Patient Experience and Decision-Making Process for Laser Photocoagulation for Monochorionic Twin Pregnancy: A Qualitative Exploration.

INTRODUCTION: The aim of the study was to explore patients' perspectives on diagnosis and treatment options for complicated monochorionic multiple gestations, and experiences with fetoscopic laser photocoagulation. METHODS: This is a prospective cohort study of patients undergoing laser photocoagulation. Participants were interviewed during pregnancy and the postpartum period. Qualitative analysis was performed. RESULT: Twenty-seven patients who were candidates for laser photocoagulation were included. All elected to have laser photocoagulation. Patients chose surgery with goals of improving survival, decreasing the risk of preterm delivery, and improving the long-term health of their fetuses. They demonstrated accurate knowledge of the risks and benefits of treatment. Most (74%) felt that laser photocoagulation represented their only viable clinical option. Few seriously considered pregnancy termination or selective reduction (7% and 11% respectively). Postpartum, patients expressed no regrets about their decisions for surgery, but many felt unprepared for the challenges of preterm delivery. CONCLUSION: Participants weighed treatment options similarly to fetal specialists. They acknowledged but did not seriously consider treatments other than fetoscopic laser photocoagulation and were highly motivated to do whatever they could to improve outcomes for their fetuses.

Relationships and trust: Two key pillars of a well-functioning freestanding midwifery unit.

BACKGROUND: Despite strong evidence supporting the expansion of midwife-led unit provision, as a result of optimal maternal and perinatal outcomes, cost-effectiveness, and positive service user and staff experiences, scaling-up has been slow. Systemic barriers associated with gender, professional, economic, cultural, and social factors continue to constrain the expansion of midwifery as a public health intervention globally. This article aimed to explore relationships and trust as key components of a well-functioning freestanding midwifery unit (FMU). METHOD(S): A critical realist ethnographic study of an FMU located in East London, England, was conducted over a period of 15 months. Recruitment of the 82 participants was purposive. Data collection included participant observation and semi-structured interviews, and data were analyzed thematically along with relevant local guidelines and documents. RESULTS: Twelve themes emerged. Relationships and Trust were identified as a core theme. The other 11 themes were grouped into six families, three of which: Ownership, Autonomy, and Continuous Learning; Team Spirit, Interdependency, and Power Relations; and Salutogenesis will be covered in this paper. The remaining three families: Friendly Environment; Having Time and Mindfulness; and Social Capital, will be covered in a separate paper. CONCLUSIONS: A relationship-based model of care was crucial for both the functioning of the FMU and service users' satisfaction and may offer a compelling response to high levels of stress and burnout among midwives.

Relationship-based care model in paediatrics: A randomized controlled trial to implement the parents' perception of the quality of nursing care.

AIM: To evaluate whether the application of the Relationship-based care model as a new treatment, called "Take 5 min", affects the level of anxiety, depression, and perceived quality of nursing care of parents of paediatric patients and the work satisfaction of the nursing staff. DESIGN: Single-blind randomized controlled trial. METHODS: The trial was performed from February-July 2016. The trial was conducted with one intervention (N = 101) and one control group (N = 90). Nurses applied the treatment named "Take 5 Minutes", which consisted of dedicating some short time (from 5 to 10 min) to the relationship with the parents using specifically designed communication strategies. The primary outcome was the evaluation of anxiety and depression of parents; the secondary was the parent perceived quality of nursing care. RESULTS: In the experimental group, participants had a lower level of anxiety and depression and highlighted that the effect of the "Take 5 Minutes" was proportional to the initial seriousness of parents' anxiety and depression. Higher scores for the perception of the quality of care were given from the parents of the experimental group. CONCLUSION: The "Take 5 Minutes" treatment offered to parents of paediatric patients demonstrated significant improvements in terms of their anxiety, depression, and perceived quality of nursing care. IMPACT: Caregivers of paediatric patients are subject to psychological disorders such as depression and anxiety. The communication by the nursing community is of fundamental importance in the management of anxiety and depression in the caregivers of hospitalized patients. Caregivers who received the "Take 5 Minutes" treatment demonstrated a significant decrease in anxiety and depression compared with the control group caregivers. The perceived level of quality of nursing care showed a significant increase in the group of caregivers who received the T5M treatment. The RBC model does not require extra costs for health organizations and can be applied during the usual practice of care. Practices such as T5M could become part of paediatric patient care guidelines and nurses should be trained to apply them. TRIAL REGISTRATION NUMBER: Padua Research: ID No. 10,034; ClinicalTrials.gov: ID No. NCT04199429.

