The barometer of moral distress in midwifery: A pilot study.

BACKGROUND: Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery. AIM: The aim of this study was to pilot the Barometer of Moral Distress in Midwifery. METHODS: This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity. FINDINGS: A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores. DISCUSSION/CONCLUSION: This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress.

Exploring moral distress in Australian midwifery practice.

PROBLEM: Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice. BACKGROUND: Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals' moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice. AIM: To explore Australian midwives experience and consequences of moral distress. METHODS: Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©. FINDINGS: Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care. DISCUSSION: It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding. CONCLUSION: This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.

Moral distress in midwifery practice: A concept analysis.

Research suggests that the incidence of moral distress experienced by health professionals is significant and increasing, yet the concept lacks clarity and remains largely misunderstood. Currently, there is limited understanding of moral distress in the context of midwifery practice. The term moral distress was first used to label the psychological distress experienced following complex ethical decision-making and moral constraint in nursing. The term is now used across multiple health professions including midwifery, nursing, pharmacy and medicine, yet is used cautiously due to confusion regarding its theoretical and contextual basis. The aim of this study is to understand the concept of moral distress in the context of midwifery practice, describing the attributes, antecedents and consequences. This concept analysis uses Rodgers' evolutionary framework and is the first stage of a sequential mixed-methods study. A literature search was conducted using multiple databases resulting in eight articles for review. Data were analysed using NVivo12©. Three core attributes were identified: moral actions and inactions, conflicting needs and negative feelings/emotions. The antecedents of clinical situations, moral awareness, uncertainty and constraint were identified. Consequences of moral distress include adverse personal professional and organisational outcomes. A model case depicting these aspects is presented. A midwifery focused definition of moral distress is offered as 'a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments'. This concept analysis affirms the presence of moral distress in midwifery practice and provides evidence to move towards a consistent definition of moral distress.

Midwifery students experience of continuity of care: A mixed methods study.

BACKGROUND: Continuity of Care Experiences are a mandated component of Australian midwifery programs leading to registration. Despite research evidence of the benefits of Continuity of Care Experiences for student learning and for women, there is limited evidence on the personal impact of this experience to students. Additionally, there is limited guidance on how to best support students to successfully complete this valuable component of their program. OBJECTIVE: To identify the emotional, psychological, social and financial costs of undertaking the Continuity of Care Experience component of a midwifery program and to provide information which may lead to educational strategies within CoCE aimed to improve student support and alleviate challenges. DESIGN: Using surveys and diary entries, a convergent parallel mixed methods approach was used to collect qualitative and quantitative data concurrently. Descriptive statistics were used to analyse financial cost, and clinical, travel and wait times. A constant comparative analysis was used for qualitative data about student's Continuity of Care Experiences. Integrative analysis was used to reconstruct the two forms of data. SETTING: Two Australian universities offering Bachelor of Midwifery programs. PARTICIPANTS: Seventy students completed the demographic survey and 12 students submitted 74 diaries describing 518 episodes of care. There was a response rate of 18% recorded. FINDINGS: Analysis identified four themes: perception of Continuity of Care Experiences; personal safety; impact on self and family; and professional relationships. The mean time spent per completed experience was 22.20 hours and the mean cost was $367.19. Although students found Continuity of Care Experiences to be a valuable learning experience, they identified numerous factors including time, money, and personal circumstances that impacted on their ability to successfully meet the requirements. IMPLICATIONS FOR PRACTICE: Continuity of Care Experiences are a highly valuable, but often challenging component of midwifery education in Australia. Using a model of social interdependence, students, educators and maternity care providers may engage better with the process and philosophies of CoCE.

Linking Out Loud (LOL): Developing critical thinking.

This article was migrated. The article was marked as recommended. Background: Developing critical thinking in health care education is pivotal in student development and patient outcomes. Gamification and learning through play within health care education is rising in popularity and may assist to develop problem-solving and critical thinking skills. Aim: To develop and enhance students' capacity to rapidly recall and communicate critical links in practice through a modified 'snap' game. Method: Students are provided decks of cards depicting clinical pictures (syringe, bath, blood, medications etc). Turning over two cards at a time, the students race to link the two concepts together. Findings: Linking Out Loud was well received by students and worked to develop knowledge, critical thinking, communication and problem-solving. Linking Out Loud could be easily replicated for all health disciplines.

Quality improvement collaborative: A novel approach to improve infection prevention and control. Perceptions of lead infection prevention nurses who participated.

