Physiological plateaus during normal labor and birth: A novel definition.

BACKGROUND: Diagnoses of labor dystocia, and subsequent labor augmentation, make one of the biggest contributions to childbirth medicalization, which remains a key challenge in contemporary maternity care. However, labor dystocia is poorly defined, and the antithetical concept of physiological plateaus remains insufficiently explored. AIM: To generate a definition of physiological plateaus as a basis for further research. METHODS: This qualitative study applied grounded theory methods and comprised interviews with 20 midwives across Australia, conducted between September 2020 and February 2022. Data were coded in a three-phase approach, starting with inductive line-by-line coding, which generated themes and subthemes, and finally, through axial coding. RESULTS: Physiological plateaus represent a temporary slowing of one or multiple labor processes and appear to be common during childbirth. They are reported throughout the entire continuum of labor, typically lasting between a few minutes to several hours. Their etiology/function appears to be a self-regulatory mechanism of the mother-infant dyad. Physiological plateaus typically self-resolve and are followed by a self-resumption of labor. Women with physiological plateaus during labor appear to experience positive birth outcomes. DISCUSSION: Despite appearing to be common, physiological plateaus are insufficiently recognized in contemporary childbirth discourse. Consequently, there seems to be a significant risk of misinterpretation of physiological plateaus as labor dystocia. While findings are limited by the qualitative design and require validation through further quantitative research, the proposed novel definition provides an important starting point for further investigation. CONCLUSION: A better understanding of physiological plateaus holds the potential for a de-medicalization of childbirth through preventing unjustified labor augmentation.

How do professional connections and relationships impact midwives' well-being and career sustainability? A Grounded Theory study protocol.

Significant attrition and projected workforce shortages within the midwifery profession are global issues. Extensive research has identified that high levels of workplace adversity, chronic stress, and increasing rates of vicarious trauma and moral injury experienced by midwives, underpin this situation. Researchers have explored midwives' intention to stay in the midwifery workforce and identified ways to support students' transition to professional practice. Supportive collegial relationships have been reported to be protective for new and early career midwives' well-being and resilience. However, there is a gap in knowledge and understanding of the impact and significance of professional connections and relationships for midwives across their careers. This article describes a protocol for a study designed to explore and understand how professional connections and relationships impact midwives' well-being and career sustainability. Glaserian Grounded Theory (GT) methodology will be used to conduct the study. Constant comparison will be used to analyze data collected from in-depth interviews with midwives at various stages in their professional careers, with the aim of understanding the significance of professional connections and relationships on their well-being and career sustainability, and in understanding the potential protections and benefits. It is anticipated that the findings and theory generated from this study will have national and international implications and provide evidence about the impacts, including benefits and any potential disadvantages, of professional relationships in sustaining midwifery careers. This will be of significant value to, as well as inform, the development of midwife retention strategies.

Development of a Midwifery Student Peer Debriefing Tool: An interpretive descriptive study.

BACKGROUND: Psychosocial traumatisation associated with giving birth, can occur in those present with the woman giving birth, a phenomenon known as vicarious trauma. It has been identified that there are currently no interventions available for midwifery students who have experienced vicarious trauma following difficult birth experiences. OBJECTIVE: To explore whether the counselling intervention developed by Gamble et al. (2005), can be adapted for midwifery students to be appropriately and feasibly used as a counselling intervention with peers who have experienced midwifery practice-related vicarious trauma. DESIGN: Interpretive descriptive methodology. SETTING: This study was set at two Australian universities from which pre-registration midwifery courses are delivered. PARTICIPANTS: The work of reviewing the original tool and adapting it for use by and with midwifery students associated with this project was conducted by a key stakeholder group of seven representative midwifery students and five midwifery academics. METHODS: Ethics were approved. Data were collected via one face to face and two online conversations using the Microsoft Teams™ platform. Reflexive Thematic analysis were applied to revise the tool following each round of data collection and to finalise the adaptation of the intervention for its new intended purpose. RESULTS: The Midwifery Student Peer Debriefing Tool is presented as a six-step intervention that guides the midwifery student through a process of debriefing with their peer. The feasibility of the tool resulted in an overarching theme labelled "I want this to mean something" and captures the therapeutic power of peer debriefing toward a meaningful outcome that fostered growth, and a deeper understanding of the profession. CONCLUSION: Vicarious trauma is widely recognised as a core reason for midwives and midwifery students leaving the workforce. The peer debriefing tool helps midwifery students move through the process of recovering from adversity but also fostered learnings about midwifery practice and the profession.