The effects of the Newborn Behavioral Observations (NBO) system in early intervention: A multisite randomized controlled trial.

The purpose of this pilot study was to evaluate the effect of an infant mental health intervention, the Newborn Behavioral Observations system (NBO), versus usual care (UC) on infant neurodevelopment and maternal depressive symptoms in early intervention (EI). This multisite randomized trial enrolled newborns into the NBO (n = 16) or UC group (n = 22) and followed them for 6 months. Outcome measures included the Battelle Developmental Inventory (BDI-2), Bayley Scales of Infants Development (BSID-III), and Center for Epidemiologic Studies Depression Scale (CES-D). The CES-D and BSID-III were collected at 3- and 6-months post EI entry and the BDI-2 was collected at EI entry and 6-months post-EI entry. We estimated group differences [95% CI], adjusting for program characteristics. At 6 months, the NBO group had greater gains in Communication (b = 1.0 [0.2, 1.8]), Self-Care (b = 2.0 [0.1, 3.9]), Perception and Concepts (b = 2.0 [0.4, 3.6]), and Attention and Memory (b = 3.0 [0.4, 6.0]) than the UC group. The NBO group also had greater decline in maternal postnatal depressive symptoms (b = -2.0 [-3.7, -0.3]) than the UC group. Infants receiving the NBO infant mental health intervention had greater gains in cognitive and adaptive functions at 6 months than infants receiving UC. Caregivers receiving NBO care had greater improvements in maternal depressive symptoms than caregivers receiving UC.

El propósito de este estudio piloto fue evaluar el efecto que una intervención de salud mental infantil, el sistema de Observación de Comportamiento del Recién Nacido (NBO), versus el cuidado usual (UC), tiene en el desarrollo neurológico del infante y los síntomas de depresión materna en la Temprana Intervención (EI). Este ensayo al azar de múltiples lugares inscribió a recién nacidos en el NBO (n = 16) o en el grupo UC (n = 22) y les dio seguimiento por 6 meses. Las medidas de los resultados incluyeron el Inventario Battelle del Desarrollo (BDI-2), las Escalas Bayley del Desarrollo de Infantes (BSID-III), y la Escala de Depresión del Centro para Estudios Epidemiológicos (CES-D). El CES-D y BSID-III fueron implementados a los 3 y 6 meses posteriores a la entrada en EI y el BDI-2 fue implementado al momento de entrar en EI y a los 6 meses posteriores a dicha entrada. Estimamos las diferencias de grupos [95% CI], con ajustes en cuanto a características del programa. A los 6 meses, el grupo NBO presentaba mayores logros en Comunicación (b = 1.0 [0.2, 1.8]), Autocuidado (b = 2.0 [0.1, 3.9]), Percepción y Conceptos (b = 2.0 [0.4, 3.6]) y Atención y Memoria (b = 3.0 [0.4, 6.0]) que el grupo de UC. El grupo NBO también tuvo una mayor baja en síntomas maternos depresivos postnatales (b = 2.0 [-3.7, -0.3]) que el grupo UC. Los infantes que recibían la intervención NBO tuvieron mayores logros en la función cognitiva y adaptiva a los 6 meses que los infantes del grupo UC. Aquellos cuidadores que recibían el cuidado NBO presentaron mejoras significativamente mayores en síntomas depresivos maternos que los cuidadores del grupo UC.

