Analysis of policy interventions to attract and retain nurse midwives in rural areas of Malawi: A discrete choice experiment.

BACKGROUND: Inadequate and unequal distribution of health workers are significant barriers to provision of health services in Malawi, and challenges retaining health workers in rural areas have limited scale-up initiatives. This study therefore aims to estimate cost-effectiveness of monetary and non-monetary strategies in attracting and retaining nurse midwife technicians (NMTs) to rural areas of Malawi. METHODS: The study uses a discrete choice experiment (DCE) methodology to investigate importance of job characteristics, probability of uptake, and intervention costs. Interviews and focus groups were conducted with NMTs and students to identify recruitment and retention motivating factors. Through policymaker consultations, qualitative findings were used to identify job attributes for the DCE questionnaire, administered to 472 respondents. A conditional logit regression model was developed to produce probability of choosing a job with different attributes and an uptake rate was calculated to estimate the percentage of health workers that would prefer jobs with specific intervention packages. Attributes were costed per health worker year. RESULTS: Qualitative results highlighted housing, facility quality, management, and workload as important factors in job selection. Respondents were 2.04 times as likely to choose a rural job if superior housing was provided compared to no housing (CI 1.71-2.44, p<0.01), and 1.70 times as likely to choose a rural job with advanced facility quality (CI 1.47-1.96, p<0.01). At base level 43.9% of respondents would choose a rural job. This increased to 61.5% if superior housing was provided, and 72.5% if all facility-level improvements were provided, compared to an urban job without these improvements. Facility-level interventions had the lowest cost per health worker year. CONCLUSIONS: Our results indicate housing and facility-level improvements have the greatest impact on rural job choice, while also creating longer-term improvements to health workers' living and working environments. These results provide practical evidence for policymakers to support development of workforce recruitment and retention strategies.

A Look Back at the Year of the Nurse and the Midwife.

An unprecedented year highlighted the essential care nurses provide.

The role of nurses and midwives in the provision of abortion care: A scoping review.

AIMS AND OBJECTIVES: To define the role and scope of the nurse and midwife within the global context of abortion. BACKGROUND: An estimated 56 million women seek abortions each year; nurses and midwives are commonly involved in their care (Singh et al., 2018, https://www.guttmacher.org/sites/default/files/report_pdf/abortion-worldwide-2017.pdf). As new models of abortion care emerge, there is a pressing need to develop a baseline understanding of the role and scope of nurses and midwives who care for women seeking abortions. DESIGN: The review design was Arksey and O'Malley's five-stage methodological framework. The review follows the PRISMA-ScR checklist. METHODS: MEDLINE, CINAHL, Scopus and ScienceDirect were used to identify original research, commentaries and reports, published between 2008-2019, from which we selected 74 publications reporting on the nursing or midwifery role in abortion care. RESULTS: Nurses and midwives provide abortion care in a variety of practice. Three themes emerged from the literature: the regulated role; providing psychosocial care; and the expanding scope of practice. CONCLUSIONS: The literature on nursing and midwifery practice in abortion care is broad. Abortion-related practices are potentially over-regulated. Appropriately trained nurses and midwives can provide abortions as safely as physicians. The preparation of nurses and midwives to provide abortion care requires further research. Also, healthcare organisations should explore person-centred models of abortion care. RELEVANCE TO CLINICAL PRACTICE: Abortion care is a common procedure performed across many healthcare settings. Nurses and midwives provide technical and psychosocial care to women who seek abortions. Governments and regulatory bodies could safely extend their scope of practice to increase women's access to safe abortions. Introduction of education programmes, as well as embedding practice in person-centred models of care, may improve outcomes for women seeking abortions.

Implementing the skilled birth attendance strategy in Uganda: a policy analysis.

BACKGROUND: Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda's skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care. METHODS: This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis. RESULTS: The skilled birth attendance policy was an important priority on Uganda's maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional. CONCLUSION: Uganda's skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Midwives' use of best available evidence in practice: An integrative review.

