Nursing Home Organization Mealtimes and Staff Attitude Toward Nutritional Care: A Multicenter Observational Study.

OBJECTIVES: The aims of this study were to investigate the practices of registered nurses and nurse aides at mealtimes in nursing homes (NHs) and to evaluate the attitudes of health care staff toward the nutritional care of older people. DESIGN: This is a multicenter cross-sectional study. SETTING AND PARTICIPANTS: The study involved a convenience sample of NH health care staff: physicians, registered nurses, and nurse aides. METHODS: Data were collected on characteristics of the dining environment, organizational and nutritional care practices, staff-resident ratio, and staff activities during meals, using 2 questionnaires and staff attitudes were assessed with Staff Attitudes to Nutritional Nursing Care Geriatric Scale (SANN-G). Total score ranges from 18 to 90 points, with the following cutoffs: ≥72, positive attitude; ≤54, negative; and 55-71 points, neutral attitude. RESULTS: A total of 1267 workers from 29 NHs in northern Italy participated in the study. The most common nutritional assessment tool used by nurses was the Malnutrition Universal Screening Tool. A median of 4.0 and 4.2 people (family caregivers, volunteers and staff) were present for feeding support, respectively, at lunch and dinner. A median of 2.5 and 2.0 staff members at lunch and at dinner, respectively, fed residents. Overall, 1024 health care workers responded to SANN-G of which 21.9% showed a negative attitude, 57.2% neutral, and 20.9% a positive attitude. Nurse aides (190/714) showed worse attitudes compared with registered nurses (20/204) and physicians (2/36); differences were statistically significant. Overall, the best attitudes were toward "habits," "interventions," and "individualization" of nutritional care. Staff who had received nutritional training (29.2%) had best attitudes. CONCLUSIONS AND IMPLICATIONS: The results suggest that NHs should ensure adequate staff-resident ratio during meals, involving trained volunteers and relatives. Moreover, health professionals' knowledge and attitude toward nutritional care should be improved through continuous training.

Reluctance of general practice staff to register patients without documentation: a qualitative study in North East London.

BACKGROUND: Lack of access to documentation is a key barrier to GP registration, despite NHS England guidance stating that documents are not required. Staff attitudes and practice regarding registration of those without documentation are under- researched. AIM: To understand the processes through which registration might be refused for those without documents, and the factors operating to influence this. DESIGN AND SETTING: Qualitative study conducted in general practice across three clinical commissioning groups in North East London. METHOD: In total, 33 participants (GP staff involved in registering new patients) were recruited through email invitation. Semi-structured interviews and focus groups were conducted. Data were analysed using Braun and Clarke's reflexive thematic analysis. Two social theories informed this analysis: Lipsky's street-level bureaucracy and Bourdieu's theory of practice. RESULTS: Despite good knowledge of guidance, most participants expressed reluctance to register those without documentation, often introducing additional hurdles or requirements in their everyday practice. Two explanatory themes were generated: that those without documents were perceived as burdensome, and/or that moral judgements were made about their deservedness to finite resources. Participants described a context of high workload and insufficient funding. Some felt that GP services should be restricted by immigration status, as is widespread in secondary care. CONCLUSION: Improving inclusive registration practice requires addressing staff concerns, supporting navigation of high workloads, tackling financial disincentives to registering transient groups, and challenging narratives that undocumented migrants represent a 'threat' to NHS resources. Furthermore, it is imperative to acknowledge and address upstream drivers, in this instance the Hostile Environment.

Conflict management: A qualitative study of mental health staff's perceptions of factors that may influence conflicts with forensic mental health inpatients.

Internationally, clinical services are under pressure to reduce their use of restrictive practices. The aim was to explore how mental health nurses and nursing assistants perceive conflict and their use of restrictive practices with mental health inpatients in forensic mental health care. A total of 24 semi-structured interviews with forensic mental health staff were conducted and analysed using thematic analysis. The findings propose a dynamic model that explains how tolerance of potential conflict situations changes depending on individual staff members' perceptions of patients and colleagues, and their relationships.

The Staff Attitude to Coercion Scale (SACS) - Polish adaptation. / Kwestionariusz Postaw Personelu Wobec Przymusu (SACS) ­ Polska adaptacja.

