The midwifery capabilities theory: How midwives enact woman-centered care to address systemic inequity.

BACKGROUND: Healthcare for childbearing women with complex needs demands a multi-disciplinary approach requiring transitions between care providers, paradigms, and models of care. These transitions may create disconnects between women and the maternity care "system." Poorly managed care transitions can lead to women becoming hostage to the power struggles between healthcare organizations and the professionals working within them, further increasing the risk of poor outcomes. This paper presents the findings of a study that aimed to better understand how midwives provide woman-centered care for women with complex needs in the real world of maternity services. METHODS: A constructivist grounded theory approach, using Clarke's situational analysis to extend critical and feminist perspectives in data analysis. Qualitative data were obtained from two sources: publicly available data, and individual interviews with providers of care (midwives) and recipients of care (women with complex pregnancies). RESULTS: Woman-centered care is defined as care in which the woman is seen, heard, and known. "The midwifery capabilities theory" describes the process whereby midwives create opportunities to develop women's capabilities. Capabilities are enabled through the midwifery relationship creating space, moments in time, and equalizing power and positionality. CONCLUSIONS: Aligning with contemporary theories surrounding the provision of midwifery care, the midwifery capabilities theory recognizes the individual health and social status of women and the rights to self-determination. This centers care around each individual's needs, which, in addition to improving health and well-being outcomes, contributes to improved self-confidence, enhancing engagement through authentic professional relationships.

Exploring the Challenges of Context in Accessing Mental Health Support in Rural New Zealand: A Case Study Approach.

OBJECTIVE: This paper explores the complexities that impact access to mental health services in rural New Zealand. Historical, cultural, social and political factors will be examined against the philosophical positioning of Foucault and Fairclough. STUDY DESIGN: This research is a single-embedded case study design exploring participants' discourses in the context of a rural, bounded geographical area of New Zealand. RESULTS: The results show that mental health support that addresses people's actual needs rather than the needs that governments map against ever-changing policy is required and that an awareness of context within case study research is important. DISCUSSION: The process of case study design is described, including building upon a rationale for selecting the case, collecting data and conducting case analysis and interpretation. This study examines factors influencing the real-life rural context of accessing mental health support. This article demonstrates that case-study research can be valuable for navigating context complexity and developing nuanced understandings of complex phenomena. CONCLUSION: The paper highlights how the multifaceted case study context is more than mapping discourses against a rural backdrop. It is necessary to consider the power dynamics that shape experiences and their impact on service creation and its consequent delivery. IMPLICATIONS FOR RESEARCH POLICY AND PRACTICE: Rather than services being created that are complex and not meeting people's needs, there is a need to listen to the people who have experienced mental health distress and provide services and support in locations other than clinical settings.

Nurse and midwife navigator resilience, well-being, burnout, and turnover intent: A multi-methods study.

PURPOSE: To explore levels of Navigator resilience, well-being, burnout, and turnover intent. DESIGN: A longitudinal, multi-methods study concurrently collected quantitative and qualitative data over three years. METHODS: A survey and Action Learning Groups. FINDINGS: No statistically significant change in resilience, well-being, burnout, or turnover intent. Supports, self-care and leaving the position, were used to maintain well-being. CONCLUSIONS: While quantitative measures did not change, qualitative data demonstrated how adaptive coping mechanisms maintain well-being. Recommendations for nurses working in Navigator, or similar community/public health roles include work-based programs targeting support, good leadership, governance systems including their impact on turnover intent. CLINICAL EVIDENCE: Job turnover intent can be used as a mechanism to monitor resilience and well-being.

The discourse of delivering person-centred nursing care before, and during, the COVID-19 pandemic: Care as collateral damage.

