'Bringing forth' skills and knowledge of newly qualified midwives in free-standing birth centres: A hermeneutic phenomenological study.

AIM: To understand and interpret the lived experience of newly qualified midwives (NQMs) as they acquire skills to work in free-standing birth centres (FSBCs), as well as the lived experience of experienced midwives in FSBCs in Germany who work with NQMs. BACKGROUND: In many high-, middle- and low-income countries, the scope of practice of midwives includes autonomous care of labouring women in all settings, including hospitals, home and FSBCs. There has been to date no research detailing the skills acquired when midwives who have trained in hospitals offer care in out-of-hospital settings. METHODS: This study was underpinned by hermeneutic phenomenology. Fifteen NQMs in their orientation period in a FSBC were interviewed three times in their first year. In addition to this, focus groups were conducted in 13 FSBCs. Data were collected between 2021 and 2023. FINDINGS: Using Heidegger's theory of technology as the philosophical underpinning, the results illustrate that the NQMs were facilitated to bring forth competencies to interpret women's unique variations of physiological labour, comprehending when they could enact intervention-free care, when the women necessitated a gentle intervention, and when acceleration of labour or transfer to hospital was necessary. CONCLUSION: NQMs learned to effectively integrate medical knowledge with midwifery skills and knowledge, creating a bridge between the medical and midwifery approaches to care. IMPLICATIONS: This paper showed the positive effects that an orientation and familiarization period with an experienced team of midwives have on the skill development of novice practitioners in FSBCs. IMPACT: The findings of this study will have an impact on training and orientation for nurse-midwives and direct-entry midwives when they begin to practice in out-of-hospital settings after training and working in hospital labour wards. PATIENT AND PUBLIC CONTRIBUTION: This research study has four cooperating partners: MotherHood, Network of Birth Centres, the Association for Quality at Out-of-Hospital Birth and the German Association of Midwifery Science. The cooperating partners met six times in a period of 2 ½ years to hear reports on the preliminary research findings and discuss these from the point of view of each organization. In addition, at each meeting, three midwives from various FSBCs were present to discuss the results and implications. The cooperating partners also helped disseminate study information that facilitated recruitment.

Patient knowledge and preferences for peripheral artery disease treatment.

BACKGROUND: Shared medical decision making requires patients' understanding of their disease and its treatment options. Peripheral artery disease (PAD) is a condition for which preference-sensitive treatments are available, but for which little is known about patients' knowledge and treatment preferences as it relates to specific treatment goals. METHODS: In a prospective, multicenter registry that involved patients with PAD experiencing claudication, the PORTRAIT Knowledge and Preferences Survey was administered at 1 year. It asks questions about PAD treatment choices, symptom relief options, disease management, and secondary prevention. PAD treatment preferences were also queried, and patients ranked 10 PAD treatment goals (1-10 Likert scale; 10 being most important). RESULTS: Among 281 participants completing the survey (44.8% women, mean age 69.6 ± 9.0 years), 54.1% knew that there was more than one way to treat PAD symptoms and 47.1% were offered more than one treatment option. Most (82.4%) acknowledged that they had to manage their PAD for the rest of their life. 'Avoid loss of toes or legs,' 'decreased risk of heart attack/stroke,' 'long-lasting treatment benefit,' 'living longer,' 'improved quality of life,' and 'doing what the doctor thinks I should do' had mean ratings > 9.0 (SD ranging between 1.21 and 2.00). More variability occurred for 'avoiding surgery.' 'cost of treatment,' 'timeline of pain relief,' and 'return to work' (SD ranging between 2.76 and 3.58). The single most important treatment goal was 'improving quality of life' (31.3%). CONCLUSIONS: Gaps exist in knowledge for patients with PAD who experience claudication, and there is a need for increased efforts to improve support for shared decision-making frameworks for symptomatic PAD.(ClinicalTrials.gov Identifier: NCT01419080).

Skills and knowledge of midwives at free-standing birth centres and home birth: A meta-ethnography.