Le but de cette étude pilote était d'évaluer l'effet d'une intervention en santé mentale du nourrisson, le système d'Observation Comportementale du Nourrisson (en anglais, Newborn Behavioral Observation system, soit NBO utilisé ici dans ce texte), par rapport aux soins ordinaires (ici abbrégé SI) sur le neurodéveloppement du nourrisson et les symptômes dépressifs maternels dans l'Intervention Précoce (IP). Cet essai randomisé effectué sur plusieurs sites a concerné des nouveaux-nés dans le NBO (n = 16) ou le groupe SI (n = 22) et les a suivis pendant 6 mois. Les mesures de résultat ont inclus l'Inventaire du Développement de Battelle (BDI-2), les Echelles Bayley de Développement des Nourrissons (BSID-III) et les Echelles de Dépression du Centre d'Etudes Epidémiologiques (CES-D). Les CES-D et BSID-III ont été faites à 3 et à 6 mois après l'entrée en IP et la BDI-2 a été faite à l'entrée en IP et à 6 mois après l'entrée en IP. Nous avons estimé les différences de groupe [95% CI), en faisant des ajustements pour les caractéristiques du programme. A six mois, le groupe NBO avait fait de plus grands gains en Communication (b = 1,0 [0,2, 1,8]), Autosoin (b = 2,0 [0,1, 3,9]), Perception & Concepts (b = 2,0 [0,4, 3,6]), et Attention & Mémoire (b = 3,0 [0,4, 6,0]) que le groupe SI. Le groupe NBO a également vu le plus grand déclin dans les symptômes dépressifs postnatals maternels (b = -2,0 [-3,7, -0,3]) par rapport au groupe SI. Les nourrissons recevant l'intervention NBO ont fait preuve de plus grands gains dans la fonction cognitive et adaptive à 6 mois, par rapport aux nourrissons SI. Les personnes prenant soin des enfants et recevant le soin NBO ont témoigné d'améliorations plus importantes dans les symptômes dépressifs maternels que le groupe SI.

Commonalities of nurse-designed models of health care.

The American Academy of Nursing has identified examples of care redesign developed by nurses who address the health needs of diverse populations. These models show important clinical and financial outcomes as summarized in the Select Edge Runner Models of Care table included in this article. A study team appointed by the Academy explored the commonalities across these models. Four commonalities emerged: health holistically defined; individual-, family-, and community-centric approaches to care; relationship-based care that enables partnerships and builds patient engagement and activation; and a shift from episodic individual care to continuous group and public health approaches. The policy implications include examining measures of an expanded definition of health, paying for visionary care, and transparency and rewards for community-level engagement.

Caring nurse practice in the intrapartum setting: nurses' perspectives on complexity, relationships and safety.

AIM: This article reports on a qualitative study of nurse perceptions of caring nurse practice in the complex adaptive system of health care. BACKGROUND: Caring nurse practice encompasses technical skills and caring behaviours. Maternity care in the USA has seen worsening maternal and neonatal outcomes and safety has become a priority. As a result, hospital systems have begun efforts to improve outcomes, initiating safety and quality programmes that standardize care and implementing nursing frameworks that enhance relationships. DESIGN: Qualitative hermeneutic phenomenology. METHODS: A qualitative design analysed 13 nurses' perspectives on caring practice during the second stage of labour. In June and July of 2012, interviews were conducted with 13 labour and delivery nurses located in a hospital that had adopted a perinatal safety initiative and relationship-focused nursing model. The nurses described caring nurse practice and the factors that affected its provision. Transcripts of audio recordings and notes taken during interviews were analysed for themes and fundamental meanings. FINDINGS: Nurses' perspectives about the provision of caring nurse practice was affected by the complexity of the healthcare system, interactions with team members, challenges related to documentation; and respect for natural birth. CONCLUSION: Nurses at all levels of practice can use these perspectives to identify patterns in the complex adaptive healthcare system to improve quality and safety. Best practices include enhancing teamwork, implementing safety initiatives and promoting a Relationship-Based framework. Continued study of caring nurse practice could lead to establishment of additional safety and quality protocols vital to improving patient outcomes.

Development of a master of science, nursing and interprofessional leadership program: AACN essentials in action.