The global COVID-19 pandemic challenged the world-how it functions, how people move in the social worlds and how government/government services and people interact. Health services, operating under the principles of new public management, have undertaken rapid changes to service delivery and models of care. What has become apparent is the mechanisms within which contemporary health services operate and how services are not prioritising the person at the centre of care. Person-centred care (PCC) is the philosophical premise upon which models of health care are developed and implemented. Given the strain that COVID-19 has placed on the health services and the people who deliver the care, it is essential to explore the tensions that exist in this space. This article suggests that before the pandemic, PCC was largely rhetoric, and rendered invisible during the pandemic. The paper presents an investigation into the role of PCC in these challenging times, adopting a Foucauldian lens, specifically governmentality and biopolitics, to examine the policies, priorities and practical implications as health services pivoted and adapted to changing and acute demands. Specifically, this paper draws on the Australian experience, including shifting nursing workforce priorities and additional challenges resulting from public health directives such as lockdowns and limitations. The findings from this exploration open a space for discussion around the rhetoric of PCC, the status of nurses and that which has been lost to the pandemic.

Nurse Navigators - Champions of the National Rural and Remote Nursing Generalist Framework: A solution.

INTRODUCTION: Nurse Navigators were introduced in Queensland, Australia, in 2016. Nurse Navigators coordinate person-centred care, create partnerships, improve care coordination and outcomes and facilitate system improvement, independently of hospital or community models. They navigate across all aspects of hospital and social services, liaising, negotiating and connecting care as needed. People stay with Nurse Navigators for as long as required, though the intent is to transition them from high-care needs to self-management. Nurse Navigators are a working model in rural and remote areas of Queensland. OBJECTIVE: To describe where the rural and remote Nurse Navigator position fits within the Rural Remote Nursing Generalist Framework and to define the depth and breadth of the rural and remote Nurse Navigator's scope of practice. DESIGN: Using template analysis, data from focus groups and interviews were analysed against the domains of the recently released National Rural and Remote Nursing Generalist Framework. Navigators working in rural and remote areas across Queensland Health were invited to an interview (n = 4) or focus group (n = 9), conducted between October 2019 and August 2020. FINDINGS: Rural and remote Nurse Navigators are proficient in all domains of the framework and actively champion for their patients, carers and the communities where they live and work. DISCUSSION: This research demonstrates that rural and remote Nurse Navigators are a working model of advanced nursing practice, acting as 'champions' of The Framework. CONCLUSION: The Nurse Navigator model of care introduced to Queensland exemplifies proficient registered nurse practice to the full extent of their knowledge and skill.

Front-line health professionals' recognition and responses to nonfatal strangulation events: An integrative review.

AIM: The aim of this study was to determine how front-line health professionals identify and manage nonfatal strangulation events. DESIGN: Integrative review with narrative synthesis was conducted. DATA SOURCES: A comprehensive database search was conducted in six electronic databases (CINAHL, Wed of Science, DISCOVER, SCOPUS, PubMed and Scholar) resulting in 49 potentially eligible full texts, reduced to 10 articles for inclusion after exclusion criteria were applied. REVIEW METHODS: An integrative review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Data were extracted, and a narrative synthesis using Whittemore and Knafl (2005) framework was undertaken to determine how front-line health professionals identify and manage nonfatal strangulation events. RESULTS: The findings identified three main themes: an overall failure by health professionals to recognize nonfatal strangulation, a failure to report the event and a failure to follow up on victims after the event. Stigma and predetermined beliefs around nonfatal strangulation, along with a lack of knowledge about signs and symptoms, were the salient features in the literature. CONCLUSION: Lack of training and fear of not knowing what to do next are barriers to providing care to victims of strangulation. Failure to detect, manage and support victims will continue the cycle of harm through the long-term health effects of strangulation. Early detection and management of strangulation are essential to prevent health complications, particularly when the victims are exposed to such behaviours repeatedly. IMPACT: This review appears to be the first to explore how health professionals identify and manage nonfatal strangulation. It identified the significant need for education and robust and consistent screening and discharge policies to assist health providers of services where victims of nonfatal strangulation attend. NO PATIENT OR PUBLIC CONTRIBUTION: This review contains no patient or public contribution since it was examining health professionals' knowledge of identifying nonfatal strangulation and the screening and assessment tools used in clinical practice.

Spiritual lives of children with cancer: A qualitative descriptive study in Lithuania.