AIMS AND OBJECTIVES: To synthesise international research that relates to midwives' use of best available evidence in practice settings and identify key issues relating to the translation of latest evidence into everyday maternity care. BACKGROUND: Midwifery is a research-informed profession. However, a gap persists in the translation of best available evidence into practice settings, compromising gold standard maternity care and delaying the translation of new knowledge into everyday practice. DESIGN: A five-step integrative review approach, based on a series of articles published by the Joanna Briggs Institute (JBI) for conducting systematic reviews, was used to facilitate development of a search strategy, selection criteria and quality appraisal process, and the extraction and synthesis of data to inform an integrative review. METHODS: The databases CINAHL, MEDLINE, Web of Science, Implementation Science Journal and Scopus were searched for relevant articles. The screening and quality appraisal process complied with the PRISMA 2009 checklist. Narrative analysis was used to develop sub-categories and dimensions from the data, which were then synthesised to form two major categories that together answer the review question. RESULTS: The six articles reviewed report on midwives' use of best available evidence in Australia, the UK and Asia. Two major categories emerged that confirm that although midwifery values evidence-based practice (EBP), evidence-informed maternity care is not always employed in clinical settings. Additionally, closure of the evidence-to-practice gap in maternity care requires a multidimensional approach. CONCLUSION: Collaborative partnerships between midwives and researchers are necessary to initiate strategies that support midwives' efforts to facilitate the timely movement of best available evidence into practice. RELEVANCE TO CLINICAL PRACTICE: Understanding midwives' use of best available evidence in practice will direct future efforts towards the development of mechanisms that facilitate the timely uptake of latest evidence by all maternity care providers working in clinical settings.

Implementation of HPV-based Cervical Cancer Screening Combined with Self-sampling Using a Midwifery Network Across Rural Greece: The GRECOSELF Study.

Self-sampling for human papillomavirus (HPV) testing is an alternative to physician sampling particularly for cervical cancer screening nonattenders. The GRECOSELF study is a nationwide observational cross-sectional study aiming to suggest a way to implement HPV-DNA testing in conjunction with self-sampling for cervical cancer screening in Greece, utilizing a midwifery network. Women residing in remote areas of Greece were approached by midwives, of a nationwide network, and were provided with a self-collection kit (dry swab) for cervicovaginal sampling and asked to answer a questionnaire about their cervical cancer screening history. Each sample was tested for high-risk (hr) HPV with the Cobas HPV test. HrHPV-Positive women were referred to undergo colposcopy and, if needed, treatment according to colposcopy/biopsy results. Between May 2016 and November 2018, 13,111 women were recruited. Of these, 12,787 women gave valid answers in the study questionnaire and had valid HPV-DNA results; hrHPV prevalence was 8.3%; high-grade cervical/vaginal disease or cancer prevalence was 0.6%. HrHPV positivity rate decreased with age from 20.7% for women aged 25-29 years to 5.1% for women aged 50-60 years. Positive predictive value for hrHPV testing and for HPV16/18 genotyping ranged from 5.0% to 11.6% and from 11.8% to 27.0%, respectively, in different age groups. Compliance to colposcopy referral rate ranged from 68.6% (for women 25-29) to 76.3% (for women 40-49). For women residing in remote areas of Greece, the detection of hrHPV DNA with the Cobas HPV test, on self-collected cervicovaginal samples using dry cotton swabs, which are provided by visiting midwives, is a promising method for cervical cancer secondary prevention.

Midwifery pre-registration education and mid-career workforce participation and experiences.