BACKGROUND: In response to the ongoing infection prevention (IP) challenges in England, a 90-day quality improvement (QI) collaborative programme was developed. The paper discusses the approach, benefits, challenges and evaluation of the programme. OBJECTIVE: The objective of the collaborative was to develop new approaches to enable sustainable and effective IP. METHODOLOGY: Six trusts in the region participated in the collaborative. Each defined their bespoke IP focus. There was no expectation that statistically significant measurable improvements would be identified during the short time frame. The experiences of the participants were sought both during the programme to facilitate its constant review and at the end of the programme to evaluate its effectiveness. The feedback focused on achievements, barriers to change and benefits of participating in a QI collaborative. To measure the potential success of the projects, participants completed the Model for Understanding Success in Quality framework. (MUSIQ; Kaplan et al., 2012). RESULTS: Since each trusts IP focus was bespoke commonalities of success were not evaluated. Participants identified a positive outcome from their QI interventions. The MUSIQ score identified the projects had the potential for success. DISCUSSION: The feedback from the participants demonstrated that it is worthy of further development.

International trends in health science librarianship Part 9: the UK - Scotland and Wales.

This is the 9th in a series of articles exploring international trends in health science librarianship. The previous article in this series looked at Northern Ireland and the Republic of Ireland. In this issue the focus is Scotland and Wales. There will be three or four more articles this year tracking trends in the Far East, Africa, South Asia and the Middle East. JM.

What can zookeepers tell us about interacting with big cats in captivity?

Despite the potential dangers involved, interactions between zookeepers and captive big cats are increasing. Research with other animals, particularly nonhuman primates, suggests that closer interactions can be beneficial not only for the animals and their keepers, but also for zoo visitors. This study sought to determine whether the same benefits may apply to keeper-big cat interactions. An online questionnaire was completed by 86 keepers worldwide, assessing which types of handling (hands-on, protected, hands-off) they practice with their big cats, whether they practice training, and what their opinions of these methods are (through a series of rating scales and open-ended questions). Protected contact was the most frequently used handling method among this sample, particularly with lions, tigers, and cheetahs, and training was practiced by the majority of participants with all big cat species. Participants perceived protected contact as the most beneficial handling practice for big cats, keepers, and visitors, noting how it can allow a close bond between keeper and cat, as well as its educational value for zoo visitors. Contrastingly, concerns were raised about the use of hands-on approaches, particularly with regard to the safety of all parties involved and the potential for wrong messages to be sent to visitors. Further, training was reported to be more beneficial for each group than any handling practice, yielding similar potential benefits as protected contact. Consistent with existing information with other species, these findings will be useful in directing objective research examining the use of different handling and training methods with big cats.

Patient characteristics associated with venous thromboembolic events: a cohort study using pooled electronic health record data.

OBJECTIVE: To demonstrate the potential of de-identified clinical data from multiple healthcare systems using different electronic health records (EHR) to be efficiently used for very large retrospective cohort studies. MATERIALS AND METHODS: Data of 959 030 patients, pooled from multiple different healthcare systems with distinct EHR, were obtained. Data were standardized and normalized using common ontologies, searchable through a HIPAA-compliant, patient de-identified web application (Explore; Explorys Inc). Patients were 26 years or older seen in multiple healthcare systems from 1999 to 2011 with data from EHR. RESULTS: Comparing obese, tall subjects with normal body mass index, short subjects, the venous thromboembolic events (VTE) OR was 1.83 (95% CI 1.76 to 1.91) for women and 1.21 (1.10 to 1.32) for men. Weight had more effect then height on VTE. Compared with Caucasian, Hispanic/Latino subjects had a much lower risk of VTE (female OR 0.47, 0.41 to 0.55; male OR 0.24, 0.20 to 0.28) and African-Americans a substantially higher risk (female OR 1.83, 1.76 to 1.91; male OR 1.58, 1.50 to 1.66). This 13-year retrospective study of almost one million patients was performed over approximately 125 h in 11 weeks, part time by the five authors. DISCUSSION: As research informatics tools develop and more clinical data become available in EHR, it is important to study and understand unique opportunities for clinical research informatics to transform the scale and resources needed to perform certain types of clinical research. CONCLUSIONS: With the right clinical research informatics tools and EHR data, some types of very large cohort studies can be completed with minimal resources.

Hypertrophic osteopathy associated with pulmonary Eikenella corrodens infection in a dog.

CASE DESCRIPTION: A 4-year-old English Pointer was examined because of chronic, progressive signs of pulmonary disease and failure to respond to medical treatment. CLINICAL FINDINGS: At examination, radiography of the thorax revealed increased pulmonary opacity and air bronchograms in the right caudal lung lobe, and radiography of the forelimbs revealed periosteal bone production typical of hypertrophic osteopathy. Attempts to isolate a causative organism included bacterial culture of bronchoalveolar lavage fluid and a lung tissue specimen obtained via fine-needle aspiration. Despite a cytologic diagnosis of septic suppurative inflammation in the lavage fluid, those specimens did not yield bacterial growth. However, a biopsy specimen obtained during a lung lobectomy procedure yielded growth of Eikenella corrodens. TREATMENT AND OUTCOME: Despite successful surgical removal of the consolidated lung lobe and initiation of antimicrobial treatment, the dog died 6 days after surgery. CLINICAL RELEVANCE: The authors are not aware of reports of pulmonary infection with E. corrodens in animals. Infection with the organism is rare, but it is possible that infections are underreported given that the organism is difficult to culture and biopsy may be necessary to obtain enough tissue to yield a diagnosis.