PURPOSE: To explore the experience and perception of spiritual lives of children with cancer. DESIGN AND METHODS: A qualitative descriptive study included the collection of narratives on spiritual lives of children drawn from two university hospitals in Lithuania in the form of a semi-structured face-to-face interviews. Purposive sample of twenty-seven hospitalized children (5-12 y.) with non-terminal stage of cancer participated in the study. RESULTS: The final four themes emerged from across all the questions as: being normal, community, comfort and connections with God. CONCLUSIONS: Children with cancer needed to maintain as normal a life as posssible, despite being ill and undergoing treatment. Connections with family and friends were echoed in all the themes that emerged in the study. Children seemed to own their views about needing to pray or not; their needs revolved around asking for health and remission of their illness. Children diagnosed with cancer have a unique understanding of spirituality that is linked to their age, gender, and family composition. These ideas change as children develop and mature. PRACTICAL IMPLICATIONS: The need to explore the spiritual lives of children with life threatening illnesses from an early age is evident. Health professionals need to recognize that a child is the product of their family, their community, their culture and their spirituality. Conversations with children about what God means to them and how prayer supports them, is essential. The opinion that spirituality topic might be hardly understood or too sensitive to children is rejected by the researchers.

A protocol for exploring patients' and support peoples' experiences after prolonged critical illness.

BACKGROUND: Improved survival of critically ill people has increased the number of patients who experience an extended stay in intensive care units (ICU). Evidence suggests the complexities, vulnerabilities, and traumas created by critical illness are substantial for both patients and their support people with a number experiencing devastating impairments across multiple domains of health and function including physical, mental, cognitive, and social health. However, research on survivors predominantly focuses on those who have experienced a relatively short length of stay; only a limited number of studies seek to explore the experiences of survivors and their support people who have had a prolonged stay in intensive care. AIMS: To describe the experiences of survivors of prolonged critical illness (invasively mechanically ventilated in ICU for ≥eight days) and their support people during the first 12 months following hospital discharge in New Zealand. STUDY DESIGN: This research will be a multi-centre study recruiting from three intensive care units in New Zealand. A narrative inquiry methodology will be used to interview 6-8 former long stay patients and 6-8 support people of a former long stay patient. Each participant will be interviewed at 3-, 6-, 9-, and 12-months following hospital discharge. Data will be collected via narrative inquiry interviews. Data analysis will combine two theoretical frameworks: the Clandinin and Connelly narrative inquiry three-dimensional space and the Fairclough situation, discourse and context framework. RESULTS: The phenomenon of investigation will be experiences after prolonged critical illness explored longitudinally across the first-year post-hospital discharge. RELEVANCE TO CLINICAL PRACTICE: This protocol provides a methodological framework for exploring the lived experiences of survivors of prolonged critical illness and their support people. Data analysis will support understanding of the human journey of ICU survivorship and add to the body of knowledge on how to support post-ICU recovery in this population. The barriers and enablers of survivorship at the micro, meso, and macro levels of the health service will also be illuminated.

A systematic review: Unfinished nursing care and the impact on the nurse outcomes of job satisfaction, burnout, intention-to-leave and turnover.

AIM: To investigate the association of unfinished nursing care on nurse outcomes. DESIGN: Systematic review in line with National Institute for Health and Care Excellence guideline. DATA SOURCES: CINAHL, the Cochrane Library, Embase, Medline, ProQuest and Scopus databases were searched up until April 2020. REVIEW METHODS: Two independent reviewers conducted each stage of the review process: screening eligibility, quality appraisal using Mixed Methods Appraisal Tool; and data extraction. Narrative synthesis compared measurements and outcomes. RESULTS: Nine hospital studies were included, and all but one were cross-sectional multicentre studies with a variety of sampling sizes (136-4169 nurses). Studies had low internal validity implying a high risk of bias. There was also a high potential for bias due to non-response. Only one study explicitly sought to examine nurse outcomes as a primary dependent variable, as most included nurse outcomes as mediating variables. Of the available data, unfinished nursing care was associated with: reduced job satisfaction (5/7 studies); burnout (1/3); and intention-to-leave (2/2). No association was found with turnover (2/2). CONCLUSION: Unfinished nursing care remains a plausible mediator of negative nurse outcomes, but research is limited to single-country studies and self-reported outcome measures. Given challenges in the sector for nurse satisfaction, recruitment and retention, future research needs to focus on nurse outcomes as a specific aim of inquiry in relation to unfinished nursing care. IMPACT: Unfinished nursing care has previously been demonstrated to be associated with staffing, education and work environments, with negative associations with patient outcomes (patient satisfaction, medication errors, infections, incidents and readmissions). This study offers new evidence that the impact of unfinished nursing care on nurses is under investigated. Policymakers can prioritize the funding of robust observational studies and quasi-experimental studies with a primary aim to understand the impact of unfinished nursing care on nurse outcomes to better inform health workforce sustainability.

