service practitioners, and researchers of maternity care. Members of the panel self-assessed their expertise in evaluating models of maternity care. RESULTS: A total of 320 people from 28 countries expressed willingness to take part in this survey. Round 1 was completed by 218 (68.1%) participants, of whom 173 (79.4%) completed round 2 and 152 (87.9%) of these completed round 3. Fifty outcomes were identified, with both a mean value greater than the overall group mean for all outcomes combined (x=4.18) and rated 4 or more on a 5-point Likert-type scale for importance of inclusion in a minimum data set of outcome measures by at least 70 percent of respondents. Three outcomes were collapsed into a single outcome so that the final minimum set includes 48 outcomes. CONCLUSIONS: Given the inconsistencies in the choice of outcome measures routinely collected and reported in randomized evaluations of maternity care, it is hoped that use of the data set will increase the potential for national and international comparisons of models for maternity care. Although not intended to be prescriptive or to inhibit the collection of other outcomes, we hope that the core set will make it easier to assess the care of women and their babies during pregnancy and childbirth.