OBJECTIVES: The aim of the study was to prepare the Polish adaptation of the SACS. The scale is a self-assessment tool designed to measure staff attitudes towards direct coercion of psychiatric wards patients. METHODS: The sample consisted of 120 adults, staff from 7 psychiatric wards. The SACS is a tool created in Norway by Tonje Husum, comprising of 15 items describing psychiatric healthcare professionals attitudes towards direct coercion. The validation procedure incorporated three basic methods to be applied in the reliability analysis - the comparison of double tests with the same method, the analysis of statistical properties of test items as well as analysis of the relation of test items and subscales with the general test result. RESULTS: After a "think aloud" type pilot study and a language validation, the internal consistency was assessed. The Cronbach's alpha ranged from 0.57 to 0.81 in the subscales, and it was 0.82 for the total score. The best solution obtained in exploratory factor analysis was a three-factor model, almost identical to the original one, confirming the division into three subscales: coercion as offending (critical attitude), as care and security (pragmatic attitude) and as treatment (positive attitude). CONCLUSIONS: The psychometric characteristics of the Polish adaptation of the SACS are similar to those reported in the original version. The results allow to recommend the method for scientific research. However, further analyses are necessary to assess validity and discriminative power in larger settings.

Emergency department leaders and levels of engagement among their nursing staff.

AIM: Researchers have begun to examine work engagement in nursing, but there is little research specific to work engagement in emergency department (ED) nurses. The erratic nature and increased requirements of EDs adds to the burden on leaders to meet patient demands while keeping staff engaged. The aim of this pilot study was to describe and explore the relationship between levels of ED registered clinical nurses' (RNs) work engagement and age, years of experience and shift worked to determine if there are differences between ED nurses and those working in other areas and whether this information could help ED leaders in their approach to staff engagement. METHOD: A descriptive pilot study was used with RNs from a Midwestern urban level 1 trauma ED in the US. Participants completed an electronic survey that included demographics and the Utrecht Work Engagement Scale (UWES). FINDINGS: Participants had a Bachelor of Science in nursing or higher and 62% had five years' or less nursing experience. UWES scores compared to national benchmark scores were average and Cronbach alpha coefficients were 0.90. Reliability for each subscale differed. Analysis found no significant difference in relation to age. CONCLUSION: Participants scored high in total engagement with absorption ranking highest. Evidence reinforces the need for leaders to develop positive relationships with novice nurses to foster engagement and increase tenure.

Pressure ulcer prevalence and perceptions on prevention: a hospital-wide survey of health professionals.

OBJECTIVE: Hospital-acquired pressure ulcers (HAPUs) remain a problem despite numerous prevention initiatives. To understand why, it is necessary to know health professionals' perceptions regarding the importance of prevention, and the usability of current initiatives. We hypothesised that positive perceptions of existing initiatives would not be correlated with low HAPU prevalence, and that health professionals would perceive the initiatives to have a low usability. METHOD: A two-part, online survey was developed and distributed electronically to nurses, in-training physicians and attending physicians, across all inpatient and perioperative departments of an academic hospital. Part one of the survey was the Agency for Healthcare Research and Quality (AHRQ) Staff Attitude Scale on beliefs regarding PU prevention; part two was additional questions on the usability of existing preventative initiatives. The results of the survey were compared with quarterly HAPU prevalence data by hospital unit. RESULTS: In total, 839 health professionals completed the survey (579 nurses, 131 residents, 119 attending physicians). The mean score for the AHRQ survey was 42.5 (≥40 denoting positive perceptions). There was a moderate correlation between AHRQ scores and prevalence of HAPUs (r=-0.60, p=0.402). For usability, repositioning was felt to be the most effective intervention (mean: 4.54, standard deviation (SD): 0.64), while educational posters were felt to be the least effective (mean: 3.31, SD: 0.99). Respondents generally rated satisfaction much lower, with no single initiative significantly better than the others (range: 3.21-3.79). Perceived effectiveness and satisfaction were all positively correlated. CONCLUSION: High HAPU prevalence, despite position perceptions, suggests that prevention methods are not as effective as thought, or they are not being used as widely as they should. Further research should take advantage of positive attitudes by prospectively investigating the usability of novel interventions.

The construction of the health professional in palliative care contexts: a scoping review on caring for the person at the end of life.