PROBLEM: When midwives offer birth assistance at home birth and free-standing birth centres, they must adapt their skill set. Currently, there are no comprehensive insights on the skills and knowledge that midwives need to work in those settings. BACKGROUND: Midwifery care at home birth and in free-standing birth centres requires context specific skills, including the ability to offer low-intervention care for women who choose physiological birth in these settings. AIM: To synthesise existing qualitative research that describes the skills and knowledge of certified midwives at home births and free-standing birth centres. STUDY DESIGN: We conducted a systematic review that included searches on 5 databases, author runs, citation tracking, journal searches, and reference checking. Meta-ethnographic techniques of reciprocal translation were used to interpret the data set, and a line of argument synthesis was developed. RESULTS: The search identified 13 papers, twelve papers from seven countries, and one paper that included five Nordic countries. Three overarching themes and seven sub-themes were developed: 'Building trustworthy connections,' 'Midwife as instrument,' and 'Creating an environment conducive to birth.' CONCLUSION: The findings highlight that midwives integrated their sensorial experiences with their clinical knowledge of anatomy and physiology to care for women at home birth and in free-standing birth centres. The interactive relationship between midwives and women is at the core of creating an environment that supports physiological birth while integrating the lived experience of labouring women. Further research is needed to elicit how midwives develop these proficiencies.

Women's experience of early labour in a free-standing birth centre: Midwifing embodied labour.

ISSUE: Women who present at hospital labour wards in early labour must often meet measurable diagnostic criteria before admission. BACKGROUND: Early labour is a phase of neurohormonal, emotional, and physical changes that are often not measurable. When admission to birthplace is based on results of diagnostic procedures, women's embodied knowledge may be disregarded. AIM: To describe the early labour experience of women with spontaneous onset of labour in a free-standing birth centre, as well as midwifery care when women arrived in labour. METHODOLOGY: An ethnographic study was conducted in 2015 in a free-standing birth centre after receiving ethics approval. The findings for this article were drawn from a secondary analysis of the data, which included interview data with women and detailed field notes of midwives' activities related to early labour. FINDINGS: The women in this study were instrumental in the decision-making process to stay at the birth centre. Observational data showed that vaginal exams were rarely conducted when women arrived at the birth centre and were not a deciding factor in admission. DISCUSSION: The women and midwives co-constructed early labour based on the lived experience of women and the meaning that this experience held for both. CONCLUSION: Given the growing concern about the need for respectful maternity care, this study provides examples of good practice in listening to women, as well as an illustration of the consequences of not doing so.

The shifting care and outcomes for patients with endangered limbs - Critical limb ischemia (SCOPE-CLI) registry overview of study design and rationale.

BACKGROUND: Critical limb ischemia (CLI), the most severe form of peripheral artery disease, is associated with pain, poor wound healing, high rates of amputation, and mortality (>20% at 1 year). Little is known about the processes of care, patients' preferences, or outcomes, as seen from patients' perspectives. The SCOPE-CLI study was co-designed with patients to holistically document patient characteristics, treatment preferences, patterns of care, and patient-centered outcomes for CLI. METHODS: This 11-center prospective observational registry will enroll and interview 816 patients from multispecialty, interdisciplinary vascular centers in the United States and Australia. Patients will be followed up at 1, 2, 6, and 12 months regarding their psychosocial factors and health status. Hospitalizations, interventions, and outcomes will be captured for 12 months with vital status extending to 5 years. Pilot data were collected between January and July of 2021 from 3 centers. RESULTS: A total of 70 patients have been enrolled. The mean age was 68.4 ± 11.3 years, 31.4% were female, and 20.0% were African American. CONCLUSIONS: SCOPE-CLI is uniquely co-designed with patients who have CLI to capture the care experiences, treatment preferences, and health status outcomes of this vulnerable population and will provide much needed information to understand and address gaps in the quality of CLI care and outcomes.ClinicalTrials.gov identifier (NCT Number): NCT04710563 https://clinicaltrials.gov/ct2/show/NCT04710563.

"Putting the baby back in the body": The re-embodiment of pregnancy to enhance safety in a free-standing birth center.