BACKGROUND: Leadership acumen, interprofessional relationships, and knowledge of healthcare operations are essential proficiencies for nurses to navigate the dynamic and complex healthcare landscape. The American Association of Colleges of Nursing (AACN) re-envisioned the academic nursing standards, The Essentials: Core Competencies for Professional Nursing Education (Essentials), to guide curricular development in preparing nurses with the aptitude to meet these challenges. PURPOSE: The purpose of this project was to develop an innovative Master of Science nursing program to address the challenges facing the RN workforce. METHODS: A relationship-based framework and the Analysis, Design, Development, Implementation and Evaluation (ADDIE) model were used to guide the development of the program using the Essentials to inform curricular design. RESULTS: A Nursing and Interprofessional Leadership Master of Science program was designed comprising seven core courses with two tracks, Bachelor of Nursing and Post Graduate Option. LIMITATION: The program was created during the COVID-19 pandemic, which may have influenced the data used for the program's design. CONCLUSION: Healthcare complexities are requiring nursing education to evaluate curricula for advanced knowledge and skills. A Nursing and Interprofessional Leadership Master of Science degree program guided by the Essentials was developed to meet this challenge.

Nursing educational framework: A new nurse-driven, conceptually guided approach.

PURPOSE: The aim of this article is to present the Nursing Educational Framework (NEF) as an opportunity to integrate core elements of a humanistic person/family-centered view and as guidance in structuring a relationship-based curriculum. DATA SOURCES: Empirical and theoretical literature studies were reviewed to define the framework rationale and its components. DATA SYNTHESIS: A deductive/inductive collaborative expert-informed approach was undertaken to develop this evidence-based codesigned framework. Its mission, along with unique components, implementation strategies, and outcomes, were successively integrated into the framework to guide nursing knowledge, learning, and curriculum development. A hermeneutic collaborative process of circular reflection was used in the development process. CONCLUSIONS: The NEF contains central guiding principles and concepts that are intended to provide structural consistency across its included programs from a humanistic person/family-centered approach. IMPLICATIONS FOR NURSING PRACTICE: This comprehensive theory-guided framework allows educators to suggest specific directions for nursing practice within the nursing discipline and articulate nursing's unique and specialized approach to promoting excellent patient care outcomes. It can assist students to develop critical lens from a person/family-centered relationship-based practice approach.

PROPÓSITO: El objetivo de este artículo es presentar el Modelo Formativo de Enfermería como una oportunidad para integrar los elementos principales de una visión humanística centrada en la persona/familia y como una guía para estructurar un currículo basado en la relación enfermera/paciente. FUENTES DE DATOS: Se revisó literatura teórica y empírica con el fin de definir las bases fundamentales del modelo y sus componentes. SÍNTESIS DE LOS DATOS: Con el fin de desarrollar el modelo, se planteó una aproximación deductiva/inductiva con enfoque colaborativo y basado en expertos. Su misión, junto con los componentes conceptuales más específicos, estrategias de implementación y resultados, fueron progresivamente integrados en él, para guiar el desarrollo del conocimiento, el aprendizaje y la conformación curricular. Se empleó un proceso hermenéutico colaborativo de reflexión circular. CONCLUSIONES: El modelo contiene los principios guía y conceptos que dan consistencia estructural a todos los programas incluidos, desde un punto de vista humanístico y centrado en la persona/familia. IMPLICACIONES PARA LA PRÁCTICA DE ENFERMERÍA: Este amplio marco teórico permite a los educadores sugerir direcciones específicas para la práctica de la enfermería dentro de la disciplina y articular su enfoque único y especializado para promover excelentes resultados en el cuidado del paciente. Puede ayudar a los estudiantes a desarrollar una lente crítica desde un enfoque de la práctica basada en la relación enfermera/paciente ycentrado en la persona y la familia.

Use of the Newborn Behavioral Observations System as an early intervention for infants and their parents: A scoping review.

