Multicomponent perinatal breastfeeding support in women with BMI >25: The Latch On multi-centre randomised trial.

OBJECTIVE: To investigate the effectiveness of a multicomponent breastfeeding support intervention on breastfeeding prevalence at 3 months among women with a body mass index (BMI) >25 kg/m2. DESIGN: Multicentre multicomponent randomised controlled trial. SETTING: Four maternity centres in Ireland. POPULATION: A total of 225 primiparous women and their nominated support partners. Participants were aged 18 years and over, with BMI ≥25 kg/m2, carrying a singleton pregnancy and without contraindication for breastfeeding. METHODS: The intervention included an antenatal group breastfeeding education session for participants and their support partners, followed by a planned postnatal breastfeeding assessment and telephone support for up to 6 weeks by a lactation consultant. MAIN OUTCOME MEASURES: Any breastfeeding at 3 months postpartum. RESULTS: Any breastfeeding prevalence was 68.7% (n = 68) in the intervention group and 62.1% (n = 59) in the control group at 3 months postpartum (odds ratio 1.33, 95% confidence interval 0.72-2.46, p = 0.36). Any and exclusive breastfeeding rates did not significantly differ at any other time point. More women in the control group accessed support from private lactation consultants (intervention 23.5% [n = 12], control 45.3% [n = 24], p = 0.02). CONCLUSIONS: The control group had higher than expected breastfeeding rates, and the study found no evidence of effect on the primary outcome. Providing comprehensive education and support for women intending to breastfeed remains of paramount importance.

Enablers and challenges to advanced nursing and midwifery practice roles.

AIM: To describe the enablers and challenges to the development and implementation of advanced nursing and midwifery practice roles in Ireland. BACKGROUND: Leadership strategies need to be put in place to enhance the development and implementation of advanced nursing and midwifery practice roles. METHOD: A descriptive qualitative approach using semi-structured interviews with key stakeholders (n = 15) was undertaken with nurses and midwives working in specialist and advanced practice roles and participants from other areas such as legislative, regulatory, policy, pharmacy, medicine and education. RESULTS: Participant's perspectives on the enablers and challenges to enacting specialist and advanced practice roles resulted in the generation of three themes: organisational factors; collegial, interprofessional and interpersonal support; and role clarity, economic and regulatory contexts. CONCLUSION: Addressing organisational factors, encouraging collegial and interprofessional support and establishing role clarity contribute to the effective development and implementation of the role of advanced practitioners. IMPLICATIONS FOR NURSING AND MIDWIFERY MANAGEMENT: Managers of nursing services need to provide leadership in developing strategies to enhance the enablers and overcome the challenges to advanced practice role development in their own organisation.

Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers.

AIMS AND OBJECTIVES: To collate, synthesise and discuss published evidence and expert professional opinion on enablers and barriers to the development and sustainability of specialist and advanced practice roles in nursing and midwifery. BACKGROUND: Expanded practice is a response to population health needs, healthcare costs and practitioners' willingness to expand their scope of practice through enhanced responsibility, accountability and professional autonomy. DESIGN: This discursive paper is based on a rapid review of literature on enablers and barriers to the development and sustainability of specialist and advanced practice roles and is part of a wider policy analysis. METHODS: We analysed and synthesised of 36 research articles, reviews and discussion papers on enablers and barriers in the development and sustainability of expanded practice roles. RESULTS: Several factors enable role expansion, including: role clarity; credentialing and endorsement; availability of education for expanded roles; individual practitioners' dispositions towards role expansion; support from peers, other professionals and the work organisation; and costs. Where limited or absent, these same factors can constrain role expansion. CONCLUSIONS: Enabling nurses and midwives to practice to their full scope of education and expertise is a global challenge for disciplinary leadership, a national challenge for professional regulation and a local challenge for employers and individual clinicians. These challenges need to be addressed through multistakeholder coordinated efforts at these four levels. RELEVANCE TO CLINICAL PRACTICE: This discursive paper synthesises empirical evidence and expert professional opinion on the factors that enable or hinder the development and sustainability of specialist and advanced practice roles. Providing a critical appraisal of current knowledge, it provides a reference source for disciplinary debate and policy development regarding the nursing and midwifery resource and informs clinicians of the myriad issues that can impact on their capacity to expand their scope of practice.

Using rapid reviews: an example from a study conducted to inform policy-making.

