The prevalence of and factors associated with prior induced abortion among women who gave birth in Victoria, 2010-2019.

OBJECTIVE: To assess the prevalence of a history of induced abortion among women who gave birth in Victoria during 2010-2019; to assess the association of socio-demographic factors with a history of induced abortion. STUDY DESIGN: Retrospective cohort study; analysis of cross-sectional perinatal data in the Victorian Perinatal Data Collection (VPDC). SETTING, PARTICIPANTS: All women who gave birth (live or stillborn) in Victoria, 1 January 2010 - 31 December 2019. MAIN OUTCOME MEASURES: Self-reported induced abortions prior to the index birth; outcome of the most recent pregnancy preceding the index pregnancy. RESULTS: Of the 766 488 women who gave birth during 2010-2019, 93 251 reported induced abortions (12.2%), including 36 938 of 338 547 nulliparous women (10.9%). Women living in inner regional (adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.93-0.96) or outer regional/remote/very remote areas (aOR, 0.86; 95% CI, 0.83-0.89) were less likely than women in major cities to report induced abortions. The likelihood increased steadily with age at the index birth and with parity, and was also higher for women without partners at the index birth (aOR, 2.20; 95% CI, 2.16-2.25) and Aboriginal and Torres Strait Islander women (aOR, 1.32; 95% CI, 1.25-1.40). The likelihood was lower for women born in most areas outside Australia than for those born in Australia. The likelihood of a history of induced abortion declined across the study period overall (2019 v 2010: 0.93; 95% CI, 0.90-0.96) and for women in major cities (0.88; 95% CI, 0.84-0.91); rises in inner regional and outer regional/remote/very remote areas were not statistically significant. CONCLUSIONS: Access to abortion care in Victoria improved during 2010-2019, but the complex interplay between contraceptive use, unintended pregnancy, and induced abortion requires further exploration by remoteness of residence. Robust information about numbers of unintended pregnancies and access to reproductive health services are needed to guide national sexual and reproductive health policy and practice.

Barriers and enablers to accessing perinatal health services for rural Australian women: A qualitative exploration of rural health care providers perspectives.

OBJECTIVE: To identify perceived barriers and enablers for rural women in accessing perinatal care within their own community from the perspective of perinatal health care providers. DESIGN: A qualitative descriptive study design utilising reflexive thematic analysis, using the socioecological framework to organise and articulate findings. SETTING: Victoria, Australia. PARTICIPANTS: Semi-structured interviews were conducted with nine perinatal health care providers who provide care to pregnant women or new mothers in rural communities. Participants were recruited across Victoria in 2023. RESULTS: Providers reported multi-level barriers and enablers that exist for rural women in accessing perinatal care within their communities. Barriers included women's personal circumstances, challenging professional relationships, inequitable service provision, ineffective collaboration between services and clinicians and government funding models and policies. Enablers included strength and resilience of rural women, social capital within rural communities, flexible care delivery and innovative practice, rural culture and continuity of care models. CONCLUSION: Rural perinatal health care providers perceived that rural women face multiple barriers that are created or sustained by complex interpersonal, organisational, community and policy factors that are intrinsic to rural health care delivery. Several addressable factors were identified that create unnecessary barriers for rural women in engaging with perinatal care. These included education regarding health systems, rights and expectations, equitable distribution of perinatal services, improved interprofessional relationships and collaborative approaches to care and equity-based funding models for perinatal services regardless of geographical location.

Perinatal outcomes of socially disadvantaged women in Australia: A population-based retrospective cohort study.