AIM: The aim of the study was to map of the literature on the elements contributing to the construction of the health care professional in the context of palliative care. METHODS: Scoping review based on Arksey and O'Malley framework. PubMed, Embase, CINAHL, Scopus databases, and gray literature were the sources searched (2005-2015), completed by reference searching, hand searching, and expert consultations. Primary studies focusing on different professionals working in palliative care units or hospice centers were eligible for inclusion. RESULTS: From a total of 3632 articles, 22 met the inclusion criteria. The content of the studies was described and classified in 5 elements: (i) construction and application of the concept of care; (ii) psychosocial effects that the daily care produces; (iii) working conditions that influence the caregiving provided; (iv) knowledge mobilized in the provision of care; and (v) strategies adopted by health care professionals to build relationships. Data about nurses, physicians, and psychologists were found, but no data were found about social workers. Gaps identified in the publications were as follows: relationship competencies and strategies adopted; the real needs from educational programs; and the view of other professionals. CONCLUSIONS: Key elements identified in the concept of the construction of the health care professional should be addressed in future interventions: prevention of emotional exhaustion, depersonalization, and achievement of a greater personal accomplishment. In addition, none of the articles retrieved offered the different perspectives of all the disciplines in a multidisciplinary team.

Reality of working in a community-based, recovery-oriented mental health rehabilitation unit: A pragmatic grounded theory analysis.

In the present study, we explored the experiences of staff working at a recovery-oriented, community-based residential mental health rehabilitation unit in Brisbane, Australia, called a 'community care unit' (CCU). A pragmatic approach to grounded theory was taken in the analysis of the transcripts of semistructured interviews with eight staff. Convenience sampling was used, and there was representation of junior and senior staff across nursing, allied health, and non-clinical support roles. Four key themes emerged from the analysis: (i) rehabilitation is different to treatment; (ii) the CCU is a positive transitional space; (iii) they (consumers) have to be ready to engage; and (iv) recovery is central to rehabilitation practice. Staff understandings of recovery in rehabilitation work were complex and included consideration of both personal and clinical recovery concepts. Rehabilitation readiness was considered important to the ability to deliver recovery-oriented care; however, the shared role of staff in maintaining engagement was acknowledged. Threats to recovery-oriented rehabilitation practice included staff burnout and external pressure to accept consumers who are not ready. The reality of working at a community-based recovery-oriented rehabilitation unit is complex. Active vigilance is needed to maintain a focus on recovery and rehabilitation. Leadership needs to focus on reducing burnout and in adapting these services to emergent needs.

Preference for a single or shared room in a UK inpatient hospice: patient, family and staff perspectives.

OBJECTIVE: This study investigated the preferences of patients, family and staff for single or shared rooms in a UK hospice. METHOD: Semistructured interviews were conducted with patients, informal carers and staff at a hospice, focusing on room type preference. RESULTS: 14 current and former hospice inpatients, 15 patients attending the hospice day centre, 23 carers of current and former inpatients and 10 hospice staff were interviewed. Patients most often stated a preference for a shared room, especially if they had experience of being in this room type at the hospice. The main reason for this preference was the company of others. Patients preferring single rooms cited the benefits of increased privacy, reduced noise and private facilities. Other patients said their room preference would depend on how ill they were. Carers valued the social contact and increased staff presence in shared rooms, but felt that single rooms were easier for visitors and more appropriate when patients reached the end of life. Staff found it easier to observe patients in a shared room, and to maintain privacy and confidentiality in a single room. CONCLUSIONS: The study concludes that single and shared rooms should be available in a hospice. Innovative planning can enable the social benefits of shared rooms to be maintained without compromising patients' privacy and dignity.

Mobile technologies: expectancy, usage, and acceptance of clinical staff and patients at a university medical center.