The general discourse in most countries is that technological surveillance during pregnancy and childbirth is synonymous with safety, while women's individual experiences are less likely regarded as critical. The aim of this ethnographic study at a birth center in Germany was to describe how midwives and their clients construct risk and safety. The data collection methods included participant observation and semi-structured interviews. 'Putting the baby back in the body' was the major theme that emerged, supported by three sub-themes. The women in this study relied on scans at the beginning of pregnancy to make their baby real to them, but became more confident in their capacity to sense their baby after experiencing the first fetal movements. The midwives fostered this confidence by using interactive palpation of the abdomen with the women, thus supporting their individual sensory experience, and, in the midwives' view, enhancing overall safety during pregnancy and at birth.

Treatment decisions for patients with peripheral artery disease and symptoms of claudication: Development process and alpha testing of the SHOW-ME PAD decision aid.

Patients with peripheral artery disease (PAD) face a range of treatment options to improve survival and quality of life. An evidence-based shared decision-making tool (brochure, website, and recorded patient vignettes) for patients with new or worsening claudication symptoms was created using mixed methods and following the International Patient Decision Aids Standards (IPDAS) criteria. We reviewed literature and collected qualitative input from patients (n = 28) and clinicians (n = 34) to identify decisional needs, barriers, outcomes, knowledge, and preferences related to claudication treatment, along with input on implementation logistics from 59 patients and 27 clinicians. A prototype decision aid was developed and tested through a survey administered to 20 patients with PAD and 23 clinicians. Patients identified invasive treatment options (endovascular or surgical revascularization), non-invasive treatments (supervised exercise therapy, claudication medications), and combinations of these as key decisions. A total of 65% of clinicians thought the brochure would be useful for medical decision-making, an additional 30% with suggested improvements. For patients, those percentages were 75% and 25%, respectively. For the website, 76.5% of clinicians and 85.7% of patients thought it would be useful; an additional 17.6% of clinicians and 14.3% of patients thought it would be useful, with improvements. Suggestions were incorporated in the final version. The first prototype was well-received among patients and clinicians. The next step is to implement the tool in a PAD specialty care setting to evaluate its impact on patient knowledge, engagement, and decisional quality. ClinicalTrials.gov Identifier: NCT03190382.

Making physiological birth possible: birth at a free-standing birth centre in Berlin.

BACKGROUND: the practical training in midwifery education in Germany takes place predominantly in hospital delivery wards, where high rates of intervention and caesarean section prevail. When midwives practice birth assistance at free-standing birth centres, they have to make adjustments to what they learned in the clinic to support women without the interventions common to hospital birth. OBJECTIVES: the primary aim of this study was to investigate and describe the approach of midwives practicing birth assistance at a free-standing birth centre. METHODOLOGY: a qualitative approach to data collection and analysis with grounded theory was used which included semi-structured expert interviews and participant observation. Five midwives were interviewed and nine births observed in the research period. The setting was a free-standing birth centre in a large German city with approximately 115 births per year. FINDINGS: the midwives all had to re-learn birth assistance when commencing work outside of the hospital. However, having been trained predominantly in hospital maternity wards, they have retained many aspects characteristic of their training. The midwives use technology, although minimal, and medical discourse in combination with 1:1, woman-centred care. The birthing woman and midwife share authority at birth. The fetus is treated as an ally of the mother, suited for birth and cooperative. Through use of objective and subjective criteria, the midwives have their own approach to making physiological birth possible. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: to prepare midwives to support low-intervention birth, it is necessary to include training in birth assistance with women who birth physiologically, without interventions common to hospital birth. The results of this study would also suggest that the rate of interventions in hospital could be reduced if midwives gain more experience with women birthing without the above-mentioned interventions.

Systems-based practice assessed with a performance-based examination simulated and scored by standardized participants in the health care system: feasibility and psychometric properties.

BACKGROUND: Systems-based practice is one of the six general competencies proposed by the Accreditation Council for Graduate Medical Education in their Outcome Project. However, little has been published on its assessment--possibly because the systems-based practice competency has been viewed as difficult to define and measure. PURPOSE: The purpose of this study was to determine whether a full performance-based examination of systems-based practice cases simulated and scored by standardized participants in the health care system could feasibly be constructed and implemented that would provide reliable and valid measurements. METHODS: In the 1st year of the project (2008), four systems-based practice cases were developed and pilot tested with 13 residents. Videotapes of residents were studied to develop an instrument for subsequent assessment of performance by standardized participants. In the 2nd year (2009), the examination was expanded to a full 12 cases, which were completed by 11 second-year residents, and psychometric analyses were performed on the scores. RESULTS: The generalizability coefficient for the full 12-case examination based on scoring by standardized participants was .71, which is nearly equal to that based on scoring by faculty physician observers, which was .78. The correlation between total scores obtained with standardized participants and physician observers was .78. CONCLUSIONS: A performance-based examination can provide a feasible and reliable assessment of systems-based practice. However, attempts to evaluate convergent validity and discriminant validity-by correlating systems-based practice performance assessments with mean global ratings of residents on the 6 competencies by faculty throughout training-were unsuccessful, due to a lack of independence between the rated dimensions.