AIM: A discussion of the potential use of rapid review approaches in nursing and midwifery research which presents a worked example from a study conducted to inform policy decision-making. BACKGROUND: Rapid reviews, which can be defined as outputs of a knowledge synthesis approach that involves modifying or omitting elements of a systematic review process due to limited time or resources, are becoming increasingly popular in health research. This paper provides guidance on how a rapid review can be undertaken and discusses the strengths and challenges of the approach. DESIGN: Data from a rapid review of the literature undertaken in 2015 is used as a worked example to highlight one method of undertaking a rapid review. IMPLICATIONS FOR NURSING: Seeking evidence to inform health policy-making or evidence based practice is a process that can be limited by time constraints, making it difficult to conduct comprehensive systematic reviews. Rapid reviews provide a solution as they are a systematic method of synthesizing evidence quickly. CONCLUSIONS: There is no single best way to conduct a rapid review but researchers can ensure they are adhering to best practice by being systematic, having subject and methodological expertise on the review team, reporting the details of the approach they took, highlighting the limitations of the approach, engaging in good evidence synthesis and communicating regularly with end users, other team members and experts.

The perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners.

AIM: To explore the perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners. BACKGROUND: There is evidence that the contribution of these roles to patient care is poorly understood. DESIGN: This research took place over 2 months in 2015 and is part of a larger study involving a rapid review to inform policy development on the specialist and advanced nursing and midwifery practice in Ireland. As an added value, a qualitative element involving thematic analysis was undertaken with key stakeholders. METHODS: A phenomenological qualitative study was conducted incorporating semi-structured interviews with key stakeholders (n = 15). Purposive sampling with maximum diversity was used to recruit a wide range of perspectives. FINDINGS: Participant's perspectives led to seven themes: Impact of these roles; role preparation, experience and organizational support; specialist and advanced practice roles in an interdisciplinary context; different folks but not such different roles; impact of specialist and advanced practice roles on patient outcomes; barriers and facilitators to enacting specialist and advanced practice roles; future development of these roles. CONCLUSION: There is acknowledgement of the positive impact of specialist and advanced practitioners; however, the evidence is currently not conclusive. Preparation for these roles needs to reflect changes in the calibre of today's professional applicants, and organizational support is paramount to their successful execution. The contribution of their activity to patient outcome needs to be made visible to enhance these roles and to justify the development of new roles across a variety of healthcare areas.

Intraoperative risk factors associated with postoperative pressure ulcers in critically ill patients: a retrospective observational study.

OBJECTIVE: The risk for pressure ulcers is rarely identified in the perioperative period, and the influence of this period on risk factors has not been as rigorously studied as the postoperative period. We hypothesized that intraoperative risk factors exist, which increase the likelihood of a postoperative new-onset pressure ulcer. DESIGN: A retrospective observational study. SETTING: A large midwestern U.S. quaternary care institution. PATIENTS: A total of 2,695 adult surgical patients underwent operative procedures and received care in one of three ICUs using an electronic documentation application. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital-acquired pressure ulcer categorized as stages II, III, and IV; deep tissue injury; or unstageable. Univariate analyses comparing patients with and without the outcome of pressure ulcers were conducted for each preoperative characteristic or comorbidity. Patients were matched using the logit of the propensity score based solely on their preoperative comorbidities. Adjusted associations between development of pressure ulcers and intraoperative characteristics were determined in the postmatch cohort. We identified seven independent preoperative patients' characteristics and comorbidities in our adult surgical patient sample: American Society of Anesthesiologists risk classification 4 or 5, underweight body mass index, noncardiac surgery, history of congestive heart failure, renal disease, existing airway present prior to arrival in the operating room, and age. The only significant association in the matched dataset accounting for patient preoperative variability is the use of intraoperative blood products. CONCLUSION: Postoperative pressure ulcers developed in 10.7% of critically ill patients in our study. Only intraoperative use of blood products, not operative case length, hypotension, or vasopressor use, was associated with postoperative pressure ulcer development on adjusted analysis.

A cross-sectional survey study of nurses' self-assessed competencies in obstetric and surgical postanesthesia care units.