BACKGROUND: Despite their increasing popularity, little is known about how users perceive mobile devices such as smartphones and tablet PCs in medical contexts. Available studies are often restricted to evaluating the success of specific interventions and do not adequately cover the users' basic attitudes, for example, their expectations or concerns toward using mobile devices in medical settings. OBJECTIVE: The objective of the study was to obtain a comprehensive picture, both from the perspective of the patients, as well as the doctors, regarding the use and acceptance of mobile devices within medical contexts in general well as the perceived challenges when introducing the technology. METHODS: Doctors working at Hannover Medical School (206/1151, response 17.90%), as well as patients being admitted to this facility (213/279, utilization 76.3%) were surveyed about their acceptance and use of mobile devices in medical settings. Regarding demographics, both samples were representative of the respective study population. GNU R (version 3.1.1) was used for statistical testing. Fisher's exact test, two-sided, alpha=.05 with Monte Carlo approximation, 2000 replicates, was applied to determine dependencies between two variables. RESULTS: The majority of participants already own mobile devices (doctors, 168/206, 81.6%; patients, 110/213, 51.6%). For doctors, use in a professional context does not depend on age (P=.66), professional experience (P=.80), or function (P=.34); gender was a factor (P=.009), and use was more common among male (61/135, 45.2%) than female doctors (17/67, 25%). A correlation between use of mobile devices and age (P=.001) as well as education (P=.002) was seen for patients. Minor differences regarding how mobile devices are perceived in sensitive medical contexts mostly relate to data security, patients are more critical of the devices being used for storing and processing patient data; every fifth patient opposed this, but nevertheless, 4.8% of doctors (10/206) use their devices for this purpose. Both groups voiced only minor concerns about the credibility of the provided content or the technical reliability of the devices. While 8.3% of the doctors (17/206) avoided use during patient contact because they thought patients might be unfamiliar with the devices, (25/213) 11.7% of patients expressed concerns about the technology being too complicated to be used in a health context. CONCLUSIONS: Differences in how patients and doctors perceive the use of mobile devices can be attributed to age and level of education; these factors are often mentioned as contributors of the problems with (mobile) technologies. To fully realize the potential of mobile technologies in a health care context, the needs of both the elderly as well as those who are educationally disadvantaged need to be carefully addressed in all strategies relating to mobile technology in a health context.

O conceito de competência: uma análise do discurso docente / The concept of competence: an analysis of the teachers' perspective

As Diretrizes Curriculares Nacionais para o Curso de Medicina de 2001 têm como eixo norteador 28 competências, sem uma definição do conceito de competência utilizado. Na literatura há uma série de definições, sendo esse tema vasto e polêmico. Desse modo, a forma como a competência é compreendida pelo docente terá um impacto direto na formação do aluno. Com a finalidade de clarificar o conceito de competência médica adotado por docentes do curso de Medicina de uma universidade, foi realizada uma pesquisa qualitativa a partir da apresentação e questionamentos frente a um caso clínico comum. Para a síntese, organização e análise desses discursos foi utilizado o método do Discurso do Sujeito Coletivo. Entre os conceitos de competência pode-se notar a aplicabilidade prática dos conhecimentos, das habilidades e atitudes, aliada a uma prática reflexiva e ética. Esta última tem destaque e é um pilar das competências. Atitudes como comprometimento e respeito foram apontadas como essenciais para apresentar competência. As atitudes e a ética têm um papel central na competência do egresso, e estratégias para estimular seu desenvolvimento devem ser um dos focos da formação médica.

The National Curriculum Guidelines for the Medical course of 2001 have 28 core competences, but lack any defined concept of competence used. A number of definitions can be found in literature; this is a vast and controversial subject. Thus, the way in which teachers understand competence will have a direct impact on student education. A qualitative study was conducted among medicine teachers in order to clarify their concept of medical competence, based on the presentation of a common clinical case and related questions. Discourse of the Collective Subject was the method used to organize and analyze these persepctives. The concepts of competence found included the practical applicability of knowledge, skills and attitudes combined with reflective and ethical practice. The latter is given particular merit and can be seen as a pillar of the competences. Attitudes such as commitment and respect were identified as essential for displaying competence. It follows that the attitudes and ethics of graduates are key elements to their competence and encouraging their development should be one of the focuses of medical training.

The analysis of challenging relations: influences on interactive behaviour of staff towards clients with intellectual disabilities.