BACKGROUND: Midwives in Australia are educated through a range of routes providing flexible ways to become a midwife. Little is known about whether the route to registration impacts on mid-career experiences, in particular, whether the pathway (post-nursing pathway compared with 'direct-entry') makes any difference. AIM: The aim of this study was to explore the midwifery workforce experiences and participation in graduates six to seven years after completing either a post-nursing Graduate Diploma in Midwifery (GradDip) or an undergraduate degree, the Bachelor of Midwifery (BMid), from one university in New South Wales, Australia. METHODS: Data were collected from mid-career midwives having graduated from one NSW university from 2007-2008 using a survey. The survey included validated workforce participation instruments - the Maslach Burnout Inventory (MBI), the Practice Environment Scale-Nursing Work Index (PES-NWI) and the Perceptions of Empowerment in Midwifery Scale (PEMS). RESULTS: There were 75 respondents: 40% (n=30) Bachelor of Midwifery and 60% (n=45) GradDip graduates. The age range was 27-56 years old (mean age=36 years) Bachelor of Midwifery graduates being on average 7.6 years older than Graduate Diploma in Midwifery graduates (40 vs 33 years; p<0.01). Almost 80% (59), were currently working in midwifery. Nine of the 12 not working in midwifery (75%) planned to return. There were no differences in workforce participation measures between the two educational pathways. Working in a continuity of care model was protective in regards to remaining in the profession. CONCLUSION: Most mid-career graduates were still working in midwifery. There were no differences between graduates from the two pathways in relation to burnout, practice experiences or perceptions of empowerment.

O trabalho das enfermeiras obstétricas na ótica das acadêmicas de enfermagem / The work of nurse-midwives from the perspective of academic nursing students

Trata-se de uma pesquisa exploratória, descritiva, com abordagem qualitativa, cujo objeto de estudo foram as percepções das acadêmicas de enfermagem sobre a organização do trabalho das enfermeiras obstétricas nas maternidades. Este estudo objetivou descrever como as acadêmicas de enfermagem percebem a organização do trabalho das enfermeiras obstétricas que atuam nas maternidades e discutir quais os sofrimentos, prazeres e defesas que as acadêmicas de enfermagem apresentam em decorrência dessa organização. Participaram da pesquisa 13 acadêmicas de enfermagem que seguiram os critérios de inclusão. Após aprovação pelo Comitê de Ética, através do Parecer sob o nº CAAE 82003517.6.00005259, foram realizadas entrevistas semiestruturadas mediante um roteiro composto por duas partes: a primeira que se destinou à apreensão de características gerais das participantes e a segunda parte constituiu-se de tópicos abertos com base nas categorias teóricas de Christophe Dejours. Os dados obtidos, após a aplicação da análise temática de conteúdo de Bardin, foram agrupados em duas categorias: "A percepção das acadêmicas sobre o contexto do trabalho das enfermeiras", com 53 URs e "Vivência de sofrimento e prazer pelas acadêmicas", com 50 URs. Os resultados mostraram que as acadêmicas percebem que a enfermeira obstétrica possui autonomia (16 URs), mediante a realização do parto. Percebem também que o trabalho das enfermeiras generalistas privilegia mais o preenchimento de formulários, folhas de evolução e delegação das atividades (características de autoridade burocrática), em detrimento da assistência ao paciente. Todas as participantes do estudo perceberam a liderança da enfermeira no processo de trabalho da enfermagem. Para as acadêmicas de enfermagem, é fonte de prazer e felicidade o reconhecimento das atividades desenvolvidas por elas, a proximidade de tornar-se de fato enfermeira e sentir-se útil para a sociedade. Como causa de sofrimento, as participantes relataram a falta de reconhecimento e a vivência da violência obstétrica nas maternidades. Conclui-se a necessidade de repensar a formação das acadêmicas de enfermagem, uma vez que os aspectos referentes à organização do trabalho das enfermeiras ­ não somente os aspectos físicos, mas, também, sociais, culturais, ambientais e afetivos ­ refletem no processo de formação educacional e na transformação de sujeitos críticos e reflexivos capazes de avaliar a importância da organização do trabalho, evitando, assim, o adoecimento e o alienamento das causas do sofrimento, causados pela organização do trabalho que se mantém inalterada.