BACKGROUND: The Newborn Behavioral Observations (NBO) system is an infant-focused, family-centered, relationship-based tool designed to help parents become aware of their baby's abilities and to promote a positive parent-child relationship from the very beginning of birth. AIMS: The aim of this scoping review was to provide an overview of the key characteristics of the research and evidence accumulated over the past 17 years on the early NBO intervention for infants and their parents to identify the existing research gaps and to inform the future direction of research on the NBO System. STUDY DESIGN: A scoping review guided by Arksey and O'Malley's methodological framework and the PRISMA-ScR Checklist was conducted. This review used six databases (PubMed, CINAHL, MEDLINE, Google Scholar, Ichushi-Web, and CiNii) and was limited to English and Japanese language articles from January 2006, when the NBO was developed, to September 2022. Reference lists were also hand-searched to further identify relevant articles from the NBO site. RESULTS: A total of 29 articles were selected. Through the analysis of included articles, four overarching themes were identified: (1) usage pattern of the NBO; (2) participants, setting, duration, and frequency of the NBO intervention; (3) outcome measures and effects of the NBO intervention; and (4) findings from a qualitative perspective. The review suggested that early NBO intervention had a positive impact on maternal mental health and sensitivity to the infant, confidence and knowledge of practitioners, and infant development. CONCLUSIONS: This scoping review shows that the early NBO intervention has been implemented in a variety of cultures and settings and by professionals of various disciplines. However, research to evaluate the long-term effects of this intervention on a wider range of subjects is needed.

The relationship competencies guiding tool: A development, content validation and implementation study.

AIM: The aims of this paper are (1) to present the results of the development, content validation and implementation study of the Relationship Competencies Guiding Tool; (2) to provide examples of how each item in the tool is reflected in clinical narratives written by nurses and justify the corresponding scores after the evaluation; (3) to present how the language and content of the narratives are interpreted with the tool and to describe an exemplar; and (4) to present barriers to and facilitators of the application of the tool. BACKGROUND: From a person-centered care approach, the fostering of authentic relationships with patients is key to achieving therapeutic benefits. Therefore, it is essential to help nurses establish meaningful relationships with patients and help them acquire these abilities. Clinical narratives can be used as a way to promote reflective practice and professional competency development among nurses. A tool to evaluate the knowledge, skills, attitudes and values necessary for developing authentic encounters with patients through clinical narratives was developed, validated and implemented. DESIGN: An instrument-development study comprised of three steps: (1) conceptualization; (2) item generation and content validity; and (3) implementation of the tool and linguistic evaluation. METHODS: This study was conducted in three major steps. Step one entailed conceptualization. Step two included the generation of items and content validation. In step three, the tool was used to independently evaluate 25 narratives. One of these narratives was also linguistically analysed to provide a comprehensive view of the interpretative strategies deployed by evaluators. RESULTS: The Relationship Competencies Guiding Tool was developed, validated and implemented. It could help nurses work on nursing relationship-based professional competencies, guided the evaluators in the process of assigning scores to the corresponding items and helped the researchers identify certain barriers and facilitators before and during the narrative evaluation process. CONCLUSIONS: The tool has been shown to be clear, relevant and conceptually and linguistically suitable for evaluating clinical narratives. The Relationship Competencies Guiding Tool could be applied to interpret how nurses reflect professional competencies in a clinical narrative as a preliminary step in the construction of a measurement tool. TWEETABLE ABSTRACT: From a person-centered relationship-based care approach, clinical narratives can be used to promote professional competencies between nurses. The Relationship Competencies Guiding Tool may help evaluate the knowledge, skills, attitudes and values necessary for developing authentic encounters with persons/families, as reflected by nurses' clinical narratives.

An Exploratory Multi-Case Study of the Health and Wellbeing Needs, Relationships and Experiences of Health and Social Care Service Users and the People who Support them at Home.

Introduction: International policies and legislation set a precedence of person-centred sustainable integrated Health and Social Care (HSC) that meets the health and wellbeing needs of service users through improved experiences. However, current research focuses on service models, with fewer studies investigating experiences and needs. Methods: This qualitative multi-case [n = 7] study was co-designed with key stakeholders and aimed to explore experiences and needs of people who access and provide HSC at home. Data were collected in a regional area of Scotland (UK) via single [n = 10] or dyad [n = 4] semi-structured interviews with service users [n = 6], informal carers [n = 5] and HSC staff [n = 7] and synthesised using Interpretive Thematic Analysis. Findings: Interpersonal connections and supportive relationships were instrumental in helping all participant groups feel able to cope with their changing HSC needs and roles. They promoted reassurance, information sharing and reduced anxiety; when they were lacking, it negatively impacted upon experiences of HSC. Discussion: Promoting inter-personal connections that encourage supportive relationships between people who access and provide HSC and their communities, could promote person-centred Relationship-based care and improve HSC experiences. Conclusions: This study identifies indicators for improved HSC, advocating co-produced community-driven services to meet the self-defined needs of those who access and provide care.