BACKGROUND: Relationships between support staff and clients with intellectual disability (ID) are important for quality of care, especially when dealing with challenging behaviour. Building upon an interpersonal model, this study investigates the influence of client challenging behaviour, staff attitude and staff emotional intelligence on interactive behaviour of one of these relationship partners, being support staff. METHOD: A total of 158 support staff members completed a questionnaire on staff interactive behaviour for 158 clients with ID and challenging behaviour, as well as two questionnaires on staff interpersonal attitude and emotional intelligence. RESULTS: Confronted with challenging behaviour as opposed to no challenging behaviour, staff reported less friendly, more assertive control and less support-seeking interpersonal behaviour. Also, staff used more proactive thinking and more self-reflection in dealing with challenging behaviour. Staff interpersonal attitude in general, mainly a harsh-dominant-resentful attitude, had a significant influence on most staff interactive behaviours towards an individual client with challenging behaviour. The influence of staff emotional intelligence, specifically intrapersonal abilities, on staff interactive behaviour towards an individual client with challenging behaviour was somewhat limited. CONCLUSIONS: This research supports the necessity for training staff in general interpersonal attitudes towards clients as well as training in intrapersonal emotional intelligence, when confronted with challenging behaviour. Future research should focus more on the bidirectional dynamics of staff and client interactions.

Reflexiones de los funcionarios del Instituto Teletón Valparaíso sobre la familia y el quehacer técnico profesional: un análisis de contenido latente / Latent content analysis: staff considerations on family, technical and professional work at Valparaíso's Teleton Institute

Introduction: In Chile, as well as in the rest of Latin America and the Caribbean region, a progressive change from a bio-medical to a bio-psycho-socio-environmental paradigm has taken place, with regards to the disability/rehabilitation phenomena. The former, is the reference framework for the current paper, which derived from previous research results from "Teletón Valparaíso's staff member's vision on a profile of social inclusion skills to be developed by children and youngsters with disabilities, who exit the institution: A qualitative study", based on the Grounded Theory (GT) methodology. GT recognizes a "manifest content" and a "latent content", gathered througth the research process. Objetive: Centered on the latent content, the objetive of this study, is to find out Valparaíso's Rehabilitation Institute's staff considerations on family, technical and professional work, related to the change in the rehabilitation paradigm mentioned above. Method: Based on the GT qualitative data gathering method, individual semi-structured interviews were conducted with 96.5 percent of staff. Data was processed with Atlas-ti, and the Constant Comparative Method (CCM). Results: The phenomena "Institute's practice" was indentified, which subdivides into two subphenomena: rehabilitation approach and family. Conclusion: A theorical-practical tension was identified about the institution's mission, which promotes some staff tendency to change technical and professional work, and the conception of the family's role in rehabilitation.

Introducción: El paulatino cambo de paradigma, del biomédico al biopsicosocioambiental, que se ha ido experimentando en Chile tanto como en la Región de América Latina y El Caribe, en relación al fenómeno discapacidad/rehabilitación, es el marco de referencia de este trabajo. Este se basa en los resultados de la investigación "Visión de los/as funcionarios de Teletón Valparaíso sobre perfil de competencias de inclusión social a desarrollar en jóvenes viviendo en situación de discapacidad egresados de la institución: un estudio cualitativo" en la que se utilizó el enfoque metodológico de la teoría fundamentada (T.F). Este reconoce un "contenido manifiesto" y un "contenido latente" en la información obtenida a través del proceso investigativo. Objetivo: Conocer las reflexiones que emergen del contenido latente de los/as funcionarios/as sobre la familia y el quehacer técnico profesional y su relación con un cambio en el enfoque de rehabilitación en el instituto de Valparaíso. Metodología: Abordaje cualitativo basado en el método de la T.F. Las técnicas de recolección de datos utilizados fueron las entrevistas individuales semiestructuradas, aplicadas al 96,5 por ciento de los funcionarios de Teletón Valparaíso. Para el procesamiento de la información se utilizó el software Atlas-ti y el "MCC" Método de Comparación Constante. Resultados: Se identificó el fenómeno análisis "Prácticas en el Instituto" aludiendo al enfoque de rehabilitación que los funcionarios reflejan en su quehacer y visión de las familias. Conclusión: Se percibe una tensión teórico-práctica en relación a la misión institucional, lo cual promueve la tendencia de algunos/as funcionarios/as a transformar el quehacer técnico profesional y la concepción del rol familiar.

Medical abortion service delivery.

Medical abortion with mifepristone and methotrexate regimens may be offered in a variety of American medical practice settings. In this article the new provider will find information on all aspects of the patient care delivery system for medical abortion, including physical space requirements, staffing and training, patient flow, cost, security, marketing, and quality assurance. Because of the limited published data available regarding logistic issues surrounding abortion care, the information in this article derives largely from the experiences of providers who have established medical abortion practices in their offices or clinics. Its goals are to help make the initial start-up phase briefer and more rewarding for new providers, to offer helpful guidelines for incorporation of medical abortion into practice, and to encourage more practitioners to see the benefits of adding this option to their practices.