PURPOSE: The purpose of this study was to identify priorities to guide development of an obstetric PACU continuing education curriculum. DESIGN: A cross-sectional, survey design was used. METHODS: A total of 54 obstetric nurses and 68 perianesthesia Phase I nurses at an academic, tertiary care center completed online surveys for self-assessment of recent education, competency, and encounters with 14 topics related to postanesthesia nursing (eg, basic life support [BLS], advanced cardiac life support [ACLS], neonatal resuscitation, and the American Society of Perianesthesia Nurses' standards). FINDINGS: Obstetric nurses reported low encounters, competency, and recent training in all study topics except oxygen administration, phlebotomy, BLS, and neonatal resuscitation. Perianesthesia Phase I nurses indicated high encounters, competency, and recent training for all topics except for ACLS and malignant hyperthermia. All nurses indicated the need for arranging debriefing sessions after life-threatening situations. CONCLUSION: Results suggest that obstetric-postanesthesia care unit (PACU) nursing should focus on continuing education curriculum development, whereas main surgical-PACU emphasis should be on skills assessment. Future research should be directed to knowledge- (didactics) and skills- (simulation) educational programs, including maintenance and assessment of skills unique to obstetric-PACU care.

Mother's Emotional Experiences of Breastfeeding with Primary Low Milk Supply in the First Four Months Postpartum: An Interpretative Phenomenological Analysis.

Background: Primary low milk supply (PLMS) prevents mothers from producing sufficient milk to breastfeed exclusively. However, limited evidence exists regarding women's experiences of breastfeeding with PLMS. Objective: This article aims to investigate the emotional experiences of mothers breastfeeding with PLMS in the first 3 months postpartum. Materials and Methods: The study was conducted in Ireland and used a phenomenological methodology to investigate the lived experiences of breastfeeding mothers with PLMS. Nine first-time breastfeeding mothers with PLMS participated, and data collection took the form of unstructured interviews. Data analysis was completed using Interpretative Phenomenological Analysis. Results: Being in the Whirlwind is one of four superordinate themes identified in this study. This theme relates to participants' internalized experiences of breastfeeding with PLMS in the first 3 months postpartum. During this time, participants struggled to come to terms with having PLMS and became caught up in all-consuming efforts to increase their milk supply. They experienced guilt, sadness, confusion, anger, and anxiety, with many describing the early months postpartum as traumatic. Participants revealed how triple-feeding (a regime of breastfeeding, pumping, and supplementing) negatively affected their mental health and reported that supplementing with infant formula was emotionally upsetting. Conclusions: Our findings reveal that the combination of PLMS and triple feeding can negatively impact a mothers' mental health. A greater understanding among health care professionals of the emotional impact of having PLMS and triple-feeding could enhance the provision of sensitive and person-centered support for those with PLMS. Antenatal breastfeeding education should acknowledge that PLMS is a challenge for a small cohort of women and place greater emphasis on the emotional aspects of breastfeeding challenges.

The importance of communication and involvement in decision-making: A study in Ireland exploring birth satisfaction using the Birth Satisfaction Scale-Revised (BSS-R).

INTRODUCTION: Evaluation in healthcare services has become a priority, globally1. The Government of Ireland has highlighted the importance of stakeholder engagement to identify the needs of women in the design and delivery of high-quality health services, driven by necessity rather than financial ability2. The Birth Satisfaction Scale-Revised (BSS-R), an internationally validated tool, and recommended for measuring childbirth satisfaction by the International Consortium for Health Outcomes Measurement (ICHOM)3; however, it has yet to be considered in the Irish context. The aim of the study was to explore birth satisfaction with a sample of new mothers in Ireland. METHODS: A mixed-methods study was conducted including a survey that involved collection of data from the BSS-R 10-item questionnaire from 307 mothers over an 8-week period in 2019, in one urban maternity hospital in Ireland. Quantitative and qualitative data were collected. Qualitative data from the free-text comments of the survey questions were analyzed using content analysis. RESULTS: Overall, women reported positive relationships with their care providers and were satisfied with the communication and support they received, as well as high levels of control and choice. Postnatal care, however, was highlighted as being less satisfactory with staffing levels described as inadequate. CONCLUSIONS: Understanding women's birth experiences and what is important to them could facilitate midwives and other health professionals to improve the quality of their care and develop guidelines and policies that focus on women and their families' needs. The vast majority of women rated their birthing experience as extremely positive. The main elements of care that contributed to a positive birthing experience for women were quality relationships with clinicians, choice and control, and emotional safety.

Prone positioning: is it safe and effective?