Using the principles of practice development to address challenges in recruitment and data collection when face-to-face methods are unavailable.

BACKGROUND: Researchers conducting studies involving pregnant women often find recruitment challenging. The COVID-19 pandemic added further complexity to studies requiring face-to-face participation. AIM: To demonstrate how to maintain the principles of practice development (PD) when a study must switch from face-to-face to remote methods of collecting data. DISCUSSION: The number of participants in the authors' study increased when they moved from face-to-face to telephone engagement during the COVID-19 pandemic. They continued using PD principles when they changed method and the quality of the data they collected remained constant, even once lockdown restrictions were in place. CONCLUSION: PD principles can offer ways for nurse researchers to engage, collaborate with and reflect with people for research projects, including when constraints compete with participation. They can also assist researchers in optimising and maintaining recruitment and data collection when face-to-face research methods are impossible. IMPLICATIONS FOR PRACTICE: The telephone can be a valuable alternative medium for recruiting participants and collecting data when face-to-face methods are impossible to use. PD principles can be maintained and response rates and participation may even be greater when using it.

Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth.

BACKGROUND AND PROBLEM: During childbirth, one of the most common diagnoses of pathology is 'failure to progress', frequently resulting in labour augmentation and intervention cascades. However, failure to progress is poorly defined and evidence suggests that some instances of slowing, stalling and pausing labour patterns may represent physiological plateaus. AIM: To explore how midwives conceptualise physiological plateaus and the significance such plateaus may have for women's labour trajectory and birth outcome. METHODS: Twenty midwives across Australia participated in semi-structured interviews between September 2020 and February 2022. Constructivist grounded theory methodology was applied to analyse data, including multi-phasic coding and application of constant comparative methods, resulting in a novel theory of physiological plateaus that is firmly supported by participant data. FINDINGS: This study found that the conceptualisation of plateauing labour depends largely on health professionals' philosophical assumptions around childbirth. While the Medical Dominant Paradigm frames plateaus as invariably pathological, the Holistic Midwifery Paradigm acknowledges plateaus as a common and valuable element of labour that serves a self-regulatory purpose and results in good birth outcomes for mother and baby. DISCUSSION: Contemporary medicalised approaches in maternity care, which are based on an expectation of continuous labour progress, appear to carry a risk for a misinterpretation of physiological plateaus as pathological. CONCLUSION: This study challenges the widespread bio-medical conceptualisation of plateauing labour as failure to progress, encourages a renegotiation of what can be considered healthy and normal during childbirth, and provides a stimulus to acknowledge the significance of childbirth philosophy for maternity care practice.

Midwives' experiences of the consequences of navigating barriers to maternity care.

Midwives in Low- and middle-income countries, experience myriad barriers that have consequences for them and for maternity care. This article provides insight into the consequences of the barriers that Ghanaian midwives face in their workplaces. Glaserian Grounded Theory methodology using semi-structured interviews and non-participant observations was applied in this study. The study participants comprised of 29 midwives and a pharmacist, a social worker, a health services manager, and a National Insurance Scheme manager in Ghana. Data collection and analysis occurred concurrently while building on already analyzed data. In this study it was identified that barriers to Ghanaian midwives' ability to provide maternity care can have physiological, psychological, and socioeconomic consequences for midwives. It also negatively impacted maternity care. Implementing new ameliorating measures to mitigate the barriers that Ghanaian midwives encounter, and the consequences that those barriers have on them would improve midwife retention and care quality.

"I believe " - graduating midwifery students' midwifery philosophies and intentions for their graduate year: A longitudinal descriptive study.