Health (il)literacy: Structural vulnerability in the nurse navigator service.

Health literacy is a contemporary term used in health services, often used to describe individuals requiring additional support to access, understand and implement health service information. It is used as a measure of self-efficacy in chronic disease models of care such as the nurse navigator service. The aim of the research was to investigate the concept of health literacy in the nurse navigator service, particularly in relation to the defined role objective of person-centred care. Fairclough's critical discourse analysis was used to analyse the experiential, relational and expressive elements of texts, investigating the hidden truths which are represented in discourse. Texts from a variety of health service micro-, meso- and macro-hierarchical sources were selected for analysis using the nurse navigator evaluation data set and other associated texts. Health literacy in the nurse navigator service is a technology of government used to increase participation of individuals in their own health and well-being. The discourse suggests that health literacy responsibilises both individuals and nurses and is discursively formed within a matrix of rational choice. In this context, health literacy contributes to structural vulnerability.

The grounded theory of Coalescence of Perceptions, Practice and Power: An understanding of governance in midwifery practice.

AIMS: This study aimed to understand midwifery care during labour, particularly decision-making processes, within Australian health systems. BACKGROUND: Midwifery, founded on a wellness model of motherhood, is at risk of being medicalized. Whilst medical intervention is lifesaving, it requires judicious use. Governance provides oversight to care. Exploring decision-making contributes to understanding governance of practices. METHOD: Straussian grounded theory using semi-structured interviews. Eighteen Australian registered midwives were interviewed about their practice when caring for women during labour. RESULTS: Midwives were caught between divergent positions; birth as natural versus birth as risk. Experienced midwives discussed focussing on the woman, yet less experienced were preoccupied with mandatory protocols like early warning tools. Practice was governed by midwives approach within context of labour. The final theory: The Coalescence of Perceptions, Practice and Power, comprising three categories: perceptions and behaviour, shifting practice and power within practice, emerged. CONCLUSIONS: Coalescence Theory elucidates how professional decision making by midwives during care provision is subject to power within practice, thereby governed by tensions, competing priorities and organizational mandates. IMPLICATIONS FOR MIDWIFERY MANAGERS: Midwifery managers are well positioned to negotiate the nuanced space that envelopes birthing processes, namely, expert knowledge, policy mandates and staffing capability and resources, for effective collaborative governance. In this way, managers sustain good governance.

Workplace bullying, burnout and resilience amongst perioperative nurses in Australia: A descriptive correlational study.

AIM: This study aimed to investigate workplace bullying and explore correlations between bullying, burnout and resilience amongst perioperative nurses in Australia. BACKGROUND: Workplace bullying in perioperative nursing involves verbal, physical and psychological violence. However, no prior studies have measured Australian perioperative nurses' experiences of workplace bullying nor sought to understand if there is a relationship with burnout and resilience. METHODS: A descriptive correlational study was conducted utilizing an online survey incorporating four validated instruments. Descriptive statistics and regression models analysed workplace bullying, burnout and resilience. RESULTS: Over half of perioperative nurses (n = 158/257, 61%) were exposed to workplace bullying. Consequences included fatigue and exhaustion (n = 129/192, 67%), anxiety (n = 123/192, 64%) and sleeplessness (n = 121/192, 63%). Organisational processes (r = .458, p < .001), bullying acts (r = .289, p < .001) and avoidance and withdrawal at work (r = .440, p = .001) increased burnout. Psychosocial distress (r = -.216, p < .001) was associated with decreased resilience. CONCLUSIONS: Workplace bullying is a persistent issue with negative impacts upon burnout, resilience and well-being. IMPLICATIONS FOR NURSING MANAGEMENT: The psychological well-being of employees can be prioritized by establishing and maintaining an organisational climate of psychosocial safety, thereby inhibiting the potential of bullying to manifest and positively influencing employee well-being to help promote workplace engagement, productivity and reduced burnout.