This is an exploratory, descriptive research with qualitative approach, whose object of study was the perceptions of nursing academics on the nurse-midwives' organization of work in the maternity wards. This study aimed to describe how the nursing academics perceive the work organization of nurse-midwives who work in maternity wards and discuss the sufferings, pleasures and defenses that these academics present as a consequence of such organization. Thirteen nursing academics who fulfilled the inclusion criteria participated in the study. After approval by the Ethics Committee through the CAAE number 82003517.6.00005259, semi-structured interviews were held following a script which consisted of two parts: the first part was destined to the apprehension of the participants' general characteristics; and the second part consisted of open topics based on the theoretical categories of Christophe Dejours. The data obtained, after the thematic content analysis of Bardin was applied, were grouped into two categories: "The academics' perception about the work context of nurses", with 53 RU and "Experience of suffering and pleasure by academics", with 50 RU. The results showed that the academics realize the nurse-midwife has autonomy (16 RU) in childbirth. They also notice that the work of the generalist nurses favors more the filling out of forms and evolution sheets, as well as the delegation of activities (characteristics of bureaucratic authority), to the detriment of patient care. All the participants in the study realized the nurses' leadership in the nursing work process. For the nursing academics, the recognition for the activities developed by them, the proximity of becoming a nurse and feeling useful to society are a source of pleasure and happiness. As a cause of suffering, the participants reported the lack of recognition and experiencing obstetric violence in maternity wards. It is concluded the need to rethink the training of nursing academics, since the aspects related to the nurses' work organization - not only physical, but also social, cultural, environmental and emotional ones - reflect on the process of education and on the transformation of critical and reflective subjects able to assess the importance of work organization, thereby avoiding illness and alienation from the causes of suffering originating from a work organization that remains unchanged.

Outcomes for women with BMI>35kg/m2 admitted for labour care to alongside midwifery units in the UK: A national prospective cohort study using the UK Midwifery Study System (UKMidSS).

OBJECTIVE: To describe and compare outcomes in severely obese (body mass index (BMI)>35kg/m2) women and other women admitted to alongside (co-located) midwifery units (AMU) in the United Kingdom. METHODS: We carried out a national prospective cohort study using the UK Midwifery Study System (UKMidSS) in all 122 AMUs in the UK. We identified and collected data about 1122 severely obese women admitted to an AMU, 1st January-31st December 2016, and 1949 comparison women (BMI≤35kg/m2), matched on time of admission, and used Poisson regression to calculate relative risks adjusted for maternal characteristics. RESULTS: 92% of the severely obese cohort had BMI 35.1-40kg/m2. Severely obese multiparous women were no more likely than comparison women to experience the composite primary outcome (one or more of: augmentation, instrumental birth, Caesarean, maternal blood transfusion, 3rd/4th degree tear, maternal admission to higher level care) (5.6% vs. 8.1%, aRR = 0.68, 95% CI 0.44-1.07). For severely obese nulliparous women we found a non-significant 14% increased risk of the primary outcome (37.6% vs 34.8%, aRR = 1.14, 95% CI 0.97-1.33). High proportions of severely obese women had a 'straightforward vaginal birth' (nulliparous 67.9%; multiparous 96.3%). Severely obese women were more likely than comparison women to have an intrapartum Casearean section, but Caesarean section rates were low and the absolute difference small (4.7% vs 4.1%; aRR = 1.62; 95% CI 1.02-2.57). In nulliparous women, severely obese women were more likely to have an urgent Caesarean section (12.2% vs. 6.5%, aRR = 1.80, 95% CI 1.05-3.08), or a PPH≥1500ml (5.1% vs. 1.7%, aRR = 3.01, 95% CI 1.24-7.31). CONCLUSIONS: We found no evidence of significantly increased risk associated with planning birth in an AMU for carefully selected multiparous severely obese women, with BMI 35.1-40kg/m2. Severely obese nulliparous women have a potential increased risk of having a more urgent Caesarean section or severe PPH compared with other women admitted to AMUs.