OBJECTIVE: To examine the perinatal outcomes of women who experience social disadvantage using population-based perinatal data collected between 1999 and 2016. DESIGN: Population-based, retrospective cohort study. SETTING: Victoria, Australia. POPULATION OR SAMPLE: A total of 1 188 872 singleton births were included. METHODS: Cohort study using routinely collected perinatal data. Multiple logistic regression was performed to determine associations between social disadvantage and adverse maternal and neonatal outcomes with confidence limits set at 99%. Time-trend analysis for perinatal outcomes was performed in relation to area-level disadvantage measures. MAIN OUTCOME MEASURES: Incidence of maternal admission to intensive care unit (ICU), postpartum haemorrhage (PPH) and caesarean section, perinatal mortality, preterm birth, low birthweight (LBW), and admission to special care nursery/neonatal intensive care unit (SCN/NICU). RESULTS: Social disadvantage was associated with higher odds of adverse perinatal outcomes. Disadvantaged women were more likely to be admitted to ICU, have a PPH or experience perinatal mortality (stillbirth or neonatal death) and their neonates were more likely to be admitted to SCN/NICU, be born preterm and be LBW. A persistent social gradient existed across time for the most disadvantaged women for all outcomes except caesarean section. CONCLUSIONS: Social disadvantage has a marked negative impact on perinatal outcomes. This aligns with national and international evidence regarding the impact of disadvantage. Strategies that improve access to, and reduce fragmentation in, maternity care in addition to initiatives that address the social determinants of health may contribute to improving perinatal outcomes for socially disadvantaged women.

Professional care workforce: a rapid review of evidence supporting methods of recruitment, retention, safety, and education.

BACKGROUND: Across the care economy there are major shortages in the health and care workforce, as well as high rates of attrition and ill-defined career pathways. The aim of this study was to evaluate current evidence regarding methods to improve care worker recruitment, retention, safety, and education, for the professional care workforce. METHODS: A rapid review of comparative interventions designed to recruit, retain, educate and care for the professional workforce in the following sectors: disability, aged care, health, mental health, family and youth services, and early childhood education and care was conducted. Embase and MEDLINE databases were searched, and studies published between January 2015 and November 2022 were included. We used the Quality Assessment tool for Quantitative Studies and the PEDro tools to evaluate study quality. RESULTS: 5594 articles were initially screened and after applying the inclusion and exclusion criteria, 30 studies were included in the rapid review. Studies most frequently reported on the professional nursing, medical and allied health workforces. Some studies focused on the single domain of care worker education (n = 11) while most focused on multiple domains that combined education with recruitment strategies, retention strategies or a focus on worker safety. Study quality was comparatively low with a median PEDro score of 5/10, and 77% received a weak rating on the Quality Assessment tool for Quantitative Studies. Four new workforce strategies emerged; early career rural recruitment supports rural retention; workload management is essential for workforce well-being; learning must be contextually relevant; and there is a need to differentiate recruitment, retention, and education strategies for different professional health and care workforce categories as needs vary. CONCLUSIONS: Given the critical importance of recruiting and retaining a strong health and care workforce, there is an immediate need to develop a cohesive strategy to address workforce shortfalls. This paper presents initial evidence on different interventions to address this need, and to inform care workforce recruitment and retention. Rapid Review registration PROSPERO 2022 CRD42022371721 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022371721.

'What is it we are trying to achieve here'? Community maternal and child health nurses and clinical supervision: A qualitative descriptive study.

AIMS: To explore clinical supervision practice by Victorian Maternal and Child Health nurses, identify the self-reported supervision needs of nurses and the facilitators and barriers to meeting those needs. BACKGROUND: Community-based Maternal and Child Health nurses have responsibilities for the safety and wellbeing of children and specific clinical support needs. Clinical supervision has the potential to support nurses' clinical practice and reflective skills; however, little is known internationally about child and family health nurses' supervision practices. DESIGN: Qualitative descriptive study. METHODS: Twenty-three semi-structured interviews were conducted between October and December 2021 with nurses, managers and supervisors across metropolitan, regional/rural areas of Victoria, Australia. Inductive thematic analysis was applied to the data. The Consolidated Criteria for Reporting Qualitative Research guided this study. RESULTS: Three main themes, with subthemes were generated; 'Understand what we do', 'It's the gathering of the nurses' and 'Bringing a case'. A lack of agreed purpose, aims and varied understandings of clinical supervision contributed to suboptimal clinical supervision. Although participants agreed about the importance of clinical supervision, the perceived benefits were inconsistently realized. CONCLUSIONS: This study points to a need for greater organizational awareness of the conditions and leadership needed to build reflective skills and culture in community-based child and family nursing. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research has guided this study. NO PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution in the conduct of this study. IMPACT: A stronger focus is needed to build reflective culture and skill in child and family nursing. Areas for improving child and family nurses' use of clinical supervision have been identified. This study can inform nurse education, policy and service leaders, to strengthen clinical supervision in child and family nursing contexts.

