Sources of stress and coping mechanisms: Experiences of maternal health care providers in Western Kenya.

The dynamic and complex nature of care provision predisposes healthcare workers to stress, including physical, emotional, or psychological fatigue due to individual, interpersonal, or organizational factors. We conducted a convergent mixed-methods study with maternity providers to understand their sources of stress and coping mechanisms they adopt. Data were collected in Migori County in western Kenya utilizing quantitative surveys with n = 101 maternity providers and in-depth interviews with a subset of n = 31 providers. We conducted descriptive analyses for the quantitative data. For qualitative data, we conducted thematic analysis, where codes were deductively developed from interview guides, iteratively refined based on emergent data, and applied by a team of five researchers using Dedoose software. Code queries were then analysed to identify themes and organized using the socioecological (SE) framework to present findings at the individual, interpersonal, and organizational levels. Providers reported stress due to high workloads (61%); lack of supplies (37%), poor salary (32%), attitudes of colleagues and superiors (25%), attitudes of patients (21%), and adverse outcomes (16%). Themes from the qualitative analysis mirrored the quantitative analysis with more detailed information on the factors contributing to each and how these sources of stress affect providers and patient outcomes. Coping mechanisms adopted by providers are captured under three themes: addressing stress by oneself, reaching out to others, and seeking help from a higher power. Findings underscore the need to address organizational, interpersonal, and individual level stressors. Strategies are needed to support staff retention, provide adequate resources and incentives for providers, and ultimately improve patient outcomes. Interventions should support and leverage the positive coping mechanisms identified.

Context Matters: Factors Affecting Implementation of Simulation Training in Nursing and Midwifery Schools in North America, Africa and Asia.

Background: Robust evidence supports the effectiveness of simulation training in nursing and midwifery education. Simulation allows trainees to apply newly-learned skills in a supportive environment. Method: This study was conducted using the Consolidated Framework for Implementation Research (CFIR). We conducted in-depth individual interviews with simulation experts around the world. Results: Findings from this study highlight best-practices in facilitating simulation implementation across resources settings. Universal accelerators included: (1) adaptability of simulation (2) "simulation champions" (3) involving key stakeholders and (4) culturally-informed, pre-implementation planning. Conclusions: Shared constructs reported in diverse settings provide lessons to implementing evidence-based, flexible simulation trainings in pre-service curriculum.

Factors Associated With Trajectories of Externalizing Behavior in Preschoolers.

OBJECTIVE: More media exposure and life stressors are associated with higher levels of externalizing behaviors in young children; however, their joint impact on externalizing behavior trajectory is unknown. This study assessed the relationship of stressful life events (SLE), media exposure, and additional demographic and family variables on the trajectory of externalizing behaviors in preschool-aged children. METHODS: Participants were children ages 3 to 5 years from a large, 18-month duration, randomized control trial to reduce inappropriate media exposure. The sample was recruited from community pediatrics' practices. Intervention and control groups were collapsed, with study arm a covariate. Latent growth modeling (LGM) was conducted, with main outcome of externalizing behaviors at 6, 12, and 18 months after study initiation. Primary exposures of interest were total daily media hours, SLE, intimate partner violence, and harsh parenting. RESULTS: Final analyses included 613 children. LGM without covariates revealed a significant decrease in mean externalizing score between baseline and 18 months. LGM with covariates revealed that individuals with more media exposure exhibited more externalizing behaviors and SLE significantly predicted a slower decline in externalizing behaviors. Externalizing behavior at 18 months was significantly predicted by SLE, child age, white non-Hispanic race, and harsh parenting. CONCLUSIONS: Exposure to a greater number of stressful life events appears to slow the age-appropriate decline in externalizing behaviors for preschool-aged children, while harsh parenting and media exposure are associated with more externalizing behavior. Findings highlight the importance of screening and surveillance in primary care and the need for early intervention efforts targeted to these risks.

Simulation and nurse-mentoring in a statewide nurse mentoring program in Bihar, India: diagnosis of postpartum hemorrhage and intrapartum asphyxia.

Background: Mentoring programs that include simulation, bedside mentoring, and didactic components are becoming increasingly popular to improve quality. These programs are designed with little evidence to inform the optimal composition of mentoring activities that would yield the greatest impact on provider skills and patient outcomes. We examined the association of number of maternal and neonatal emergency simulations performed with the diagnosis of postpartum hemorrhage (PPH) and intrapartum asphyxia in real patients. Methods: We used a prospective cohort and births were compared between- and within-facility over time. Setting included 320 public facilities in the state of Bihar, India May 2015 - 2017. The participants were deliveries and livebirths. The interventions carried out were mobile nurse-mentoring program with simulations, teamwork and communication activities, didactic teaching, demonstrations of clinical procedures and bedside mentoring including conducting deliveries. Nurse mentor pairs visited each facility for one week, covering four facilities over a four-week period, for seven to nine consecutive months. The outcome measures were diagnosis of PPH and intrapartum asphyxia. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Conclusions: Findings suggest a complex relationship between performing simulations and opportunities for direct practice with patients, and there may be an optimal balance in performing the two that would maximize diagnosis of PPH and intrapartum asphyxia.

Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana.

INTRODUCTION: The COVID-19 pandemic has compounded the global crisis of stress and burnout among healthcare workers. But few studies have empirically examined the factors driving these outcomes in Africa. Our study examined associations between perceived preparedness to respond to the COVID-19 pandemic and healthcare worker stress and burnout and identified potential mediating factors among healthcare workers in Ghana. METHODS: Healthcare workers in Ghana completed a cross-sectional self-administered online survey from April to May 2020; 414 and 409 completed stress and burnout questions, respectively. Perceived preparedness, stress, and burnout were measured using validated psychosocial scales. We assessed associations using linear regressions with robust standard errors. RESULTS: The average score for preparedness was 24 (SD = 8.8), 16.3 (SD = 5.9) for stress, and 37.4 (SD = 15.5) for burnout. In multivariate analysis, healthcare workers who felt somewhat prepared and prepared had lower stress (ß = -1.89, 95% CI: -3.49 to -0.30 and ß = -2.66, 95% CI: -4.48 to -0.84) and burnout (ß = -7.74, 95% CI: -11.8 to -3.64 and ß = -9.25, 95% CI: -14.1 to -4.41) scores than those who did not feel prepared. Appreciation from management and family support were associated with lower stress and burnout, while fear of infection was associated with higher stress and burnout. Fear of infection partially mediated the relationship between perceived preparedness and stress/burnout, accounting for about 16 to 17% of the effect. CONCLUSIONS: Low perceived preparedness to respond to COVID-19 increases stress and burnout, and this is partly through fear of infection. Interventions, incentives, and health systemic changes to increase healthcare workers' morale and capacity to respond to the pandemic are needed.

Simulation-enhanced nurse mentoring to improve preeclampsia and eclampsia care: an education intervention study in Bihar, India.

BACKGROUND: Inadequately treated, preeclampsia and eclampsia (PE/E) may rapidly lead to severe complications in both mothers and neonates, and are estimated to cause 60,000 global maternal deaths annually. Simulation-based training on obstetric and neonatal emergency management has demonstrated promising results in low- and middle-income countries. However, the impact of simulation training on use of evidence-based practices for PE/E diagnosis and management in low-resource settings remains unknown. METHODS: This study was based on a statewide, high fidelity in-situ simulation training program developed by PRONTO International and implemented in collaboration with CARE India on PE/E management in Bihar, India. Using a mixed methods approach, we evaluated changes over time in nurse mentees' use of evidence-based practices during simulated births at primary health clinics. We compared the proportion and efficiency of evidence-based practices completed during nurse mentees' first and last participation in simulated PE/E cases. Twelve semi-structured interviews with nurse mentors explored barriers and enablers to high quality PE/E care in Bihar. RESULTS: A total of 39 matched first and last simulation videos, paired by facility, were analyzed. Videos occurred a median of 62 days apart and included 94 nurses from 33 primary health centers. Results showed significant increases in the median number of 'key history questions asked,' (1.0 to 2.0, p = 0.03) and 'key management steps completed,' (2.0 to 3.0, p = 0.03). The time from BP measured to magnesium sulfate given trended downwards by 3.2 min, though not significantly (p = 0.06). Key barriers to high quality PE/E care included knowledge gaps, resource shortages, staff hierarchy between physicians and nurses, and poor relationships with patients. Enablers included case-based and simulation learning, promotion of teamwork and communication, and effective leadership. CONCLUSION: Simulation training improved the use of evidence-based practices in PE/E simulated cases and has the potential to increase nurse competency in diagnosing and managing complex maternal complications such as PE/E. However, knowledge gaps, resource limitations, and interpersonal barriers must be addressed in order to improve care. Teamwork, communication, and leadership are key mechanisms to facilitate high quality PE/E care in Bihar.

Tracking and debriefing birth data at scale: A mobile phone application to improve obstetric and neonatal care in Bihar, India.

AIM: This analysis assessed changes over time in skill and knowledge related to the use of evidence-based practices associated with quality of maternal and neonatal care during a nurse midwife mentoring intervention at primary health clinics (PHCs) in Bihar, India. DESIGN: Nurse midwife mentors (NMMs) entered live birth observation data into a mobile App from 320 PHCs. METHODS: The NMMs completed prompted questions in the App after every live birth witnessed. The App consisted of questions around three main themes, "What went well?", "What needed improvement?" and "What can be done differently next time?". RESULTS: Observational data from 5,799 births was recorded by 120 NMMs in 320 PHCs. Knowledge and skill during normal spontaneous vaginal deliveries and complicated deliveries with either a postpartum haemorrhage or non-vigorous infant all showed statistically significant improvement (p < .001) over time using a Chi-squared test for trend with a mean increase of 41% across all indicators.