OBJECTIVE: Midwifery graduates may experience transition shock that makes them question their fit for their workplace and the profession and in extreme cases, may lead to them leaving. Understanding graduate midwives' worldviews, job intentions and work experiences is important to inform retention strategies. Factors such as having a strong professional identity and experiencing strong job satisfaction are important for midwife retention. Conversely, stress, trauma and work-life imbalances are examples of factors that lead to attrition from midwifery. Transition shock experienced by some graduates can exacerbate these factors if not managed effectively. This study aimed to identify causes and impact of any changes in graduate and early career midwives' philosophy, practice, and intention to stay in the profession. DESIGN, SETTING AND PARTICIPANTS: We invited the 2021 and 2022 cohorts of graduating midwifery students from all educational pathways in Victoria, Australia to participate in a longitudinal descriptive study using a questionnaire with both closed and open -ended questions. This paper reports the findings from 16 participants that completed the first survey of a five-year longitudinal descriptive study. FINDINGS: The sixteen participants predominantly held a woman centred philosophy and ideally wanted to work in a midwife-led model of care. Although excited about moving into practice, they also disclosed a sense of needing to 'survive' in a maternity care system that their beliefs were not fully in alignment with. KEY CONCLUSIONS: The hopes, expectations and concerns of midwifery students who are anticipating moving into practice in this study resonate with those previously reported and demonstrate the need to consider personality-job fit in supporting this vulnerable group to transition. IMPLICATIONS FOR PRACTICE: This study provides insights into graduating midwives' hopes for, expectations of, and concerns about transitioning into practice that may inform the design of transition programs and support expansion of midwifery led models of care.

What is known about midwives' well-being and resilience? An integrative review of the international literature.

BACKGROUND: Internationally, the midwifery workforce is facing a professional crisis due to numerous organizational and individual factors that have led to midwives leaving the profession. These factors include high levels of workplace stress, systemic barriers to providing woman and person-centered care, trauma, and burnout. The COVID-19 pandemic magnified these pre-existing stressors and adversities and has further disrupted midwives' ability to practice within their professional norms. In order to understand how midwives can be better supported, there is a need to understand what contributes to and detracts from their well-being and resilience. AIM: To investigate and synthesize the extant international knowledge on midwives' well-being and resilience in the context of workplace stress and adversity. METHOD: Integrative review of the literature published in peer-reviewed journals. RESULTS: Thematic analysis of the literature resulted in three core themes: (1) risk factors and adversity; (2) protective factors and resilience; and (3) sustaining factors and well-being in midwifery. Findings from this integrated review highlight that several factors associated with workplace adversity can also be sources of protection depending on their presence or absence. Within the included studies, there exists a broad use of concepts and definitions that are applied to well-being and resilience, resulting in a lack of uniformity and cohesion. CONCLUSIONS: In this review, we identified a high level of workplace adversity and the subsequent impacts on midwives' well-being and resilience. A series of protective factors and strategies that can be used to improve the well-being of midwives and support resilience within the profession were also identified; however, further research of the population is required. In addition, the development of cohesive well-being and resilience concepts specific to midwifery is recommended, as is the development and application of uniform terminologies and definitions.

Working with private hospital midwives in Victoria, Australia to identify practice change priorities: Outcomes of a Delphi study.

OBJECTIVE/AIM: In this study, we invited midwives working at one metropolitan private hospital in Victoria, Australia to identify their workplace change needs and priorities for research. METHODS: In this two-round Delphi study, all midwifery staff within the maternity unit of a private hospital in Melbourne, Australia were invited to participate. In round one, participants joined face-to-face focus groups to put forward their ideas for workplace change and research ideas, and these data were developed into themes. In round two, participants ranked the themes in priority order. FINDINGS: The top four themes identified by this cohort of midwives were: 'Ways of working - investigating alternate ways of working to enable greater flexibility and opportunities'; 'Understanding midwifery - working with the executive team to highlight the nuances of maternity care'; 'Education - increase in staff in the education team to provide a greater presence and opportunity for education'; and 'Postnatal specific - review ways of working in postnatal areas'. KEY CONCLUSIONS: A number of priority research and change areas were identified which, if implemented, would strengthen both midwifery practice and midwife retention in this workplace. The findings will be of interest to midwife managers. Further research to evaluate the process and success of implementing the actions identified in this study would be valuable.