Describing Remembrance & Renewal: A Holistic Self-Care Program.

Background: Holistic care interventions include support for healthcare worker grief in a relationship-based care paradigm. Few programs support oncology healthcare worker grief and renewal prior to and during the COVID-19 pandemic. Objective: Describe "knowledge of" and "engagement with" a program about grief and resilience, Remembrance & Renewal (R&R). Method: An anonymous, electronic survey was available to healthcare workers at an academic, comprehensive cancer center. Demographic questions were analyzed against "knowledge of" and "engagement with." Results: Of 105 responding to "awareness of," 81 knew about R&R and 48 had "engaged with" the program. Statistically significant relationships between a characteristic and awareness were found for education (p = .03), setting (p < .01), and the frequency of learning about a death (p = .04). Statistically significant relationships between a characteristic and level of participation were found for profession (p = .02) and length of time in job (p = .03). Open-ended questions asked about impact of patient death (n = 93), barriers to participation (n = 54), and feelings after "engagement with" (n = 45). Responses to impact, barriers, and feelings were respectively: sadness (75.3%); time (77.8%); and calm (75.6%). Conclusion: This study describes "knowledge of" and "engagement with" a holistic grief and renewal program. Further study will add to healthcare worker holistic self-care.

Perceived Impact of a Relationship-Based Care Curriculum.

PURPOSE: Authentic client-centered practice is integral to positive health-care outcomes. This study examined facilitator perspectives of the See Me as a Person (SMAAP) relationship-based health-care curriculum. METHODS: Qualitative phenomenological interviews were conducted with five facilitators of the SMAAP curriculum. The principal question and sub questions explored the facilitation and teaching methods, perceived impact of the curriculum, and the impact on health-care practice. FINDINGS: The concepts in the SMAAP curriculum are translatable into practice and may improve health care; organizational culture, leadership, and time constraints influence impact. CONCLUSION: Relationship-based practice training can positively affect health-care delivery. Practitioners must be dedicated to the learning process; implementation should go beyond short-term training.

What's Love Got to Do With It: Teaching the Next Generation of Nurses.

Many professional medical and nursing organizations call for the reform and revision of formal nursing education. As nursing faculty work to prepare the next generations of nurses, the model of Relationship-Based Care is an ideal infrastructure for curriculum design. This paper responds to the call for transforming nursing education with a model that includes love, Relationship-Based Care, the I2E2 Model of Change, and an academic-practice partnership.

Integrative Nursing and the ANA Scope and Standards of Practice: Expanding the Reach of Nursing for Families and Society.

The American Nurses Association's (ANA) recently published 4th edition of the Scope and Standards of Practice provides authoritative guidance on actions and behaviors that all registered nurses are expected to perform competently, regardless of role, population, specialty, or setting. The newly defined scope emphasizes the art and science of caring, compassionate presence, and the expectation that nurses be advocates for all, recognizing the connections of all humanity. It also makes frequent reference to whole-person care and highlights the importance of mindfulness by inviting nurses to reflect on how they can incorporate mindfulness and other integrative therapies into their self-care and professional practice. A new standard explicitly states that advanced practice registered nurses should have the competency to prescribe evidence-based traditional and integrative treatments, therapies, and procedures that are compatible with the consumer's cultural preferences, norms, and abilities. Integrative Nursing is aligned with the ANA Scope and Standards of Practice and provides a useful framework for practice that expands the reach of nursing across clinical and community settings and patient populations. In this article, exemplars highlight how Integrative Nursing is being implemented in clinical settings and nursing education programs.

Maneuvering the care puzzle: Experiences of participation in care by frail older persons with significant care needs living at home.