Midwifery policy in contemporary and modern China: From the past to the future.

OBJECTIVE: This study aims to outline the progress of midwifery-related policies in contemporary and modern China as well as the obstacles in this process, and to provide recommendations for policy makers in the establishment of Chinese midwifery policies, ultimately promoting the development of midwifery in China. BACKGROUND AND INTRODUCTION: Policy plays an increasingly important role in midwifery development, particularly needed in modern China. A review of policies of midwifery could help policy makers develop effective strategies to address current problems in China, including the insufficient numbers of midwives, the shrinking of responsibility and the degradation of midwives' competency. METHODS: The Policy Triangle was used to examine through literature the laws and regulations regarding midwifery from 1928 in China and was conducted from April to September in 2013. This was followed by insider interviews with two senior policy makers from the National Health Commission to explain nursing policy progress, thereby identifying the reasons why midwifery has developed more slowly than nursing. RESULTS: The development of midwifery in China could be classified into four stages: (1) the beginning period (1928-1949), beginning with the first midwifery rules; (2) the development period (1949-1979), in which the quality and quantity of midwives were significant; (3) the unclear positioning period (1979-2008), without clear midwifery policy; and (4) the subordination to nursing period (2008-present), with the Nurse Byelaw 2008 stating that midwives must apply for nursing licenses. DISCUSSION: The main factors influencing midwifery policies are: (1) social background, such as the changes of different governments and health care reform, and (2) the powers of the actors. Currently, it is an appropriate time to develop strategies for policy makers to facilitate midwifery development in China. CONCLUSIONS AND IMPLICATIONS FOR HEALTH POLICY: Midwifery policy should be independently included in the frame of national medical industry reform because midwives are an indispensable part of the health care workforce. In-depth research should be conducted to confirm the position of midwifery in China to ensure its sustainable development.

Nature and scope of certified nurse-midwifery practice: A workforce study.

AIMS AND OBJECTIVES: To describe the nature and scope of nurse-midwifery practice in Texas and to determine legislative priorities and practice barriers. BACKGROUND: Across the globe, midwives are the largest group of maternity care providers despite little known about midwifery practice. With a looming shortage of midwives, there is a pressing need to understand midwives' work environment and scope of practice. DESIGN: Mixed methods research utilising prospective descriptive survey and interview. METHODS: An online survey was administered to nurse-midwives practicing in the state of Texas (N = 449) with a subset (n = 10) telephone interviewed. Descriptive and inferential statistics and content analysis was performed. RESULTS: The survey was completed by 141 midwives with eight interviewed. Most were older, Caucasian and held a master's degree. A majority worked full-time, were in clinical practice in larger urban areas and were employed by a hospital or physician group. Care was most commonly provided for Hispanic and White women; approximately a quarter could care for greater numbers of patients. Most did not clinically teach midwifery students. Physician practice agreements were believed unnecessary and prescriptive authority requirements restrictive. Legislative issues were typically followed through the professional organisation or social media sites; most felt a lack of competence to influence health policy decisions. While most were satisfied with current clinical practice, a majority planned a change in the next 3 to 5 years. CONCLUSIONS: An ageing midwifery workforce, not representative of the race/ethnicity of the populations served, is underutilised with practice requirements that limit provision of services. Health policy changes are needed to ensure unrestricted practice. RELEVANCE TO CLINICAL PRACTICE: Robust midwifery workforce data are needed as well as a midwifery board which tracks availability and accessibility of midwives. Educators should consider training models promoting long-term service in underserved areas, and development of skills crucial for impacting health policy change.

From equity to power: Critical Success Factors for Twinning between midwives, a Delphi study.