Multidisciplinary learning in family planning clinics.

PIP: This study aimed to evaluate the acceptability of joint learning between clinical and nonclinical members of family planning teams. A multidisciplinary workshop was facilitated by nonexpert facilitators comprising representatives from all disciplines who had received specific training. The workshop included sessions in which clinical and nonclinical staff learned separately and together. The program was evaluated using a questionnaire documenting participants' experience of learning in multidisciplinary teams, a pre- and post-workshop self-assessment of knowledge, a self-assessment of the predicted and actual effect of the workshop on clinical practice, and telephone interviews with the facilitators. Overall, results show that peer-facilitated multidisciplinary learning for clinical and nonclinical staff together is an acceptable form of staff training for family planning teams. Most participants felt comfortable in their learning groups and few reported feeling constrained by inter- or intradisciplinary hierarchies. In conclusion, the exclusion of nonclinical staff from interdisciplinary learning programs represents a missed opportunity for the exchange of ideas between family planning clinic teams.^ieng

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES: A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service. METHODS: A questionnaire was sent to all 560 departments providing A&E services in the UK. RESULTS: Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents. CONCLUSION: The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.

PIP: Attitudes toward emergency contraception were assessed in a questionnaire mailed in 1995 to the 560 UK departments that provide accident and emergency services. Consultants, general practitioners, and nurses from 355 departments (63.4%), half of which were located in small county towns, replied. Although 338 units (96.3%) reported they had received requests for emergency contraception, only 198 (57.2%) provided such treatment. Initial treatment only was offered by 150 of the providing units (76.9%); only 45 (23%) also discussed subsequent contraception. Follow-up was organized with general practitioners by 92 units and with family planning clinics by 66 units. 155 of the providing units (82.9%) felt emergency contraception was a worthwhile service. Overall, 177 respondents (55.8%)--78.9% of those already providing emergency contraception and 28.1% of nonproviding units--thought this regimen should be available from emergency departments. Among the reasons cited for opposing such a strategy were unprotected sexual intercourse is a social rather than an acute medical problem, lack of adequate time for counseling and follow-up, and sufficient family planning programs in the area to provide this service. 91 units (42.1%) could identify professional groups (primarily other medical staff) within the hospital who would oppose the introduction or continuation of emergency contraceptive services in the emergency room. Finally, 201 respondents (61.7%) did not support over-the-counter availability of emergency contraception. These findings indicate there is a lack of consensus on whether unprotected intercourse constitutes a medical problem requiring emergency treatment and revealed an appreciable degree of reluctance on the part of accident and emergency departments to provide this service.

The need for reliable systems: gendered work in Oxfam's Uganda programme.

PIP: This paper considers the results of a gender review of Oxfam/Great Britain's work in Uganda that sought to determine what gender approaches had been adopted (theoretically and actually) and how they could be improved. After a desk review in the UK, a team conducted a field visit to Uganda where an initial conventional approach that "targeted" women had given way to efforts to conduct an in-depth gender analysis of programs. The team noted that the post of Gender and Development Program Officer in Uganda had been eliminated so that the entire staff would be responsible for addressing gender concerns. The review revealed that the staff exhibited a poor understanding of key concepts, was unwilling to challenge traditional roles and attitudes, deployed ad hoc initiatives, and failed to interact with appropriate local organizations. This situation occurred because of a lack of systematic procedures for planning and evaluation. Also, the fact that there was no extra compensation for staff living in harsh and insecure conditions discouraged female staff from seeking or maintaining positions in the field. Oxfam needs to develop a clear and binding strategy that will spell out the type of social change the Uganda program is seeking, integrate gender concerns, and implement monitoring and evaluation mechanisms. There is also a need to adopt a more political approach to gender concerns by taking advantage of opportunities and confronting attendant risks.^ieng

Practice of standards in female sterilisation.