PURPOSE: Despite evidence that older persons want to be involved in care, little is known about how frail older people with significant care needs living at home experience participation in care provided by different stakeholders. This study investigates the experiences of participation in care by older people following their involvement in an intervention of a health care model called Focused Primary care (FPC). METHODS: Individual semi-structured interviews were conducted with 20 older persons in five municipalities in Sweden. RESULTS: The results show that older persons highlighted opportunities and limitations for participation on a personal level i.e., conditions for being involved in direct care and in relation to independence. Experiences of participation on organizational levels were reported to a lesser degree. This included being able to understand the organizational system underpinning care. The relational dimensions of caregiving were emphasized by the older persons as the most central aspects of caregiving in relation to participation. CONCLUSIONS: Primary care should involve older persons more directly in planning and execution of care on all levels. An ongoing connection with one specialized elderly team and a coordinating person in Primary care who safeguards relationships is important for providing participation in care for frail older persons with significant care needs living at home.

An interactive decision-making framework (i-DMF) to scale up maternity continuity of carer models.

BACKGROUND: Low numbers of women in Queensland receive continuity of care across their maternity episode. The Office of the Chief Nursing and Midwifery Officer was tasked with strengthening maternity service delivery by reviewing and improving Maternity Models of Care and Workforce. AIM: Develop a decision-making framework (DMF) to increase maternity continuity of carer models. METHOD: A literature review of models, specific to the public health maternity system, including suitability to rural areas and culturally appropriate to Aboriginal and Torres Strait Islander women was undertaken. Stakeholders informed development of the framework and toolkit. A prototype was built, tested and refined following input from rural, regional and metropolitan facilities. RESULTS: 42 questions guide services to contextualise delivery of continuity of carer to local circumstances. Three rural sites have applied the i-DMF and toolkit. One used the tool for quality assurance of their existing midwifery continuity model, another has developed a midwifery continuity-of-carer model for Aboriginal and Torres Strait Islander women, the other is looking to establish a local rural birth service. CONCLUSION: The i-DMF has potential to grow and sustain best practice maternity care, and particularly enable more women to receive relationship-based care with a known midwife.

The Role of Relationship-Based Care in Developing Empathy Through Vulnerability: Visual Cues for Conversation and Change.

Empathy is a word that is showing up in conversations across health-care organizations as we explore how to establish relationships with our patients to improve quality of care. According to researcher Brene' Brown, empathy is a connection with the heart, and cannot be expressed without touching our own vulnerability. In an increasingly complex and demanding health-care environment, with patient volumes and acuities impacting workflow and prioritization, it is important to explore vulnerability not only as a concept present in patient populations and our individual experiences as health-care professionals, but also as an unspoken and changing element in the entire clinical milieu. In a health-care world where focus is necessarily placed on quantitative metrics and outcomes, addressing concepts such as vulnerability can create a real challenge. Fear is an inherent by-product of vulnerability. As an aid to conversation and culture revision, this article presents a series of diagrams showing how focusing on the three relationships of Relationship-Based Care (RBC) (care for self, care for colleagues, and care for patients and families) can help shrink the fear associated with vulnerability. Fear initiates and perpetuates protective behaviors to keep us from feeling the uncertainty of vulnerability; those behaviors work against the development and nurturing of the RBC relationships. The three relationships of RBC provide a structure with which to explore vulnerability, allowing their principles and practices to help us open our hearts and lead us to the empathy we seek when serving our patients, ourselves, and each other.

Nursing Perspectives and Knowledge With an Acuity Adaptable Model.

An acuity adaptable pediatric cardiac care model provides healthcare centered on the practice of having the child remain in the same unit and receive care from the same clinical team from admission to discharge. This means the child is managed as they progress from an acute, intermediate, intensive care, and sometimes even long-term status within the same room. This article highlights the relationship-based care nursing model, a patient-centered care model, and the importance of nursing disciplinary knowledge from the Roy adaptation model and its impact on the healthcare this population receives within a unique environment.

Project 20: Midwives' insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how.

INTRODUCTION: Continuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems. OBJECTIVE: To explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women's outcomes. DESIGN: Realist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London. FINDINGS: Three main themes were identified: 'Perceptions of the model of care, 'Tailoring the service to meet women's needs', 'Going above and beyond'. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women's outcomes, and how women with different social risk factors respond to these mechanisms. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Overall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women's outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.