Nursing, midwifery, and allied health professions research capacities and cultures: a survey of staff within a university and acute healthcare organisation.

BACKGROUND: There is an increasing focus on the development of research capacity and culture in Nursing, Midwifery and Allied Health Professions (NMAHP). However, better understanding of the existing research success and skills, motivators, barriers, and development needs of NMAHP professionals is required to inform this development. This study sought to identify such factors within a university and an acute healthcare organisation. METHODS: An online survey, incorporating the Research Capacity and Culture tool, was administered to NMAHP professionals and students at a university and an acute healthcare organisation in the United Kingdom. Ratings of success/skill levels of teams and individuals were compared between professional groups using Mann-Whitney U tests. Motivators, barriers, and development needs were reported using descriptive statistics. Descriptive thematic analysis was used for open-ended text responses. RESULTS: A total of 416 responses were received (N&M n = 223, AHP n = 133, Other n = 60). N&M respondents were more positive than their AHP counterparts about the success/skill levels of their teams. There were no significant differences between N&M and AHP in their ratings of individual successes/skills. Finding and critically reviewing relevant literature were identified as specific individual strengths; with weaknesses in securing research funding, submitting ethics applications, writing for publication, and advising less experienced researchers. The main motivators for research were to develop skills, increased job satisfaction, and career advancement; whilst barriers included lack of time for research and other work roles taking priority. Key support needs identified included mentorship (for teams and individuals) and in-service training. Open-ended questions generated main themes of 'Employment & staffing', 'Professional services support', 'Clinical & academic management', 'Training & development', 'Partnerships' and 'Operating principles'. Two cross-cutting themes described issues common to multiple main themes: 'Adequate working time for research' and 'Participating in research as an individual learning journey'. CONCLUSIONS: Rich information was generated to inform the development of strategies to enhance research capacity and culture in NMAHP. Much of this can be generic but some nuances may be required to address some specific differences between professional groups, particularly related to perceived team success/skills and priorities identified for support and development.

P-FLUX: A phosphorus budget dataset spanning diverse agricultural production systems in the United States and Canada.

Quantifying spatial and temporal fluxes of phosphorus (P) within and among agricultural production systems is critical for sustaining agricultural production while minimizing environmental impacts. To better understand P fluxes in agricultural landscapes, P-FLUX, a detailed and harmonized dataset of P inputs, outputs, and budgets, as well as estimated uncertainties for each P flux and budget, was developed. Data were collected from 24 research sites and 61 production systems through the Long-term Agroecosystem Research (LTAR) network and partner organizations spanning 22 U.S. states and 2 Canadian provinces. The objectives of this paper are to (a) present and provide a description of the P-FLUX dataset, (b) provide summary analyses of the agricultural production systems included in the dataset and the variability in P inputs and outputs across systems, and (c) provide details for accessing the dataset, dataset limitations, and an example of future use. P-FLUX includes information on select site characteristics (area, soil series), crop rotation, P inputs (P application rate, source, timing, placement, P in irrigation water, atmospheric deposition), P outputs (crop removal, hydrologic losses), P budgets (agronomic budget, overall budget), uncertainties associated with each flux and budget, and data sources. Phosphorus fluxes and budgets vary across agricultural production systems and are useful resources to improve P use efficiency and develop management strategies to mitigate environmental impacts of agricultural systems. P-FLUX is available for download through the USDA Ag Data Commons (https://doi.org/10.15482/USDA.ADC/1523365).

Measuring the impact of pharmacoepidemiologic research using altmetrics: A case study of a CNODES drug-safety article.