Perpetrator and situational characteristics associated with security alerts in regional Australian emergency departments.

BACKGROUND: Workplace violence is a regular feature of emergency departments (ED) and reported to be increasing in frequency and severity. There is a paucity of data from regional EDs in Australia. The aim of this study was to identify the perpetrator and situational characteristics associated with security alerts in regional emergency departments. METHODS: This retrospective descriptive study was conducted in two regional Australian hospital EDs. All incident reports, hospital summary spreadsheets, and patient medical records associated with a security alert over a two-year period (2017 - 2019) were included. The situational and perpetrator characteristics associated with security alerts in the ED were recorded. RESULTS: One hundred fifty-one incidents were reported in the two-year period. Incidents most frequently occurred on late shifts and in an ED cubicle. Most incidents included multiple disciplines such as ED staff and paramedics, police and psychiatric services. One hundred twenty-five incidents had sufficient information to categorise the perpetrators. Mental and behavioural disorders (MBD) were the most frequent perpetrator characteristic present in security alerts (n = 102, 81.6%) and were associated with increased severity of incidents. MBDs other than psychoactive substance use (PSU) were associated with 59.2% (n = 74) of incidents and 66.7% (n = 18) of injuries. PSU was associated with 42.4% (n = 53) of incidents. Following PSU and MBDs other than PSU, repeat perpetrators were the next most prominent perpetrator category (24.8% n = 31) and were almost always associated with an MBD (93.5% n = 29). CONCLUSIONS: Violence incidents in the ED are often complex, patients present with multiple issues and are managed across disciplines. Interventions need to extend from one size fits all approaches to targeting specific perpetrator groups. Since MBDs are one of the most significant perpetrator factors, interventions focussing on this characteristic are needed to address workplace violence in EDs.

Maternal health care professionals' experiences and views on the use of obstetric ultrasound in Rwanda: A cross-sectional study.

BACKGROUND: This study, undertaken in Rwanda, aimed to investigate health professionals' experiences and views on the following topics: current clinical guidelines for ultrasound from second trimester at the clinic, regional and national levels, and adherence to clinical guidelines; medically indicated ultrasound examinations; non-medical use of ultrasound including ultrasounds on maternal request; commercialisation of ultrasound; the value of ultrasound in relation to other clinical examinations in pregnancy; and ultrasound and medicalisation of pregnancy. METHODS: A cross-sectional design was adopted. Health professionals providing antenatal care and delivery services to pregnant women in 108 health facilities were invited to complete a survey, which was developed based on the results of earlier qualitative studies undertaken as part of the CROss Country Ultrasound Study (CROCUS). RESULTS: Nine hundred and seven health professionals participated: obstetricians/gynecologists (3.2%,) other physicians (24.5%), midwives (29.7%) and nurses (42.7%). Few physicians reported the existence of clinical guidelines at clinic, regional or national levels in Rwanda, and guidelines were moderately adhered to. Three obstetric ultrasound examinations were considered medically indicated in an uncomplicated pregnancy. Most participants (73.0%) were positive about obstetric ultrasound examinations on maternal request. Commercialisation was not considered a problem, and the majority (88.5%) agreed that ultrasound had contributed to medicalisation of pregnancy. CONCLUSIONS: Findings indicate that clinical guidelines for the use of obstetric ultrasound are limited in Rwanda. Non-medically indicated obstetric ultrasound was not considered a current problem at any level of the healthcare system. The positive attitude to obstetric ultrasound examinations on maternal request may contribute to further burden on a maternal health care system with limited resources. It is essential that limited obstetric ultrasound resources are allocated where they are most beneficial, and clearly stated medical indications would likely facilitate this.

Barriers, enablers, and opportunities for organisational follow-up of workplace violence from the perspective of emergency department nurses: a qualitative study.