Prone positioning has been used as a treatment option for patients with acute lung injury or acute respiratory distress syndrome (ARDS) since the early 1970s. Prone position and extended prone position ventilation have been shown to increase end-expiratory lung volume, alveolar recruitment, and oxygenation in patients with severe hypoxemic and acute respiratory failure. Prone positioning is not a benign procedure, and there are potential risks (complications) that can occur to both the patient and the health care worker. Notable complications that can arise include: unplanned extubation, lines pulled, tubes kinked, and back and other injuries to personnel. Prone positioning is a viable, inexpensive therapy for the treatment of severe ARDS. This maneuver consistently improves systemic oxygenation in 70% to 80% of patients with ARDS. With the utilization of a standardized protocol and a trained and dedicated critical care staff, prone positioning can be performed safely.

A participatory action research study exploring midwives' understandings of the concept of burnout in Ireland.

INTRODUCTION: In depth exploration of the burnout phenomenon among midwives is sparse. The concept has been extensively studied, but predominantly reports rates and evaluates interventions to reduce burnout. A definition has yet to be offered in the literature from a midwifery perspective. AIMS: To explore midwives' understandings of burnout, professionally and personally, in the context of contemporary maternity care in Ireland. METHODS: This was a Two-phase Participatory Action Research study. Five co-operative inquiry meetings were held with practising midwives (n=21) over a six-month period between October 2018 and March 2019, in a large, urban teaching maternity hospital in Dublin, Ireland. FINDINGS: We found that multiple factors contributed to midwives' perceptions and understandings of the concept of burnout. Midwives defined burnout as persistent stress and exhaustion, with an associated reduction of their individual coping abilities, motivation, empathy and/or efficacy, is unique to the individual and is primarily, in the midwifery context, caused and inextricably linked to excessive workload. CONCLUSION: Burnout is a complex concept with many entities and its significance and impact within the midwifery profession highlights the importance of its exploration and understanding. This study is the first of its kind to explore, with midwives, the concept of burnout. The elements of stress and exhaustion in the definition mirror existing definitions in the literature.

Reducing midwife burnout at organisational level - Midwives need time, space and a positive work-place culture.

BACKGROUND: Maternity care organisations have a responsibility to ensure the health and welfare of their staff. Rates of burnout are high in midwifery compared to other professionals. Therefore, exploring how it can be reduced is imperative. AIM: To explore with midwives the contributors to burnout and how best to reduce burnout in a maternity hospital in Ireland. METHODS: A Participatory Action Research study involving Co-operative Inquiry meetings (n = 5) with practising midwives (n = 21) between October 2018 and March 2019, in a large, urban teaching maternity hospital in Ireland. The transcribed data were analysed using Thematic Network Analysis. FINDINGS: Several recommendations were made for maternity organisations, to reduce or prevent burnout. These include improving workplace culture, increasing support and acknowledgement, offering time and space for debriefing and reflection and regular rotation of staff. Consistent staff shortages are, however, a barrier to adhering to these recommendations. CONCLUSION: This study is the first of its kind to offer an in-depth exploration with midwives into the main contributors of burnout and what can be done at an organisational level to reduce burnout among midwives. The findings of this study highlighted the importance of working relationships. Additionally, owing to the nature of midwifery practice, time and space need to be created for midwives to debrief and reflect. However, there is an urgent need for healthcare systems to combat staffing shortages in order for these strategies to be successful.

Embedding continuity of care into a midwifery curriculum in the Republic of Ireland: A historical context.

Maternity services in Ireland have historically been predominantly hospital-based and obstetric-led. Although evidence suggests midwifery-led care is safe and effective, its presence in Ireland continues to be limited in practice. An increase in the available models of maternity care for women has been recommended by the Department of Health in Ireland to promote a woman-centered approach. The latest requirement for midwifery students to have a continuity of care experience within their curriculum offers educators the opportunity to facilitate differing models of care prior to qualification as a registrant, providing an experience to explore midwifery philosophy in practice. The use of a case-loading model, adopted by a university in the East of Ireland in the final year of the program may be a successful way for students to gain midwifery skills as well as offering midwifery students the exposure to another model of care. Such experiences may also enhance their ability to drive and shape midwifery-led services in the future and also build midwifery workforce capacity in continuity of care models.

'Labour Hopscotch': Women's evaluation of using the steps during labor.