Covalently closed circular DNA is the predominant form of duck hepatitis B virus DNA that persists following transient infection.

Residual hepatitis B virus (HBV) DNA can be detected in serum and liver after apparent recovery from transient infection. However, it is not known if this residual HBV DNA represents ongoing viral replication and antigen expression. In the current study, ducks inoculated with duck hepatitis B virus (DHBV) were monitored for residual DHBV DNA following recovery from transient infection until 9 months postinoculation (p.i.). Resolution of DHBV infection occurred in 13 out of 15 ducks by 1-month p.i., defined as clearance of DHBV surface antigen-positive hepatocytes from the liver and development of anti-DHBV surface antibodies. At 9 months p.i., residual DHBV DNA was detected using nested PCR in 10/11 liver, 7/11 spleen, 2/11 kidney, 1/11 heart, and 1/11 adrenal samples. Residual DHBV DNA was not detected in serum or peripheral blood mononuclear cells. Within the liver, levels of residual DHBV DNA were 0.0024 to 0.016 copies per cell, 40 to 80% of which were identified as covalently closed circular viral DNA by quantitative PCR assay. This result, which was confirmed by Southern blot hybridization, is consistent with suppressed viral replication or inactive infection. Samples of liver and spleen cells from recovered animals did not transmit DHBV infection when inoculated into 1- to 2-day-old ducklings, and immunosuppressive treatment of ducks with cyclosporine and dexamethasone for 4 weeks did not alter levels of residual DHBV DNA in the liver. These findings further characterize a second form of hepadnavirus persistence in a suppressed or inactive state, quite distinct from the classical chronic carrier state.

Effect of antiviral treatment with entecavir on age- and dose-related outcomes of duck hepatitis B virus infection.

Entecavir (ETV), a potent inhibitor of the hepadnaviral polymerases, prevented the development of persistent infection when administered in the early stages of duck hepatitis B virus (DHBV) infection. In a preliminary experiment, ETV treatment commenced 24 h before infection showed no significant advantage over simultaneous ETV treatment and infection. In two further experiments 14-day-old ducks were inoculated with DHBV-positive serum containing 10(4), 10(6), 10(8), or 5 x 10(8) viral genomes (vge) and were treated orally with 1.0 mg/kg of body weight/day of ETV for 14 or 49 days. A relationship between virus dose and infection outcome was seen: non-ETV-treated ducks inoculated with 10(4) vge had transient infection, while ducks inoculated with higher doses developed persistent infection. ETV treatment for 49 days did not prevent initial infection of the liver but restricted the spread of infection more than approximately 1,000-fold, a difference which persisted throughout treatment and for up to 49 days after withdrawal. Ultimately, three of seven ETV-treated ducks resolved their DHBV infection, while the remaining ducks developed viremia and persistent infection after a lag period of at least 63 days. ETV treatment for 14 days also restricted the spread of infection, leading to marked and sustained reductions in the number of DHBV-positive hepatocytes in 7 out of 10 ducks. In conclusion, short-term suppression with ETV provides opportunity for the immune response to successfully control DHBV infection. Since DHBV infection of ducks provides a good model system for HBV infection in humans, it seems likely that ETV may be useful in postexposure therapy for HBV infection aimed at preventing the development of persistent infection.

Entecavir therapy combined with DNA vaccination for persistent duck hepatitis B virus infection.

This study was designed to test the efficacy of antiviral treatment with entecavir (ETV) in combination with DNA vaccines expressing duck hepatitis B virus (DHBV) antigens as a therapy for persistent DHBV infection in ducks. Ducks were inoculated with 10(9) DHBV genomes at 7 days of age, leading to widespread infection of the liver and viremia within 7 days, and were then treated orally with either ETV (0.1 mg/kg of body weight/day) or distilled water from 21 days posthatch for 244 days. Treatment with ETV caused a 4-log drop in serum DHBV DNA levels within 80 days and a slower 2- to 3-log drop in serum DHBV surface antigen (DHBsAg) levels within 120 days. Following withdrawal of ETV, levels of serum DHBV DNA and DHBsAg rebounded to match those in the water-treated animals within 40 days. Sequential liver biopsy samples collected throughout the study showed that ETV treatment reduced DHBV DNA replicative intermediates 70-fold in the liver, while the level of the stable, template form, covalently closed circular DNA decreased only 4-fold. ETV treatment reduced both the intensity of antigen staining and the percentage of antigen-positive hepatocytes in the liver, but the intensity of antigen staining in bile duct cells appeared not to be effected. Intramuscular administration of five doses of a DNA vaccine expressing the DHBV presurface, surface, precore, and core antigens, both alone and concurrently with ETV treatment, on days 50, 64, 78, 127, and 141 did not result in any significant effect on viral markers.