Promoting nurses' and midwives' ethical responsibilities towards vulnerable people: An alignment of research and clinical practice.

AIM: To stimulate discussion and debate about the inclusion of vulnerable populations in primary research to inform practice change and improve health outcomes. BACKGROUND: Current research practices to safeguard vulnerable people from potential harms related to power imbalances may in fact limit the generation of evidence-based practice. EVALUATION: The authors draw on their experience working and researching with a recognized group of vulnerable people, incarcerated pregnant women, to provide insight into the application of ethics in both research and clinical practice. In a novel approach, the ethical principles are presented in both contexts, articulating the synergies between them. Suggestions are presented for how individuals, managers and organizations may improve research opportunities for clinical practitioners and enhance the engagement of vulnerable people to contribute to meaningful practice and policy change. KEY ISSUES: Ethical practice guidelines may limit the ability to create meaningful change for vulnerable populations, who need authentic system change to achieve good health outcomes. CONCLUSION: Inclusive research and practice are essential to ensuring a strengths-based approach to healthcare and addressing health needs of the whole population. Health systems and models of care recognizing the diverse lives and health needs of the broader population demand practical, sustainable support from clinical managers. IMPLICATIONS FOR NURSING MANAGEMENT: Practical suggestions for clinical managers to support point of care research is provided, embedding vulnerable voices in policy, practice development and care provision.

Yarning as an Interview Method for Non-Indigenous Clinicians and Health Researchers.

In this article, we discuss the origins, epistemology, and forms of Yarning as derived from the literature, and its use in research and clinical contexts. Drawing on three Yarns, the article addresses the extent to which non-Indigenous researchers and clinicians rightfully use and adapt this information-gathering method, or alternatively, may engage in yet another form of what can be described as post-colonialist behavior. Furthermore, we argue that while non-Indigenous researchers can use Yarning as an interview technique, this does not necessarily mean they engage in Indigenous methodologies. As we note, respectfully interviewing Aboriginal and Torres Strait Islander peoples can be a challenge for non-Indigenous researchers. The difficulties go beyond differences in language to reveal radically different expectations about how relationships shape information giving. Yarning as a method for addressing cross-cultural clinical and research differences goes some way to ameliorating these barriers, but also highlights the post-colonial tensions.

Lost voices: Using a case study to illustrate narrative inquiry: Research brief.

INTRODUCTION: In this study, we tested the feasibility of using a narrative inquiry - three-dimensional space inquiry to elicit the experiences of an adult family member who shared her journey of care and advocacy for her husband situated in a dementia care unit. BACKGROUND: The voices of family members are rarely heard in relation to their experiences about being included in or making decisions about their loved one's care. Shared decision-making has been an important patient-centred approach to nursing care since the 1990s; however, it is often not a reality in aged care facilities. METHOD: An interview was conducted with one adult family member using the three-dimension space that is inspired by narrative theorists to analyse the narrative. RESULTS: Three themes were identified in the responses: communication between staff and family, staffing in the dementia care unit, and loss of voice and shared decision making. CONCLUSION: Results of this study indicate that narrative inquiry supports the telling of personal experiences around a problem and then using that information to raise awareness of those issues that are not always heard but which are essential for change in health care policy and practice.

Nurse navigators and person-centred care; delivered but not valued?

Positioning the individual at the centre of care (person-centred care [PCC]) is essential to improving outcomes for people living with multiple chronic conditions. However, research also suggests that this is structurally challenging because health systems continue to adopt long-standing, episodic care encounters. One strategy to provide a more cohesive, individualised approach to care is the implementation of the nurse navigator role. Current research shows that although PCC is a focus of navigation, such care may be hindered by the rigid, systematised health services providing siloed specialist care. In this paper, we utilised a case study method to investigate the experiences of a nurse navigator and patient. The nurse navigator and the patient participated in individual interviews, the transcripts of which were analysed using critical discourse analysis. Findings from a larger research project suggest that traditional measures (hospital avoidance, emergency department usage) which work as the service objectives of the nurse navigator service have the potential to stifle the delivery of PCC. The analysis from this case study supports the broader findings and further highlights the need for improved alignment between service objectives and the health and well-being of the individuals utilising the services.