Women's views on obstetric fistula risk factors and prevention in north-central Nigeria: an interpretive descriptive study.

OBJECTIVE: Obstetric fistula, also known as vesicovaginal fistula or rectovaginal fistula, is an abnormal opening between the vagina and rectum caused by prolonged obstructed labour that causes substantial long-term harm to women. It is most prevalent in low resource settings and although preventative measures have been proposed, they have not, to date, taken women's own views into account. The objective of this study was to explore the views of North Nigerian women on obstetric fistula risk factors and prevention. DESIGN: This study was conducted using Interpretive Description methodology, which is a qualitative approach underpinned by Symbolic Interactionism. A semistructured questionnaire was used to explore the views of 15 women living with obstetric fistula about risk factors and prevention of the condition. Data were collected in one-to-one in-depth interviews conducted between December 2020 and May 2021. All interviews were audio-recorded and transcribed verbatim, and a thematic approach to data analysis was employed. SAMPLING AND SETTING: The setting for this study was a fistula repair centre in north-central Nigeria. The sample was formed of a purposively selected 15 women who had experienced obstetric fistula at a repair Centre in north-central Nigeria. RESULTS: Four core themes emerged from women's views on obstetric fistula risk factors and prevention: (1) Women's autonomy, (2) Economic empowerment, (3) Infrastructure/transportation and (4) Provision of skilled healthcare services. CONCLUSION: The findings from this study highlight previously unknown women's views on obstetric fistula risk factors and prevention in north-central Nigeria. Analysis of insights from women's voices directly affected by obstetric fistula demonstrated that in their views and experiences, giving women autonomy (decision-making power) to choose where to birth safely, economic empowerment, enhancement of transportation/infrastructure and provision of skilled healthcare services may mitigate obstetric fistula in Nigeria.

North-central Nigerian women's experiences of obstetric fistula risk factors and their perceived treatment services: An Interpretive Description.

BACKGROUND: An obstetric fistula also known as vesico vaginal fistula (VVF), or recto-vaginal fistula (RVF) is an abnormal opening between the urogenital tract and intestinal tract caused by prolonged obstructed labour; when the head of the baby presses on the soft tissues in the pelvis leading to loss of blood flow to the women's bladder, vagina, and rectum. This can cause necrosis of the soft tissues resulting in debilitating fistula formations. AIM: This study aimed to uncover North-central Nigerian women's experiences of obstetric fistula and their perceived treatment services. DESIGN: Qualitative, interpretive descriptive methodology underpinned by symbolic interactionism involving face-to-face semi-structured interviews was used to explore North-central Nigerian women's experiences of obstetric fistula and their perceived treatment services. SAMPLE: A purposive sample of 15 women who had experienced obstetric fistula at a repair Centre in North-central Nigeria were eligible. RESULTS: Four themes emerged from North-central Nigerian women's experiences of obstetric fistula and their perceived treatment services i) I was left alone in the room ii) Waiting for the one vehicle in the village iii) I never knew about labour until that very day iv) and We kept following the native doctors and sorcerers. CONCLUSION: The findings from this study highlighted the depth of women's experiences from the devastating complication of childbirth injury in North-central Nigeria. Analysis of insights from women's voices directly affected by obstetric fistula demonstrated that in their views and experiences the themes identified were majorly responsible for their fistula status. Thus women need to raise their collective voices to resist oppressive harmful traditions and demand empowerment opportunities that will improve their social status. Government should improve primary healthcare facilities, train more midwives and subsidise maternal care for antenatal education and birth services spending for childbirth women may result in improved childbirth experiences for women in rural and urban communities. TWEETABLE ABSTRACT: Reproductive women call for increased accessibility to healthcare services and the provision of more midwives to mitigate obstetric fistula in North-central Nigerian communities.

