Admission Decision-Making in Hospital Emergency Departments: The Role of the Accompanying Person.

In resource-stretched emergency departments, people accompanying patients play key roles in patients' care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used an ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 health care professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals' standardization of the patient-carer relationship contrasted with accompanying persons' varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients' care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relationship with the patients. Taking a relationship-centered approach could improve the attention to accompanying persons as co-producers of health care and participants in decision-making.

The long-term health and wellbeing impacts of Healthy New Towns (HNTs): protocol for a baseline and feasibility study of HNT demonstrator sites in England.

BACKGROUND: Increasing levels of non-communicable diseases (NCDs), mental health problems, high rates of unhealthy behaviours and health inequalities remain major public health challenges worldwide. In the context of increasing urbanisation, there is an urgent need to understand how evidence that living environments shape health, wellbeing and behaviour can be used to design and deliver healthy environments in local urban settings. The Healthy New Town (HNT) programme implemented in England from 2015 consists of ten major housing developments that aim to improve population health through healthy design principles, new models for integrating health and social care and the creation of strong and connected communities. The programme provides a natural experiment in which to investigate the effects on health, wellbeing and inequalities of large-scale interventions targeting the wider social determinants of health. METHODS: The research described in this protocol aims to examine the feasibility of a larger study to assess the longer-term health impacts of HNTs, by addressing two research questions: (1) what are the similarities and differences in the HNT programme developments, processes, contexts and expected impacts and outcomes across HNT sites? and (2) how feasible is the use of data from routine sources and existing HNT evaluations and as the baseline for a definitive study to assess impact on health, wellbeing, behavioural and economic outcomes and programme processes? The research will consist of (a) participatory systems mapping with stakeholders to produce a theoretical framework for a longer-term study on the HNT programme, (b) synthesis of existing qualitative data from local HNT evaluations to understand local processes and intervention mechanisms, (c) scoping local and routinely available data to establish a baseline and feasibility for a longer-term study of health and economic outcomes, and (d) building relationships and recruiting HNT sites into the proposed research. DISCUSSION: The proposed research will produce a theoretical framework and assess the feasibility of a definitive study of outcomes of the HNT programme. This research is necessary to understand how longer-term health, wellbeing, behavioural and economic outcomes can be measured, and to inform a definitive study to generate evidence on the effectiveness of the HNT programme.

Barriers to women's access to alongside midwifery units in England.

BACKGROUND: Alongside midwifery units (AMUs) are managed by midwives and proximate to obstetric units (OUs), offering a home-like birth environment for women with straightforward pregnancies. They support physiological birth, with fast access to medical care if needed. AMUs have good perinatal outcomes and lower rates of interventions than OUs. In England, uptake remains lower than potential use, despite recent changes in policy to support their use. This article reports on experiences of access from a broader study that investigated AMU organisation and care. METHODS: Organisational case studies in four National Health Service (NHS) Trusts in England, selected for variation geographically and in features of their midwifery units. Fieldwork (December 2011 to October 2012) included observations (>100 h); semi-structured interviews with staff, managers and stakeholders (n = 89) and with postnatal women and partners (n = 47), on which this paper reports. Data were analysed thematically using NVivo10 software. RESULTS: Women, partners and families felt welcome and valued in the AMU. They were drawn to the AMUs' environment, philosophy and approach to technology, including pain management. Access for some was hindered by inconsistent information about the existence, environment and safety of AMUs, and barriers to admission in early labour. CONCLUSIONS: Key barriers to AMUs arise through inequitable information and challenges with admission in early labour. Most women still give birth in obstetric units and despite increases in the numbers of women birthing on AMUs since 2010, addressing these barriers will be essential to future scale-up.

Organising safe and sustainable care in alongside midwifery units: Findings from an organisational ethnographic study.