Aging Couple Across the Curriculum.

Aging Couple Across the Curriculum is a unique program designed around a couple who "age" a decade with each year of medical school. In these half-day sessions, students encounter the aging couple through a standardized patient experience. Interactive breakout sessions conducted by multidisciplinary professionals enhance student learning and appreciation of the contributions of the team of professionals. A panel of elder specialists provides personal insight into how they have overcome and/or adapted to various health-related problems. Evaluation measures have indicated that students are benefiting from the program and that it is affecting their attitudes in a positive way toward caring for older adults.

Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion.

BACKGROUND: This study presents our implementation of a two-specimen requirement with no prior record of ABO/Rh to verify patients' blood type before transfusion. MATERIALS AND METHODS: Blood type verification was introduced, discussed, approved, and implemented over a 12-month period (May 2007 to May 2008). Potential barriers and impact on benchmark indicators were identified and tracked. RESULTS: Inpatient identification and/or specimen labeling for nursing and laboratory phlebotomists baseline corrected error rates were 1:467 and 1:5555, respectively. This study therefore sought and obtained approval to initiate a new policy of blood type verification before blood transfusion. Compliance in turnaround time (TAT) before and after implementation for completion of STAT type and screen/crossmatch within 60 minutes worsened marginally, from 90% to 80%. The impact on use of O-, uncrossmatched blood was found to be manageable. Seven (of 25 total) recorded electronic complaints were received after implementation. The corrected error rate for nurse phlebotomy draws after implementation was 1:630. CONCLUSION: Despite the lack of an instigating event, verification of blood type before blood transfusion was successfully implemented. An impact on resources and benchmark indicators such as TAT can be anticipated and managed. Further process improvement efforts will be needed to ensure safety (e.g., at time of blood transfusion) for patients receiving blood transfusions. ABO/Rh verification may be necessary even after future implementation of bar coding and/or RFID chips, because human errors continue to occur even with systems improvements.

Development of the objective structured system-interaction examination.

STUDY OBJECTIVE: The purpose of this study was to develop an objective method of evaluating resident competency in systems-based practice. STUDY DESIGN: Faculty developed a 12-station examination, the Objective Structured System-Interaction Examination (OSSIE), patterned after the Objective Structured Clinical Examinations (OSCEs), to evaluate residents' ability to effectively work within the complex medical system of care. Scenarios consisted of multiple situations, such as patient hand-offs, consultations, complicated discharges, and family meetings, in which residents interacted with simulated professionals, simulated patients, and simulated family members to demonstrate the systems-based skills. Twelve second-year residents participated in the OSSIE. FINDINGS: Along with the standardized professionals, a faculty member provided the resident with immediate feedback and completed an evaluation form designed specifically to assess systems-based practice. Residents, faculty, and staff evaluated the OSSIE and felt it provided a rich learning experience and was a beneficial means of formative assessment. The residents' third-year learning experiences were adapted to meet their needs, and suggestions were offered for curriculum revision. DISCUSSION: The OSSIE is unique in that it uses standardized professionals, involves scenarios in a variety of settings, and incorporates current technology, including an electronic health record and a state-of-the-art simulation laboratory, into the examination. Challenges to implementation include faculty time, scheduling of residents, and availability of resources. CONCLUSION: By using the OSSIE, faculty are able to assess, provide constructive feedback, and tailor training opportunities to improve resident competence in systems-based practice. Reliability and validity of an instrument developed for use with the OSSIE are currently being determined.

The physician's role in assessing and counseling aging drivers: a training session for undergraduate medical students.