BACKGROUND: A lack of follow-up of violence incidents and assaulted staff has been associated with high levels of workplace violence. There is a paucity of literature on the barriers, enablers and opportunities for organisational follow-up of workplace violence. The aim of this study was to explore the barriers, enablers and opportunities for organisational follow-up of workplace violence from the perspective of Emergency Department nurses. METHODS: This qualitative study comprised two focus groups with Emergency Department nurses. Data were analysed thematically. COREQ guidelines were followed for the design and reporting of the study. RESULTS: The barriers to follow-up in this study relate to the type of perpetrator, the initial incident response, the incident reporting process and organisational action. The enablers included hospital initiatives to manage violence and support staff wellbeing. The opportunities included strategies to improve follow-up and ideas for new follow-up strategies. CONCLUSIONS: Organisational follow-up is important for the emotional and professional wellbeing of staff who experience workplace violence. Opportunities for follow-up include exploring different approaches to patients with mental health issues and focussing on reoffenders by providing appropriate support and consequences. Managers should advocate for efficient and standardised reporting processes and ensure assaulted staff have a clear perception of follow-up and are included in the follow-up process. Including the perpetrators in the follow-up process may reduce workplace violence.

A much valued tool that also brings ethical dilemmas - a qualitative study of Norwegian midwives' experiences and views on the role of obstetric ultrasound.

BACKGROUND: Midwives are the main providers of routine antenatal care services including the routine ultrasound examination in Norway. The ultrasound examination can be perceived by expectant parents not only as a medical examination but also as a social event facilitating attachment to their fetus. This study explores Norwegian midwives' experiences and views on the role of ultrasound in clinical management of pregnancy. METHODS: A qualitative study design was applied. Twenty-four midwives who all performed obstetric ultrasound examinations were recruited for focus group discussions and individual interviews. Data collection took place in 2015 in five hospitals in two different regions of Norway. Data were analyzed using qualitative content analysis. RESULTS: Midwives described obstetric ultrasound examinations as very valuable although doing ultrasounds placed high demands on their operational and counselling skills. Increasing requests for ultrasound from pregnant women were mentioned. Advancements in ultrasound diagnosis were considered to have put the fetus in the position of a patient, and that pregnant women declining ultrasound could be viewed as irresponsible by some health professionals. Ethical concerns were raised regarding the possibility of pregnancy termination when fetal anomalies were detected. Fears were also expressed that prenatal diagnoses including those following ultrasound, might create a society where only 'perfect' children are valued. However, participants stressed that their intention in performing ultrasound was to optimize pregnancy outcome and thereby assist expectant couples and their unborn children. CONCLUSIONS: Midwives in Norwegian maternity care services describe obstetric ultrasound as very valuable, playing a central role in pregnancy management by optimizing pregnancy outcomes. Although high demands are placed on operators' technical skills and counseling, midwives described performing obstetric ultrasound as very satisfying work. However, midwives believed that expectant parents' approach to the ultrasound examination, both its medical value and the precious images obtained of the fetus, could put extra strain on the midwives performing ultrasounds. The potential of ultrasound to detect fetal anomalies and the possibility that this may lead to termination of pregnancy, seemed to create some ambivalent feelings in midwives towards its use.

Australian parents' experiences when discussing their child's overweight and obesity with the Maternal and Child Health nurse: A qualitative study.

AIMS AND OBJECTIVES: To explore parents' experiences when discussing child overweight issues with the Maternal and Child Health nurse. BACKGROUND: Community-based child and family health nurses are in a unique position to discuss child overweight and obesity with parents. However, studies of parents' experiences in this context are lacking. METHOD: Ten mothers of children identified as overweight or obese from regional Victoria, Australia, were interviewed in 2017. Data were analysed using an inductive qualitative thematic approach. The COREQ guidelines were used to ensure study rigour. RESULTS: In summary, the analysis revealed experiences of Maternal and Child Health nurses "brushing over" the topic, with a lack of information provided about how to tackle the problem at home. The interpersonal relationship aspect of continuity of care was described as facilitating awareness of the child's overweight, although mothers expressed confusion about what constituted a "healthy weight range." While some mothers perceived the nurse's role was to offer evidence-based information and support, others saw the family doctor as the appropriate health professional to address the problem. CONCLUSION: The findings of this study indicate that parents are often left unsure how to manage their child's weight despite the child being identified as overweight or obese by their Maternal and Child Health nurse. RELEVANCE TO CLINICAL PRACTICE: Discussions about overweight and obesity may be facilitated by continuity of care where established relationships serve as a facilitator for effective communication. The findings further indicate a need for more structured support of Maternal and Child Health nurses working with parents of young children identified as overweight or obese, including ongoing education, skill development and improved understanding of parental health literacy and its links to childhood obesity.

Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study.

OBJECTIVE: To explore Rwandan physicians' experiences and views on the role of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. METHODS: Physicians (n = 19) in public and private health facilities in urban and rural Rwanda were interviewed in 2015 as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed qualitatively. RESULTS: Ultrasound was described as an important tool in maternity care. Availability and quality of equipment varied across sites, and considerable disparities in obstetric ultrasound utilisation between rural and urban areas were described. The physicians wanted more ultrasound training and saw the potential for midwives to perform basic scans. Information about fetal sex and well-being was described as women's main expectations of ultrasound. Although women's right to autonomy in pregnancy was supported in principle by participating physicians, fetal rights were sometimes seen as needing physician 'protection'. CONCLUSIONS: There appears to be increasing use and demand for obstetric ultrasound in Rwanda, particularly in urban areas. It seems important to monitor this development closely to secure wise and fair allocation of scarce obstetric expertise and resources and to prevent overuse or misuse of ultrasound. Raising awareness about the benefits of all aspects of antenatal care, including ultrasound may be an important step to improve pregnant women's uptake of services. Increased opportunities for formal ultrasound training, including the training of midwives to perform basic scans, seem warranted. Moreover, in parallel with the transition to more medico-technical maternity care, a dialogue about maternal rights to autonomy in pregnancy and childbirth is imperative.

Self-reported pregnancy-related health problems and self-rated health status in Rwandan women postpartum: a population-based cross-sectional study.

BACKGROUND: Self-rated health status (SRH) can be used as a predictor of morbidity and mortality. Postpartum self-rated health has been used to estimate maternal morbidity and postpartum problems. Reproductive history factors are associated with poor self-rated health postpartum. This study investigated prevalence of self-reported health problems during first, second, and third trimesters of pregnancy, delivery, and postpartum. In addition, this study investigated SRH in Rwandan women up to 13 months from partus. METHODS: This population-based, cross-sectional study collected data in 2014 using structured interviews (N = 921). Univariable analysis was used to identify variables that were associated with poor self-rated health status (poor-SRH). Logistic regression analyses were performed to identify factors associated with poor-SRH at one day, one week, and one month postpartum and at the time of the interview. RESULTS: Mean time between latest delivery and the time of interview was 7.1 months. Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were 15.0, 4.9, 2.4, and 3.7 %, respectively. The prevalence of poor-SRH was 32.2 % at one day postpartum, 7.8 % at one month, and 11.7 % at time of the interview. Hypertension during pregnancy and significant postpartum haemorrhage were associated with poor-SRH at one day and one week postpartum. Severe bleeding during pregnancy and labour were associated with poor-SRH at one week and one month postpartum. Infection and anaemia during pregnancy were associated with poor-SRH at one month postpartum and at the time of interview. The Kaplan-Meier curves illustrate restitution of health for most women during the study period. CONCLUSIONS: This population-based study reports a high prevalence of poor SRH status among Rwandan women in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. These factors may be prevented or reduced by providing more frequent and specific attention during pregnancy and by providing timely measures that address complications during delivery, including adequate postpartum care.

A routine tool with far-reaching influence: Australian midwives' views on the use of ultrasound during pregnancy.