AIMS AND BACKGROUND: Alongside midwifery units (AMUs, also known as hospital or co-located birth centres) were identified as a novel hybrid organisational form in the Birthplace in England Research Programme. This follow-on study aimed to investigate how AMUs are organised, staffed and managed, the experiences of women, and maternity staff including those who work in AMUs and in adjacent obstetric units. This article focuses on study findings relating to the organisation and management of AMUs. METHODS: An organisational ethnography approach was used, incorporating case studies of four AMUs, selected for maximum variation on the basis of geographical context, length of establishment, size of unit, leadership and physical design. Interviews were conducted between December 2011 and October 2012 with service managers and key stakeholders (n = 35), with professionals working within and in relation to AMUs (n = 54) and with postnatal women and birth partners (n = 47). Observations were conducted of key decision-making points in the service (n = 20). FINDINGS: Managers saw four key areas as vital to developing and sustaining good quality midwifery unit care: finance and service management support, staffing, training, and appropriate guidelines. Development of AMUs was often opportunistic, with service leaders making use of service reconfigurations to achieve change, including development of MUs and new care pathways. Midwives working in AMUs valued the environment, approach and the opportunity to exercise greater clinical judgement but relations between groups of midwives in different units could be experienced as problematic. Key potential challenges for the quality, safety and sustainability of AMU care included: boundary work and management; professional issues; developing appropriate staffing models and relationships; midwives' skills and confidence; and information and access for women. Responses to such challenges included greater focus on interdisciplinary skills training, and integrated models of midwifery and care pathways. Positive leadership and appropriate development and use of guidelines were important to underpin the development and sustainability of midwifery units. CONCLUSIONS: The units studied had been developed to form a key part of the maternity service, and their role was increasingly being recognised as valid and as maintaining the quality and safety of care in the maternity service as a whole. However, each was providing birth care for only about a third of women who had been classified as eligible to plan birth outside an obstetric unit at the end of pregnancy. Developing midwifery units involves aligning physical, professional and philosophical boundaries. However, this poses challenges when managing the service, to ensure it is sustainable, of high quality and safe. In order to fulfil evidence-based guidelines on providing midwifery unit care, further attention is needed to staff training and support; the development of integrated, continuity-based staffing models; and ensuring AMUs are positioned as a core service rather than a marginal one.

Working for patient safety: a qualitative study of women's help-seeking during acute perinatal events.

BACKGROUND: Women and their relatives can play an important role in early detection and help seeking for acute perinatal events. Recent UK reports indicate that patient-professional partnership in 'working for safety' can be difficult to achieve in practice, sometimes with catastrophic consequences. This research explored the experiences of women and relatives who had experienced early warning signs about their condition and sought help in escalating care. METHODS: Secondary analysis of case study data which included qualitative interviews with 22 women purposively sampled on account of experiencing a step up in care and 4 of their relatives from two NHS Trusts in England during 2010. Analysis focused on the type of safety work participants engaged in, and the opportunities and challenges reported by women and family members when negotiating safety at home and in hospital. RESULTS: Women and relatives took on a dual responsibility for self-diagnosis, self-care and seeking triage, whilst trying to avoid overburdening stretched services. Being informed, however, did not necessarily enable engagement from staff and services. The women's narratives highlighted the work that they engaged in to build a case for clinical attention, the negotiations that took place with health care professionals and the strategies women and partners drew on (such as objective signs and symptoms, use of verbal insistence and repetition) to secure clinical help. For some women, the events left them with a lasting feeling that their concerns had been disregarded. Some described a sense of betrayal and loss of trust in an institution they believed had failed to care for them. CONCLUSION: The notion of 'safety partnerships' which suggests a sense of equality and reciprocity was not borne out by our data, especially with regards to the experiences of teenage women. To enable women and families to secure a rapid response in clinical emergencies, strategies need to move beyond the provision of patient information about warning signs. Effective partnerships for safety may be supported by system level change such as improved triage, continuity of care, self-referral pathways and staff training to address asymmetries of power that persist within the health system.

What makes alongside midwifery-led units work? Lessons from a national research project.