INTRODUCTION: Concerns have been expressed globally about the decline in rates of physiological birth and rising intervention rates during labor and birth. The 'Labour Hopscotch' Framework, a visual depiction of steps required to remain active during labor was implemented in a large tertiary maternity hospital in Ireland. The aim of this study was to evaluate the steps of the Labour Hopscotch women found most useful, examine the use of non-pharmacological and pharmacological methods of pain relief used during labor and finally to investigate the labor and birth outcomes of women who used 'Labour Hopscotch' during labor. METHODS: A descriptive cross-sectional study was conducted using a study specific questionnaire. RESULTS: A total of 809 women completed the questionnaire. The Labour Hopscotch Framework was positively evaluated. Mobilizing, the birthing ball, birthing stool, and water therapy were found to be the most useful steps. Primiparous women were more likely to use non-pharmacological methods of pain relief. Pharmacological methods used by women were entonox (67.5%), pethidine (8%) and epidural analgesia (38.5%). Primiparous women were more likely to have epidural analgesia than multiparous women (p<0.00001). Women that attended either private (p=0.004) or public-led obstetric (p=0.005) antenatal care were more likely to have epidural analgesia in labor. Women attending the community midwives were least likely to receive epidural analgesia during labor. The rates of spontaneous vaginal birth, assisted birth and cesarean section, were 77.1%, 14% and 8.7%, respectively. CONCLUSIONS: Our study findings contribute to the increasing national and international evidence that initiatives such as Labour Hopscotch can promote and advocate for women to be active and mobile during labor to support physiological birth.

Exploring midwives' experiences of implementing the Labour Hopscotch Framework: A midwifery innovation.

INTRODUCTION: Midwives are ideally placed to promote physiological birth and improve women's birth experiences. Freedom of movement in labor is highly recommended as it reduces a need for obstetric interventions in labor and prevents and corrects labor complications, such as poor progress and malposition of the fetus. The Labour Hopscotch Framework (LHF) provides women and midwives with a visual depiction of the steps they can undertake to remain active and, in this way, support physiological birth processes. The objective of this study was to explore midwives' experiences of supporting women during labor with the Labour Hopscotch Framework and identify any improvements necessary to the Labour Hopscotch Framework. METHODS: A two phased mixed-method sequential explanatory design study consisting of a survey (women, n=809 and partners, n=759) and focus group (n=8 midwives) was completed to evaluate the LHF following its implementation. This article presents the findings reporting midwives' perceptions of using the Labour Hopscotch Framework with women and their birthing partners. The setting was a large urban teaching maternity hospital in Dublin, Ireland, where eight midwives practiced in the following areas: labor suite, antenatal unit, and community midwifery. RESULTS: The Labour Hopscotch Framework was described as beneficial in promoting physiological birth, using a creative, attractive visual depiction to guide women in, and before, labor. The Labour Hopscotch Framework was deemed helpful in increasing midwifery students and newly qualified midwives' confidence to provide women with tangible, supportive assistance during labor and increased partners' involvement in the labor process. CONCLUSIONS: Labour Hopscotch Framework should be more widely promoted to all women attending the hospital for maternity care and a clear explanation of each step given and demonstrated to increase women's understanding of the steps within. Labour Hopscotch training should be included in midwifery education programs.

Cardiac arrest in the PACU: an analysis of evolving challenges for perianesthesia nursing.

Cardiac arrest in the PACU is a rare and poorly described event, with attendant limitations to experiential learning for the perianesthesia nurse. Good outcome from in-hospital cardiac arrest events differs partly because of variability in direct causes and clinical responses. Development of in-house training programs tailored to retain basic and advanced life support skills and enhance perianesthesia nurse responses to PACU arrests are essential to improving outcomes.

Correction to: A small Iowa farmer's perspective on COVID-19.

[This corrects the article DOI: 10.1007/s10460-020-10084-y.].

The importance of nurturing trusting relationships to embed shared decision-making during pregnancy and childbirth.

OBJECTIVE: To generate greater awareness of the contextual and relational factors that influence women's capacity to participate in shared decision-making during childbirth. METHODS: A three-phase participatory action research approach involving in-depth interviews and co-operative inquiry meetings. SETTING: Dublin, Ireland in a large maternity hospital. PARTICIPANTS: Five postnatal women who gave birth to live healthy babies, and attended obstetric or midwifery-led care and 13 practising midwives. FINDINGS: This paper presents the findings from the third phase of a three-phase action research study exploring the action's women consider necessary to embed informed choice, into practice. The findings reveal that multiple organisational and relational factors influence how women can participate in shared decision-making including the model of care they attended, continuity of carer, power dynamics, hospital policies and trust in self and others. Women's relationships with maternity care professionals reveals that exercising choice is not only defined by but contingent on the degree of trust in their relationships with maternity care professionals.