BACKGROUND: Ultrasound is a tool of increasing importance in maternity care. Midwives have a central position in the care of pregnant women. However, studies regarding their experiences of the use of ultrasound in this context are limited. The purpose of this study was to explore Australian midwives' experiences and views of the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and situations where maternal and fetal health interests conflict. METHODS: A qualitative study was undertaken in Victoria, Australia in 2012, based on six focus group discussions with midwives (n = 37) working in antenatal and intrapartum care, as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis. RESULTS: One overarching theme emerged from the analysis: Obstetric ultrasound--a routine tool with far-reaching influence, and it was built on three categories. First, the category'Experiencing pros and cons of ultrasound' highlighted that ultrasound was seen as having many advantages; however, it was also seen as contributing to increased medicalisation of pregnancy, to complex and sometimes uncertain decision-making and to parental anxiety. Second, 'Viewing ultrasound as a normalised and unquestioned examination' illuminated how the use of ultrasound has become normalised and unquestioned in health care and in wider society. Midwives were concerned that this impacts negatively on informed consent processes, and at a societal level, to threaten acceptance of human variation and disability. Third, 'Reflecting on the fetus as a person in relation to the pregnant woman' described views on that ultrasound has led to increased 'personification' of the fetus, and that women often put fetal health interests ahead of their own. CONCLUSIONS: The results reflect the significant influence ultrasound has had in maternity care and highlights ethical and professional challenges that midwives face in their daily working lives concerning its use. Further discussion about the use of ultrasound is needed, both among health professionals and in the community, in order to protect women's rights to informed decision-making and autonomy in pregnancy and childbirth and to curb unnecessary medicalisation of pregnancy. Midwives' experiences and views play an essential role in such discussions.

Two sides of the same coin--an interview study of Swedish obstetricians' experiences using ultrasound in pregnancy management.

BACKGROUND: The extended use of ultrasound that is seen in maternity care in most Western countries has not only affected obstetric care but also impacted on the conception of the fetus in relation to the pregnant woman. This situation has also raised concerns regarding the pregnant woman's reproductive freedom. The purpose of this study was to explore Swedish obstetricians' experiences and views on the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and in relation to situations where the interests of maternal and fetal health conflict. METHODS: A qualitative study design was applied, and data were collected in 2013 through interviews with 11 obstetricians recruited from five different obstetric clinics in Sweden. Data were analysed using qualitative content analysis. RESULTS: The theme that emerged in the analysis 'Two sides of the same coin' depicts the view of obstetric ultrasound as a very important tool in obstetric care while it also was experienced as having given rise to new and challenging issues in the management of pregnancy. This theme was built on three categories: I. Ultrasound is essential and also demanding; II. A woman's health interest is prioritised in theory, but not always in practice; and III. Ultrasound is rewarding but may also cause unwarranted anxiety. CONCLUSIONS: The widespread use of ultrasound in obstetric care has entailed new challenges for clinicians due to enhanced possibilities to diagnose and treat fetal conditions, which in turn might conflict with the health interests of the pregnant woman. There is a need for further ethical discussions regarding the obstetrician's position in management of situations where maternal and fetal health interests conflict. The continuing advances in the potential of ultrasound to impact on pregnancy management will also increase the need for adequate and appropriate information and counselling. Together with other health care professionals, obstetricians therefore need to develop improved ways of enabling pregnant women and their partners to make informed decisions regarding pregnancy management.

Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests: obstetricians' experiences in Australia.

BACKGROUND: Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women's reproductive freedom. This study aimed to explore Australian obstetricians' experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict. METHODS: A qualitative study was undertaken as part of the CROss-Country Ultrasound Study (CROCUS). Interviews were held in November 2012 with 14 obstetricians working in obstetric care in Victoria, Australia. Data were analysed using qualitative content analysis. RESULTS: One overall theme emerged from the analyses: The ethical challenge of balancing maternal and fetal health interests, built on four categories: First, Encountering maternal altruism' described how pregnant women's often 'altruistic' position in relation to the health and wellbeing of the fetus could create ethical challenges in obstetric management, particularly with an increasing imbalance between fetal benefits and maternal harms. Second, 'Facing shifting attitudes due to visualisation and medico-technical advances' illuminated views that ultrasound and other advances in care have contributed to a shift in what weight to give maternal versus fetal welfare, with increasing attention directed to the fetus. Third, 'Guiding expectant parents in decision-making' described the difficult task of facilitating informed decision-making in situations where maternal and fetal health interests were not aligned, or in situations characterised by uncertainty. Fourth, 'Separating private from professional views' illuminated divergent views on when the fetus can be regarded as a person. The narratives indicated that the fetus acquired more consideration in decision-making the further the gestation progressed. However, there was universal agreement that obstetricians could never act on fetal grounds without the pregnant woman's consent. CONCLUSIONS: This study suggests that medico-technical advances such as ultrasound have set the scene for increasing ethical dilemmas in obstetric practice. The obstetricians interviewed had experienced a shift in previously accepted views about what weight to give maternal versus fetal welfare. As fetal diagnostics and treatment continue to advance, how best to protect pregnant women's right to autonomy requires careful consideration and further investigation.