The critical need for physicians to become entrenched in the issues of older drivers and public safety is the focus of a training initiative developed as a component of an innovative geriatrics curriculum, Aging (Couple) Across the Curriculum. As the number of aging drivers in the United States rises, physicians can play an important role in helping older patients continue safe driving practices and in counseling those who need to cease driving. This article describes an inventive course designed to sensitize medical students to the many complex issues entangled in driving and aging and to prepare them to competently and compassionately assess and counsel older drivers. The act of driving connotes more than mobility. It reinforces one's independence, including the ability to go when and where one chooses. There must be a careful balance between an older person's privilege to drive and the public's right to safety. Through this training program, students can experience the complexity of this significant issue. This model has the potential to be utilized in other medical schools and could be adapted for use in interdisciplinary education.

Human factors and education: evolution and contributions.

OBJECTIVE: The major contributions of human factors to education are highlighted. BACKGROUND: Over the past 50 years, the education of human factors specialists has evolved, as well as the application of human factors and ergonomic knowledge to education. METHOD: Human factors and ergonomics professional documentation and literature were reviewed to identify major events relevant to human factors education or the application of human factors to education. RESULTS: Human factors education has evolved from training in experimental psychology to highly specialized accredited human factors programs and a number of undergraduate programs, leading to program accreditation and the certification of professionals. In addition, human factors specialists have applied their knowledge to human factors education and, more recently, to educational systems in general. The greatest focus has been on technology such as multimedia. Others have evaluated the design of the physical environment, focusing primarily on seating. The research also often targets undergraduate or graduate education. Therefore, it has been proposed that a greater focus is needed at the K-12 educational level, especially given the advancement and implementation of technology in the classroom. CONCLUSION: Human factors and ergonomic expertise can benefit the educational system. Yet, there is a need to constantly evaluate the benefits of new technology in the classroom as well as the environmental design aspects of the educational environment while considering learners of different age groups, ethnicities, and sexes. APPLICATION: Better application of human factors and ergonomics to the learning environment could enhance the educational experience for all learners.

A simulated couple aging across the four years of medical school.

BACKGROUND: The medical students of today will deliver health care to an ever-increasing aging population. Regardless of specialties, physicians must view older patients holistically with attention to medical, psychosocial, and family issues and functional status. DESCRIPTION: This program was designed around a couple who ages from 60 to 90 over the 4 years of medical school. The woman represents the healthy aging process, whereas the man represents an elder experiencing multiple health problems. Through standardized patient experiences, small-group encounters, and paper-based learning modules, students address typical age-related issues that provide experiences representative of aging in today's society. EVALUATION: Sessions were rated good to excellent. Comments were positive, especially regarding interactions with the aging couple. CONCLUSIONS: Aging Couple Across the Curriculum allowed the interweaving of multiple issues that are characteristic of many geriatric cases. Students were able to see the complexity of issues and the impact on other family members.

Effect of creatine phosphate supplementation on anaerobic working capacity and body weight after two and six days of loading in men and women.

The purpose of this study was to determine the effects of 2 and 6 days of creatine phosphate loading on anaerobic working capacity (AWC) and body weight (BW) in men and women. Sixty-one men (n = 31) and women (n = 30) randomly received 1 of 3 treatments (4 x 5 g.d(-1) x 6 days) using a double blind design: (a) 18 g dextrose as placebo (PL); (b) 5.0 g Cr + 20 g dextrose (Cr); or (c) 5.0 g Cr + 18 g dextrose + 4 g of sodium and potassium phosphates (CrP). AWC was determined at baseline and following 2 and 6 days of supplementation using the Critical Power Test. BW increased significantly over time, and the mean value for the men was significantly greater compared to that for women, but there were no interactions (p > 0.05). There were gender-specific responses for AWC expressed in both absolute values (kJ) and relative to BW (kJ. kg(-1)), with the women demonstrating no significant interactions. For the men, CrP loading significantly increased AWC following 2 days (23.8%) and 6 days (49.8%) of supplementation vs. PL (kJ and kJ.kg(-1)). Cr supplementation increased AWC 13-15% in both genders compared to PL (1.1%- 3.0% decline); although this result was not statistically significant, it may have some practical significance.