Examining the hurdles in defining the practice of Nurse Navigators.

BACKGROUND: Nurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care. PURPOSE: A critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident. DISCUSSION: Nurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance. CONCLUSION: Nurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.

Nurses' views on workload, care rationing and work environments.

AIMS: The article examines nurses' experiences to institutionally enforced choices they must make regarding what patient care will be left undone. Cognitive dissonance theory is used to discuss how missed care is reconciled with the nurses' sense of professionalism and feelings of compassion. BACKGROUND: Research into missed nursing care and care rationing is increasing, with an awareness that it impacts on nurses' coping ability. METHODS: In-depth video and telephone interviews were conducted with four experienced nurses who were asked to describe how they made choices regarding required patient care and how they managed care under workload pressures. RESULTS: Thematic analysis of interview narratives revealed four key themes describing the experiences of nurses managing their work: compromising care; incongruity between professional standards and organisational resources; emotional exhaustion; and depersonalization. CONCLUSIONS: Nurses expressed concerns that their professional values regarding patient care are being lost in a quest to achieve financial targets. It raises questions regarding ethical and psychological dilemmas created for workers by work intensification. IMPLICATIONS FOR NURSING MANAGEMENT: Financial effectiveness negatively impacts on nurses' emotional and clinical well-being cannot be easily dismissed, given that cognitive dissonance arises from attempting to provide quality care of patients whilst meeting organisational financial targets.

Balancing the scales-Nurses' attempts at meeting family and employer needs in a work-intensified environment.

AIMS: This paper describes findings from a survey conducted in New Zealand exploring nurses' decision-making about when to delay care, delegate care, hand care over or leave care undone. Unanticipated findings identified processes that nurses go through when deciding to take planned/unplanned leave when wards are constrained through budget limitations. BACKGROUND: Missed/rationed care is increasingly the focus of attention in international studies, identifying a complex interplay of organisational, professional and personal factors affecting nurses' decision-making when faced with limited organisational time, human and material resources to provide care. METHODS: The survey presented nurses with Likert-scale questions with option for free text comments. This paper reports on the commentaries about work-life balance. RESULTS: Nurses described workload pressures that lead to rationing care affected them, and the long-term effect on them as individuals. Nurses verbalized the difficulties and associated guilt about taking leaving and sick leave when wards were short staffed. CONCLUSIONS: Nurses consider how their absence will affect the workspace and their home first, considering the impact on themselves last. IMPLICATIONS: The findings may provide valuable insights for nurse managers in relation to workforce allocations and resources where acknowledgement of work-life balance is considered.

Exploring the nurse navigator role: A thematic analysis.

BACKGROUND: Patients with complex chronic conditions experience fragmentation of care, unnecessary hospitalization and reduced quality of life, with an increased incidence of poor health outcomes. AIM(S): The aim of this paper was to explore how nurse navigators manage client care. This was achieved through an examination of narratives provided by the nurse navigator that evaluated their scope of practice. METHOD(S): All nurse navigators employed by Queensland Health were invited to participate in a study evaluating the effectiveness of the service. Eighty-four self-reported vignettes were thematically analysed to understand the work from the nurses' perspectives. RESULTS: Two themes emerged from the vignettes. Theme 1, the layers of complexity, is comprised of three sub-themes: the complex patient, the complex system and patient outcomes. Theme 2, professional attributes, has two sub-themes: person-centred care and clinical excellence. CONCLUSION: Navigators innovatively integrate services and address the fragmented nature of the health system. They apply expert clinical and social skills, through consistent and robust communication, to meet the needs of those with multiple chronic conditions. IMPLICATIONS FOR NURSING MANAGEMENT: Results provide insight into the new role, illuminating the work they achieve, despite system complexities.