AIMS: To gain consensus for Critical Success Factors associated with Twinning in Midwifery. BACKGROUND: International publications identify midwifery as important for improving maternity care worldwide. Midwifery is a team effort where midwives play a key role. Yet their power to take on this role is often lacking. Twinning has garnered potential to develop power in professionals, however, its success varies because implementation is not always optimal. Critical Success Factors have demonstrated positive results in the managerial context and can be helpful to build effective Twinning relationships. DESIGN: We approached 56 midwife Twinning experts from 19 countries to participate in three Delphi rounds between 2016 - 2017. METHODS: In round 1, experts gave input through an open ended questionnaire and this was analysed to formulate Critical Success Factors statements that were scored on a 1-7 Likert scale aiming to gain consensus in rounds 2 and 3. These statements were operationalized for practical use such as a check list in planning, monitoring and evaluation in the field. FINDINGS: Thirty-three experts from 14 countries took part in all three Delphi rounds, producing 58 initial statements. This resulted in 25 Critical Success Factors covering issues of management, communication, commitment and values, most focus on equity. CONCLUSION: The Critical Success Factors formulated represent the necessary ingredients for successful Twinning by providing a practical implementation framework and promote further research into the effect of Twinning. Findings show that making equity explicit in Twinning may contribute towards the power of midwives to take on their identified key role.

Registered nurse and midwife experiences of using videoconferencing in practice: A systematic review of qualitative studies.

AIM AND OBJECTIVE: To synthesise evidence of registered nurses' and midwives' experiences with videoconferencing and identify perceptions of the appropriateness, meaningfulness and feasibility of this technology in professional and clinical practice. BACKGROUND: Videoconferencing is a form of telehealth that can facilitate access to high-quality care to improve health outcomes for patients and enable clinicians working in isolation to access education, clinical supervision, peer support and case review. Yet use of videoconferencing has not translated smoothly into routine practice. Understanding the experiences of registered nurses and midwives may provide practitioners, service managers and policymakers with vital information to facilitate use of the technology. DESIGN: A qualitative meta-synthesis of primary qualitative studies undertaken according to Joanna Briggs Institute methodology. METHOD: A systematic search of 19 databases was used to identify qualitative studies that reported on registered nurses' or midwives' experiences with videoconferencing in clinical or professional practice. Two reviewers independently appraised studies, extracted data and synthesised findings to construct core concepts. RESULTS: Nine studies met the criteria for inclusion. Five key synthesised findings were identified: useful on a continuum; broader range of information; implications for professional practice; barriers to videoconferencing; and technical support, training and encouragement. CONCLUSIONS: While videoconferencing offers benefits, it comes with personal, organisational and professional consequences for nurses and midwives. Understanding potential benefits and limitations, training and support required and addressing potential professional implications all influence adoption and ongoing use of videoconferencing. RELEVANCE TO CLINICAL PRACTICE: Registered nurses and midwives are well placed to drive innovations and efficiencies in practice such as videoconferencing. Nursing and midwifery practice must be reframed to adapt to the virtual environment while retaining valued aspects of professional practice. This includes ensuring professional standards keep pace with the development of knowledge in this area and addressing the findings highlighted in this meta-synthesis.

The universal, collaborative and dynamic model of specialist and advanced nursing and midwifery practice: A way forward?