Development of a tool to identify barriers and enablers to practice innovation in midwifery: A participatory action research study.

INTRODUCTION: Transferring research evidence into midwifery practice is fraught with challenges and obstacles. Implementation tools can streamline the process and are most effective when they are discipline-specific; however, there are currently no midwifery specific implementation tools. The aim of this study was to develop a midwifery specific tool to identify barriers and enablers to evidence-informed practice change within the clinical setting. METHODS: Participatory action research methodology was employed to ensure potential end-users contributed to content and format of the tool. Purposeful sampling ensured participants were selected from a range of midwifery practice settings in Western Australia and the United Kingdom. Data were collected through stakeholder advisory groups (SAGs) and online surveys. RESULTS: Ten midwives participated in this project. Consultation occurred through face-to-face SAG meetings and online surveys until consensus was reached among participants about the content, format, and functionality of the end product which we called the 'Midwifery Tool for Change' (MT4C). CONCLUSIONS: To our knowledge, the MT4C is the first readiness for change context assessment tool specific to midwifery practice settings. Evaluation of the MT4C in real-world practice change implementation initiatives will enable further refinement of the tool.

How should online antenatal and parenting education be structured according to parents? Qualitative findings from a mixed-methods retrospective study.

BACKGROUND: Over the past 50 years, the content and structure of antenatal education classes have varied to reflect social norms of the time, the setting and context in which they have been held and who has facilitated them. In recent times, antenatal and parenting education classes have become a smorgasbord of information, offering a range of diverse content. Where and how parents-to-be may access formal antenatal and parenting education classes are also varied. Even before the lockdown challenges of the Covid-19 pandemic, many antenatal and parenting education classes had become available and accessible online. While the flexibility and accessibility of this option are apparent, scant research to date has reported on parents' experiences of undertaking online antenatal education. OBJECTIVES: The objectives of this study were to explore new parents' experiences of engaging in online antenatal education, and to discover how consumers of online antenatal education perceive it should be designed and delivered. DESIGN/METHODS: A mixed-methods design was used for this study, which was conducted with 294 past enrolees in a range of online antenatal and early parenting education programmes delivered by one private provider in Australia. The past enrolees were invited to participate in the study by email, wherein a link to an online information sheet and survey containing closed- and open-ended questions was provided. The responses to the open-ended questions that are reported in this article were analysed using a thematic approach that involved coding, sub-categorizing and then categorizing the data. RESULTS: A total of 108 participants provided qualitative data about the delivery and design of online antenatal education and information. The data were captured in three themes: video control and content, accessibility and pre-/intra-programme support. CONCLUSIONS: The results of this study provide important insights for the development of online antenatal education programmes and courses that will be of interest to antenatal educators, maternity services and maternity care policy developers. Specifically, millennial parents want trustworthy and accurate antenatal education that is delivered in a framework that aligns with and builds on adult-learning principles. The diversity of families and of expectant parents' learning styles is also important to recognize in antenatal education curricula.

Approaches to clinical guideline development in healthcare: a scoping review and document analysis.

BACKGROUND: Over the past decade, an industry has emerged around Clinical Practice Guideline (CPG) development in healthcare, which has increased pressure on guideline-producing organisations to develop CPGs at an accelerated rate. These are intended to improve the quality of care provided to patients while containing healthcare costs and reducing variability in clinical practice. However, this has inadvertently led to discrepancies in CPG recommendations between health organisations, also challenging healthcare providers who rely on these for decision-making and to inform clinical care. From a global perspective, although some countries have initiated national protocols regarding developing, appraising and implementing high-quality CPGs, there remains no standardised approach to any aspect of CPG production. METHODS: A scoping review of the literature and document analysis were conducted according to Joanna Brigg's Institute methodology for scoping reviews. This comprised two qualitative methods: a comprehensive review of the literature (using CINAHL, Scopus and PubMeD) and a document analysis of all national and international guideline development processes (manual search of health-related websites, national/international organisational health policies and documents). RESULTS: A set of clear principles and processes were identified as crucial to CPG development, informing the planning, implementation and dissemination of recommendations. Fundamentally, two common goals were reported: to improve the quality and consistency of clinical practice (patient care) and to reduce the duplication or ratification of low-grade CPGs. CONCLUSIONS: Consultation and communication between CPG working parties, including a wide range of representatives (including professional organisations, regional and local offices, and relevant national bodies) is essential. Further research is required to establish the feasibility of standardising the approach and disseminating the recommendations.