Person-centred climate questionnaire (PCQ-S): establishing reliability and cut-off scores in residential aged care.

AIM: This study aimed to establish reliability and cut-off scores for the person-centred climate questionnaire - staff version (PCQ-S) in residential aged care. BACKGROUND: A number of tools have emerged recently to measure person-centredness, and these need psychometric evaluation and cut-off scores to enhance utilisation and interpretation. METHOD: A cross-sectional survey design was employed in a Swedish sample of residential aged care staff (n = 1237). Psychometric evaluation using Cronbach's alpha and item-total correlation was used, together with establishing cut-off scores based on quartile scores. RESULT: The PCQ-S had satisfactory psychometric properties and the following total scale cut-off scores for unit person-centredness were suggested: ≤ 49 ('well below average'), 50-56 ('below average'), 57-62 ('above average') and ≥ 63 ('well above average'). These cut-off scores were clinically meaningful as they separated the sample into four groups in which staff in more person-centred units reported significantly higher work satisfaction, social support and less stress of conscience. CONCLUSION: The PCQ-S has reliability in residential aged care samples, and cut-off scores are provided that provide important fundaments for comparative studies and aggregation of data to explore person-centredness care further. IMPLICATIONS FOR NURSING MANAGEMENT: The study enables managers with ways to measure, interpret and compare levels of person-centredness between units and facilities for research, practice development and/or benchmarking purposes.

'Ultrasound is an invaluable third eye, but it can't see everything': a qualitative study with obstetricians in Australia.

BACKGROUND: Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care. Today, most pregnant women in the developed world are exposed to obstetric ultrasound examinations, and there is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. However, at the same time, the increasing use has also raised many ethical challenges. This study aimed to explore obstetricians' experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents' experiences. METHODS: A qualitative study was undertaken in November 2012 as part of the CROss-Country Ultrasound Study (CROCUS). Semi-structured individual interviews were held with 14 obstetricians working at two large hospitals in Victoria, Australia. Transcribed data underwent qualitative content analysis. RESULTS: An overall theme emerged during the analyses, 'Obstetric ultrasound - a third eye', reflecting the significance and meaning of ultrasound in pregnancy, and the importance of the additional information that ultrasound offers clinicians managing the surveillance of a pregnant woman and her fetus. This theme was built on four categories: I:'Everyday-tool' for pregnancy surveillance, II: Significance for managing complicated pregnancy, III: Differing perspectives on obstetric ultrasound, and IV: Counselling as a balancing act. In summary, the obstetricians viewed obstetric ultrasound as an invaluable tool in their everyday practice. More importantly however, the findings emphasise some of the clinical dilemmas that occur due to its use: the obstetricians' and expectant parents' differing perspectives and expectations of obstetric ultrasound examinations, the challenges of uncertain ultrasound findings, and how this information was conveyed and balanced by obstetricians in counselling expectant parents. CONCLUSIONS: This study highlights a range of previously rarely acknowledged clinical dilemmas that obstetricians face in relation to the use of obstetric ultrasound. Despite being a tool of considerable significance in the surveillance of pregnancy, there are limitations and uncertainties that arise with its use that make counselling expectant parents challenging. Research is needed which further investigates the effects and experiences of the continuing worldwide rapid technical advances in surveillance of pregnancies.