The findings of the Birthplace in England Research Programme showed that midwife-led units are providing the safest and most cost-effective care for low risk women in England. Since the publication of the updated National Institute for Health and Care Excellence (NICE) intrapartum guidelines, there is likely to be even more interest in the development of midwife-led units to promote birth outside obstetric units (OUs) for low-risk women. Professional bodies, policy makers and trusts have focused their energies on alongside midwife-led units (AMUs), which are seen to provide the 'best of both worlds' between home and an OU. Between 2012 and 2013, we carried out a study of the organisation of four AMUs in England and the experiences of midwives and women who worked and birthed there. Learning from their experiences, this article presents five key factors which help make AMUs work.

Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey.

Robust evidence of the benefits of continuous support during childbirth led to the recommendation that it should be offered for all women. In Brazil, it has been guaranteed by law since 2005, but scarce data on implementation is available. We aimed to estimate the frequency and associated socio-demographic, obstetric and institutional predictors of women having companionship during childbirth in the Birth in Brazil survey. Descriptive statistical analysis was done for the characterization of companions (at different moments of hospital stay), maternal and institutional factors; associations were investigated in bivariate and multivariate models. We found that 24.5% of women had no companion at all, 18.8% had continuous companionship and 56.7% had partial companionship. Independent predictors of having no or partial companionship at birth were: lower income and education, brown color of skin, using the public sector, multiparity, and vaginal delivery. Implementation of companionship was associated with having an appropriate environment, and clear institution al rules about women's rights to companionship.

Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa nacional Nascer no Brasil / Implementación de la presencia de acompañantes durante el internamiento para el parto: datos de la encuesta nacional Nacer en Brasil / Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey

As evidências sobre os benefícios do apoio contínuo durante o parto levou à recomendação de que este apoio deve ser oferecido a todas as mulheres. No Brasil, ele é garantido por lei desde 2005, mas os dados sobre a sua implementação são escassos. Nosso objetivo foi estimar a frequência e fatores sociodemográficos, obstétricos e institucionais associados à presença de acompanhantes durante o parto na pesquisa Nascer no Brasil. Foi feita análise estatística descritiva para a caracterização dos acompanhantes (em diferentes momentos do tempo da internação), fatores maternos e institucionais; as associações foram investigadas em modelos bi e multivariada. Vimos que 24,5% das mulheres não tiveram acompanhante algum, 18,8% tinham companhia contínua, 56,7% tiveram acompanhamento parcial. Preditores independentes de não ter algum, ou parcial, foram: menor renda e escolaridade, cor parda da pele, usar o setor público, multiparidade e parto vaginal. A implementação do acompanhante foi associada com ambiência adequada e regras institucionais claras sobre os direitos das mulheres ao acompanhante.

La evidencia de los beneficios del apoyo continuo durante el parto llevó a la recomendación de que fuera ofrecido a todas las mujeres. En Brasil, se les garantiza a las mujeres por ley desde 2005, pero hay escasos datos sobre su aplicación. El objetivo fue estimar la frecuencia y factores asociados (socio-demográficas, obstétricos e institucionales) de las mujeres que tienen acompañantes durante el parto en la encuesta Nacer en Brasil. Una vez realizado el análisis estadístico descriptivo para la caracterización de los acompañantes (en diferentes momentos del parto), factores maternos e institucionales; las asociaciones investigaron los modelos bivariados y multivariados. El 24,5% de las mujeres no tenía ningún acompañante, el 18,7% tenían acompañantes continuos y el 56,7% los tenía parcialmente. Predictores independientes de no tener acompañantes o tenerlos parcialmente fueron: bajos ingresos y educación, color moreno de piel, usar el sector público de sanidad, la multiparidad y el parto vaginal. La implementación de acompañantes se asoció con un ambiente adecuado, y normas institucionales claras sobre los derechos de las mujeres al acompañante.

Robust evidence of the benefits of continuous support during childbirth led to the recommendation that it should be offered for all women. In Brazil, it has been guaranteed by law since 2005, but scarce data on implementation is available. We aimed to estimate the frequency and associated socio-demographic, obstetric and institutional predictors of women having companionship during childbirth in the Birth in Brazil survey. Descriptive statistical analysis was done for the characterization of companions (at different moments of hospital stay), maternal and institutional factors; associations were investigated in bivariate and multivariate models. We found that 24.5% of women had no companion at all, 18.8% had continuous companionship and 56.7% had partial companionship. Independent predictors of having no or partial companionship at birth were: lower income and education, brown color of skin, using the public sector, multiparity, and vaginal delivery. Implementation of companionship was associated with having an appropriate environment, and clear institution al rules about women’s rights to companionship.

Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study.

OBJECTIVE: To explore implementation of the modified early obstetric warning system (MEOWS) in practice to further understanding about the influence of contextual factors. METHODS: An ethnographic study using observations (>120 h), semi-structured interviews (n=45) and documentary review was performed in the maternity services in two UK hospitals over a 7-month period. Doctors, midwives and managers participated in the study and data were analysed thematically. RESULTS: For women admitted to hospital in the antenatal and postnatal period with an established risk of morbidity, the MEOWS enabled communication about vital signs from junior to senior midwives and obstetricians. The trigger prompts helped shape shared understandings of maternal complications. However, midwifery and obstetric staff questioned the added value of an extra chart in the postnatal period given the low incidence of maternal complications and the resulting increase in workload. In an effort to prioritise workload demands and respond to the immediate needs of both women and their babies, midwives exercised professional discretion regarding its use. However, discretionary use of MEOWS meant the loss of a potential universal safety net for detection of deterioration. CONCLUSIONS: Despite a decade of use in acute settings, research into the effectiveness of early warning systems still yields conflicting results. Widespread policy support for the MEOWS is based on its intuitive appeal and no validated system for use in the maternity population currently exists. Our findings suggest that, while the MEOWS has value in structuring the surveillance of hospitalised women with an established risk of morbidity, the complexities of managing risk and safety within the maternity pathway, the associated opportunity costs of MEOWS and variation in implementation currently call into question its role for routine use.

Women's safety alerts in maternity care: is speaking up enough?

Patients' contributions to safety include speaking up about their perceptions of being at risk. Previous studies have found that dismissive responses from staff discouraged patients from speaking up. A Care Quality Commission investigation of a maternity service where serious incidents occurred found evidence that women had routinely been ignored and left alone in labour. Women using antenatal services hesitated to raise concerns that they felt staff might consider irrelevant. The Birthplace in England programme, which investigated the quality and safety of different places of birth for 'low-risk' women, included a qualitative organisational case study in four NHS Trusts. The authors collected documentary, observational and interview data from March to December 2010 including interviews with 58 postnatal women. A framework approach was combined with inductive analysis using NVivo8 software. Speaking up, defined as insistent and vehement communication when faced with failure by staff to listen and respond, was an unexpected finding mentioned in half the women's interviews. Fourteen women reported raising alerts about safety issues they felt to be urgent. The presence of a partner or relative was a facilitating factor for speaking up. Several women described distress and harm that ensued from staff failing to listen. Women are speaking up, but this is not enough: organisation-focused efforts are required to improve staff response. Further research is needed in maternity services and in acute and general healthcare on the effectiveness of safety-promoting interventions, including real-time patient feedback, patient toolkits and patient-activated rapid response calls.

Organisational strategies and midwives' readiness to provide care for out of hospital births: an analysis from the birthplace organisational case studies.

OBJECTIVE: the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies. DESIGN: organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review. SETTING: a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring 'best' or 'better' performing in the Health Care Commission survey of maternity services (HCC 2008). PARTICIPANTS: professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents. FINDINGS: each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a 'hub and spoke' model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries.

Abortion discourse in Bolivian hospital contexts: doctors' repertoire conflicts and the Saving Women device.

The author proposes going Beyond attitudes (Potter and Wetherell 1987) to a more nuanced assessment of doctors' discursive variations. Through an application of Gilbert and Mulkay's (1984) interpretative repertoires, she defined three voices--technical, normative and pragmatic--in which Bolivian doctors spoke of abortion. In State and social security hospital contexts, doctors hastened to express compliance with government policy and institutional norms regulating abortion and postabortion care. Technical and pragmatic considerations, however, often entered into conflict with established rules. When contradictions became apparent in their own discourse, doctors regularly drew on the Saving Women device. This accounting strategy enabled them to save face as up-to-date professionals through justifying temporary deviance from norms in terms of benefit to women treated. The author describes her development of the repertoires, their validation with different medical audiences, and doctors' critical appropriation of the model to explain their own discursive variations.