Building the plane while it's flying: implementation lessons from integrating a co-located exercise clinic into oncology care.

BACKGROUND: Despite its therapeutic role during cancer treatment, exercise is not routinely integrated into care and implementation efforts are largely absent from the literature. The aim of this study was to evaluate a strategy to integrate the workflow of a co-located exercise clinic into routine care within a private oncology setting in two clinics in the metropolitan region of Western Australia. METHODS: This prospective evaluation utilised a mixed methods approach to summarise lessons learned during the implementation of an integrated exercise workflow and supporting implementation plan. Data collection was informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Reports detailing utilisation of the exercise service and its referral pathways, as well as patient surveys and meeting minutes documenting the implementation process informed the evaluation. RESULTS: The co-located exercise service achieved integration into routine care within the clinical oncology setting. Patient utilisation was near capacity (reach) and 100% of clinicians referred to the service during the 13-month evaluation period (adoption). Moreover, ongoing adaptations were made to improve the program (implementation) and workflows were integrated into standard operating practices at the clinic (maintenance). The workflow performed as intended for ~70% of exercise participants (effectiveness); however, gaps were identified in utilisation of the workflow by both patients and clinicians. CONCLUSION: Integration of exercise into standard oncology care is possible, but it requires the ongoing commitment of multiple stakeholders across an organisation. The integrated workflow and supporting implementation plan greatly improved utilisation of the co-located exercise service, demonstrating the importance of targeted implementation planning. However, challenges regarding workflow fidelity within and across sites limited its success highlighting the complexities inherent in integrating exercise into clinical oncology care in a real-world setting.

Sub-Saharan African women's views and experiences of risk factors for obstetric fistula: a qualitative systematic review.

BACKGROUND: Obstetric fistula used as synonymous with VVF in this study, is an abnormal communication/hole between the urinary tract and the genital tract or the gastrointestinal tract and the genital tract, resulting from prolonged obstructed labour. VVF may cause sufferers to experience chronic urinary/faecal incontinence, and the stigma of continuing foul odour. VVF is primarily caused by prolonged obstructed labour, which is brought about by a range of causes. Recently, it has been proposed that women's groups and fistula survivors should suggest interventions to reduce or prevent the incidence of obstetric fistula. OBJECTIVE: The objective of this review was to synthesise what is reported about women's views and experiences of the risk factors underlying the causes of VVF. METHODS: A systematic approach outlined in the Joanna Briggs Institute Manual for Evidence synthesis was followed for this review, articles published since the last 11 years from 2011 to 2021 were selected against several criteria and critically appraised using JBI Critical Appraisal Checklist for qualitative studies. RESULTS: Nine studies were retained for inclusion in this review and the data were then synthesised into five themes: (1) Cultural beliefs and practices impeding safe childbirth, (2) Lack of woman's autonomy in choices of place to birth safely, (3) Lack of accessibility and social support to safe childbirth, (4) Inexperienced birth attendants and, (5) Delayed emergency maternal care (childbirth). CONCLUSIONS: This review highlights the complexity of risk factors predisposing women to the known causes of VVF. It also illuminates the absence of women's voices in the identification of solutions to these risks. Women are most directly affected by VVF. Therefore, their knowledge, views, and experiences should be considered in the development and implementation of strategies to address the issue. Exploring women's views on this issue would enable the identification of gaps in maternity care provision, which would be of interest to community and health service leaders as well as policymakers in Sub-Saharan Africa.