During training of trainers (TOT) courses organised for medical personnel of Haryana Civil Medical Services (HCMS) by COE Medical College, Rohtak, 55 doctors involved in female sterilisations were interrogated regarding practices in counselling, informed decision, asepsis, surgical procedure, operative and postoperative care and follow-up of the clients accepting sterilisation as contraception. Counselling was the responsibility of auxiliary nurse cum midwife (ANM) lady health volunteer (LHV)/other paramedical workers as viewed by 89.1% participants whereas 85.4% thought that the registration clerk should take the informed consent. Eligibility criteria were always adhered to by 10.9% participants. Asepsis and sterilisation of instruments, etc, were maintained by operation theatre (OT) attendant or OT nurse as answered by 90.9% doctors. Skin preparation was done by a solution containing cetrimide and chlorhexidine alone by 70.8% doctors. The ligation and excision was the method practised by all. Catgut suture was used by only 43.6% doctors. Twenty-six maternal deaths were reported by 20 participants during their whole career. There were 7 deaths on the table, all with laparoscopic sterilisation. Peritonitis with septicaemia was the major cause of death in majority of cases. To ensure high quality and safety of voluntary surgical contraception, programmes must establish a system to ensure that standards are maintained.

PIP: The quality and safety of voluntary surgical contraception in India were evaluated as part of a training of trainers course organized for medical personnel at Haryana Civil Medical Services. A total of 55 physicians, with a mean duration of 9.35 years spent performing female sterilizations, were surveyed regarding their practices related to counseling, informed decision making, asepsis, surgical procedures, operative and postoperative care, and client follow up. Respondents performed an average of 550 minilaparotomy tubectomies and 1250 laparoscopic sterilizations per year. 89.1% of physicians considered client counseling to be the responsibility of auxiliary nurse-midwives or paramedical workers, 85.4% believed the registration clerk should take informed consent, and 94.6% thought the general practitioner should perform the pre-operative evaluation. Only 10.9% of physicians adhered to sterilization eligibility criteria. Maintenance of asepsis was left to operation theater attendants by 91.9%. All physicians practiced ligation and excision. Most patients were discharged 2-4 hours after surgery. Only 9.1% of physicians provided patients with discharge instructions and follow-up was generally handled by community workers. Finally, 20 physicians (36.3%) had experienced a tubectomy-associated death at some point in their career. Peritonitis with septicemia was the cause of death in most of these cases. Overall, these findings indicate an urgent need to improve the safety of female sterilization in India by upgrading physician standards and expanding their responsibilities.

Reducing unsafe abortion in Kenya.

PIP: In Kenya, where abortion is permitted only to save a woman's life, unsafe abortion accounts for over one-third of maternal deaths and hospital emergency rooms are overcrowded with women suffering complications of induced and spontaneous abortions. Postabortion care, a service linking emergency treatment of abortion complications with family planning counseling and comprehensive reproductive health care, is under review by the Population Council as a method of reducing maternal mortality and morbidity as well as the incidence of repeat unsafe abortion. An operations research study conducted by the Kenyan Ministry of Health identified several obstacles to such care: lack of information on abortion management, limited service provider skills, inconsistent supplies, and a lack of empathy for women presenting with incomplete abortion. Although 86% of abortion patients from 6 Kenyan hospitals expressed an interest in contraceptive counseling, only 5% reported actually receiving such information. As part of the operations research, these 6 hospitals introduced postabortion care, including, in 3 hospitals, use of manual vacuum aspiration. All 6 hospitals provided contraceptive counseling and psychosocial support. Based on the success of this experience, the Ministry of Health is considering introducing postabortion care to all hospitals in Kenya.^ieng

Building therapeutic staff: client relationships with women who self-harm.

PIP: This article examines the aims and objectives of a training package devised for nurses working directly with women who self-harm and detained in institutions. The training package aims to change and inform staff attitudes toward self-harming behavior and to encourage therapeutic responses and interventions. The first key step in helping these women is to understand why they resort to self-harm. Some of the underlying reasons why these women try to hurt themselves include dominance of older women, histories of abuse, and feelings of powerlessness. The training program uses a seminar format followed by reflective practice sessions which enables the nursing staff to explore how both theoretical constructs and women's experiences could inform and influence the delivery of care. It utilized community-produced and focused support networks, and consisted of six sessions, each lasting around 2 hours and 30 minutes. Seminar topics include reasons for self-harm, types of women who self-harm, caring for and myths about these women, and communication issues.^ieng