Experiencias en InvestigacióN Sociocultural / Experiences in Sociocultural Research

Entender la investigacion como un intecambio de conocimientos y no como una simple busqueda de datos o confirmacion de teorias, asumirla como un dialogo interactivo de profundo respeto en que investigadores e investigados tiene algo que dar y algo que recibir.(au)

Dialogo de saberes / Dialogue of knowledge

El dialogo de saberes como una metodologia alternativa para la investigacion cualitativa, permite intercambiar criterios con otras personas.(au)

Aborto, género y salud reproductiva: sesgos de género en actitudes y comportamientos de usuarios(as) y proveedores(as) de servicios de salud que influyen en la incidencia del embarazo no deseado y el aborto / Abortion, I generate and reproductive health: biases of generate in attitudes y performances of usuarios(as) and proveedores(as) of services of health that influence of the unwanted pregnancy and the abortion

El objetivo general de la investigación es de contribuir a la disminución de la morbi-mortalidad asociada al aborto en el Distrito III. Tuvo el objetivo específico de recomendar estrategias para alcanzar este fin, en base al análisis de datos etrnográficos sobre aspectos de sexualidad y fecundidad desde una perspectiva de género

Razones para la fertilidad no deseada e impedimentos para el uso de servicios de planificación familiar entre mujeres aymaras del área urbana de Bolivia / sss

Los resultados del estudio etnográfico en las mismas comunidades confirman que, engeneral, estas mujeres desean regular su fertilidad y que las normas culturales y creenciassobre el rol de la mujer y la reproducción en su mayor parte, apoyan la regulación dela fertilidad. Sin embargo, las normas también dificultan su logro. Una de las barrerasmás significativas es la renuencia a discutir asuntos sexuales y métodos anticonceptivosabiertamente. Circulan historias alarmantes sobre los efectos negativos de los métodosanticonceptivos y son asimiladas por la población. Como estos asuntos generalmente se .tratan sólo indirectamente, las historias tienen tendencia a ser vagas. La mayor partede las mujeres no buscan información sistemática. Una segunda barrera, relacionada conésta, es la profunda sospecha hacia la medicina moderna y los médicos que la practican,.a quienes no se considera como fuente confiable de información. Esta desconfianza serefuerza cuando la calidad de los servicios de salud es inferior...

Experiencias de las mujeres en los servicios de salud / Woman experiencies of health care

Una serie de estudios realizados en el pais en el ultimo decenio indica la existencia de serios problemas de calidad de atencion y trato en los servicios de salud. Existe una amplia documentacion sobre practicas inapropiadas y hasta abusivas, combinadas con formas arraigadas de discriminacion social, etnica, cultural y de genero. Estos factores contribuyen a la notoria subutilizacion de los servicios existentes, especialmente por parte de la poblacion rural, los sectores de bajos ingresos y las mujeres de origen indigena.

Necesidad de información sobre aborto / Need for information on abortion

El presente artículo resume los hallazgos de una investigación cualitativa realizada en cuatro hospitales de la ciudad de La Paz entre los meses de abril y julio de 1993. El estudio tuvo como base un convenio suscrito entre IPAS y la Dirección Nacional de Atención a las Personas (DINAP) del Ministerio de Previsión Social y Salud Pública, para ala elaboración del material informativo destinado a pacientes internadas con aborto incompleto y al personal de salud que las atiende

El Comité Nacional de Defensa de los Derechos Reproductivos / The national committee of defense of the reproductive rights

El 5 de septiembre pasado, cumplió año de vida una pequeña organización cuyo campo de actividad está despertando creciente interés en el país. El Comité Nacional de Defensa de los Derechos Reproductivios se auto define como "un grupo de mujeres y hombres decididos a que los derechos reproductivos sean una realidad para todos". En el presente artículo, describimos el origen del Comité, sus principios y su proyección hacia el futuro