Communication surrounding initiation and withdrawal of non-invasive ventilation in adults with motor neurone disease.

BACKGROUND: Motor neurone disease causes respiratory weakness that can lead to death. While non-invasive ventilation relieves symptoms, there are complex issues to consider prior to commencement. AIM: To identify what is known and understood about the clinician communication of non-invasive ventilation by people with motor neurone disease. METHOD: The Joanna Briggs Institute approach to systematic reviews was followed for literature retrieval and selection. DATA SOURCES: Research literature published between 1990-2019 in English from the Medline, CINAHL, ProQuest Research Library and the Cochrane Library of Systematic Reviews databases were used. RESULTS: A total of two themes emerged: communication challenges doctors face when discussing non-invasive ventilation withdrawal, and the importance of well-timed, effective communication by clinicians-specifically the influence clinicians have on family decision-making. CONCLUSIONS: Guidance on communications around palliative care, non-invasive ventilation introduction and withdrawal exist, however implementation is often not straightforward. Research into the communication surrounding non-invasive ventilation from those living with motor neuron disease, their families and clinicians is required to inform guideline implementation and practice.

What are the benefits and challenges of mentoring in midwifery? An integrative review.

AIM: The aim of this review was to synthesize best available evidence on mentoring programmes for midwives who have worked within the clinical setting for more than 1 year. BACKGROUND: Lack of job satisfaction, stress, burnout and limited managerial support contributes to midwifery workforce attrition and the ongoing global shortage of midwives. Mentoring may be one way to improve staff retention, leading to positive clinical and organizational outcomes. DESIGN: A five-step integrative review approach, based on a series of articles published by the Joanna Briggs Institute for conducting systematic reviews, was used to develop a search strategy, selection criteria, method for quality appraisal and the extraction and synthesis of data. METHODS: Relevant articles were sought from the following databases: Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, MIDIRS and Scopus. The search and screening process was guided by the Preferred Reporting Items for Systematic Reviews and Meta Analysis 2009 checklist. Narrative analysis was used to develop four main categories derived from the results from the included studies. RESULTS: Eight studies were included in this review from which four themes were developed that are relevant to mentoring in midwifery; the impact on midwives' direct environment, their immediate relationships with peers and management, and the overarching influence of the organization directly impact the accessibility and support midwives receive in mentoring programmes. CONCLUSION: To enhance staff retention in the workforce, midwives require support from the wider organization in which they work. RELEVANCE TO CLINICAL PRACTICE: Understanding midwives' perspectives of mentoring programmes will directly influence the development of midwifery-specific mentoring programmes, which may lead to improved staff retention in the midwifery workforce.

Nursing in a different world: Remote area nursing as a specialist-generalist practice area.

OBJECTIVE: Remote area nurses provide primary health care services to isolated communities across Australia. They manage acute health issues, chronic illness, health promotion and emergency responses. This article discusses why their generalist scope of practice should be formally recognised as a specialist nursing practice area. DESIGN: Constructivist grounded theory, using telephone interviews (n = 24) with registered nurses and nurse practitioners. SETTING: Primary health care clinics, in communities of 150-1500 residents across Australia. PARTICIPANTS: A total of 24 nurses participated in this study. RESULTS: Nurses' perceived their clinical knowledge and skill as insufficient for the advanced, generalist, scope of practice in the remote context, especially when working alone. Experience in other settings was inadequate preparation for working in remote areas. Knowledge and skill developed on the job, with formal learning, such as nurse practitioner studies, extending the individual nurse's scope of practice to meet the expectations of the role, including health promotion. CONCLUSION: Remote area nursing requires different knowledge and skills from those found in any other nursing practice setting. This study supports the claim that remote area nursing is a specialist-generalist role and presents a compelling case for further examination of the generalist education and support needs of these nurses. Combined with multidisciplinary collaboration, developing clinical knowledge and skill across the primary health care spectrum increased the availability of health resources and subsequently improved access to care for remote communities. Further research is required to articulate the contemporary scope of practice of remote area nurses to differentiate their role from that of nurse practitioners.