AIMS AND OBJECTIVES: To inform and guide the development of a future model of specialist and advanced nursing and midwifery practice. BACKGROUND: There is a sizable body of empirical literature supporting the unique contributions of specialist and advanced practice roles to health care. However, there is very little international evidence to inform the integration of a future model for advanced or specialist practice in the Irish healthcare system. DESIGN: A qualitative study was conducted to initiate this important area of inquiry. METHODS: Purposive sampling was used to generate a sample of informants (n = 15) for the interviews. Nurses and midwives working in specialist and advanced practice and participants from other areas such as legislative, regulatory, policy, medicine and education were included in the sampling frame. RESULTS: Arguments for a new model of specialist and advanced practice were voiced. A number of participants proposed that flexibility within specialist and advanced practitioner career pathways was essential. Otherwise, there existed the possibility of being directed into specialised "silos," precluding movement to another area of integrated practice. Future specialist and advanced practice education programmes need to include topics such as the development of emotional and political intelligence. CONCLUSION: The contribution of specialist and advanced practice roles to the health service includes providing rapid access to care, seamless patient flow across services, early discharge and lead coordinator of the patient's care trajectory. There was a recommendation of moving towards a universal model to cultivate specialist and advanced nurse and midwife practitioners. RELEVANCE TO CLINICAL PRACTICE: The model design has Universal application in a range of contexts "U." It is Collaborative in its inclusivity of all key stakeholders "C." The model is Dynamic pertinent to accommodating movement of nurses and midwives across health continua rather than plateauing in very specialised "silos" "D."

[Professional policies: a qualitative study of perceptions and opinions of professionals nurses/midwives and students attending the Master of Science in Nursing]. / Politiche professionali: studio qualitativo sulle percezioni e le opinioni dei professionisti infermieri/ostetriche e degli studenti della Laurea magistrale in Scienze infermieristiche e ostetriche.

INTRODUCTION: Politics, the science and the art of administering public affairs, is a very important field. Dealing with professional policy means to dedicate ourselves to the good of the profession. Professional policies are an integral part of taking care; the professional family needs clear reference points: training, tutoring, promotion and institutional representation. AIM: Exploring perceptions, ideals, shared imagination and desires about the professional policies of nurses/midwives and of master's students in order to be able to have a representation of the reality and to start a critical reflection on the subject. METHOD: A qualitative study was conducted on a proactive sample of 22 nurses / midwives as qualified witnesses of the national situation. The data was collected through a questionnaire built ad hoc. RESULTS: From the analysis of the answers given to the questionnaire, we identified 10 main themes. In the training sector two of the themes that were selected are the importance of the new knowledges and inadequate differentiation of the positions; Regarding the working sector two of the themes that came out are the lack of meritocracy and of new opportunities; meanwhile, in the research field one of the main theme identified is the gap between the theory and the practice. CONCLUSION: The present study finds out that participation in policy-making processes is occasional and of little intensity: just few nurses/midwives are actively involved in the promotion and development of projects in the health sector and of healthcare policies.

Protecting the Public: An Investigation of Midwives Perceptions of Regulation and the Regulator.

OBJECTIVE: to investigate the perceptions of a group of midwifery registrants about the influence of regulation and the regulatory body, the Nursing and Midwifery Council, on the practice of midwives in the United Kingdom DESIGN: quantitative and qualitative research using an online survey and semi-structured interviews SETTING: The South East of England, which covers both urban and rural practice settings. PARTICIPANTS: (a) 132 (n=70%) midwives responded to the online survey, and (b) 20 midwives participated in the semi-structured interviews FINDINGS: midwives were generally supportive of the need to regulate practice; however, some participants had an uneasy relationship with the Nursing and Midwifery Council and claimed to practice defensively, due to a fear that they could be removed from the register, and believed the regulator to be remote and punitive. For other participants concerns were raised about fitness to practice procedures, particularly in terms of decision-making. KEY CONCLUSIONS: the participants felt that in order for midwifery regulation to be effective the regulator needs to have detailed knowledge and appreciation of the role of the midwife, and the needs of the pregnant woman.

Variation in Cesarean Birth Rates by Labor and Delivery Nurses.

OBJECTIVE: To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses. DESIGN: Retrospective cohort study. SETTING: One high-volume labor and delivery unit at an academic medical center in a major metropolitan area. PARTICIPANTS: Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation. METHODS: Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses. RESULTS: Seventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile. CONCLUSION: The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.