PURPOSE: To provide an overview of altmetrics, including their potential benefits and limitations, how they may be obtained, and their role in assessing pharmacoepidemiologic research impact. METHODS: Our review was informed by compiling relevant literature identified through searching multiple health research databases (PubMed, Embase, and CIHNAHL) and grey literature sources (websites, blogs, and reports). We demonstrate how pharmacoepidemiologists, in particular, may use altmetrics to understand scholarly impact and knowledge translation by providing a case study of a drug-safety study conducted by the Canadian Network of Observational Drug Effect Studies. RESULTS: A common approach to measuring research impact is the use of citation-based metrics, such as an article's citation count or a journal's impact factor. "Alternative" metrics, or altmetrics, are increasingly supported as a complementary measure of research uptake in the age of social media. Altmetrics are nontraditional indicators that capture a diverse set of traceable, online research-related artifacts including peer-reviewed publications and other research outputs (software, datasets, blogs, videos, posters, policy documents, presentations, social media posts, wiki entries, etc). CONCLUSION: Compared with traditional citation-based metrics, altmetrics take a more holistic view of research impact, attempting to capture the activity and engagement of both scholarly and nonscholarly communities. Despite the limited theoretical underpinnings, possible commercial influence, potential for gaming and manipulation, and numerous data quality-related issues, altmetrics are promising as a supplement to more traditional citation-based metrics because they can ingest and process a larger set of data points related to the flow and reach of scholarly communication from an expanded pool of stakeholders. Unlike citation-based metrics, altmetrics are not inherently rooted in the research publication process, which includes peer review; it is unclear to what extent they should be used for research evaluation.

Trauma and fear in Australian midwives.

BACKGROUND: Relatively little is known about the extent of trauma and birth-related fear in midwives and how this might affect practice. AIM: (1) Determine prevalence of birth related trauma and fear in midwives and associations with midwives' confidence to advise women during pregnancy of their birth options and to provide care in labour. (2) Describe midwives' experiences of birth related trauma and/or fear. METHOD: A mixed methods design. A convenience sample of midwives (n=249) completed an anonymous online survey. Descriptive and inferential statistics were used to analyse the quantitative data. Latent content analysis was used to extrapolate meaning from the 170 midwives who wrote about their experiences of personal and/or professional trauma. RESULTS: The majority of midwives (93.6%) reported professional (n=199, 85.4%) and/or personal (n=97, 41.6%) traumatic birth experiences. Eight percent (n=20) reported being highly fearful of birth. Trauma was not associated with practice concerns but fear was. Midwives categorised as having 'high fear' reported more practice concerns (Med 23.5, n=20) than midwives with 'low fear' (Med 8, n=212) (U=1396, z=-3.79, p<0.001, r=0.24). Reasons for personal trauma included experiencing assault, intervention and stillbirth. Professional trauma related to both witnessing and experiencing disrespectful care and subsequently feeling complicit in the provision of poor care. Feeling unsupported in the workplace and fearing litigation intensified trauma. CONCLUSION: High fear was associated with lower confidence to support childbearing women. Fear and trauma in midwives warrants further investigation to better understand the impact on professional practice.

Short communication: Identifying challenges and opportunities for improved nutrient management through the USDA's Dairy Agroecosystem Working Group.

Nutrient management on US dairy farms must balance an array of priorities, some of which conflict. To illustrate nutrient management challenges and opportunities across the US dairy industry, the USDA Agricultural Research Service Dairy Agroecosystems Working Group (DAWG) modeled 8 confinement and 2 grazing operations in the 7 largest US dairy-producing states using the Integrated Farm System Model (IFSM). Opportunities existed across all of the dairies studied to increase on-farm feed production and lower purchased feed bills, most notably on large dairies (>1,000 cows) with the highest herd densities. Purchased feed accounted for 18 to 44% of large dairies' total operating costs compared with 7 to 14% on small dairies (<300 milk cows) due to lower stocking rates. For dairies with larger land bases, in addition to a reduction in environmental impact, financial incentives exist to promote prudent nutrient management practices by substituting manure nutrients or legume nutrients for purchased fertilizers. Environmental priorities varied regionally and were principally tied to facility management for dry-lot dairies of the semi-arid western United States (ammonia-N emissions), to manure handling and application for humid midwestern and eastern US dairies (nitrate-N leaching and P runoff), and pasture management for dairies with significant grazing components (nitrous oxide emissions). Many of the nutrient management challenges identified by DAWG are beyond slight modifications in management and require coordinated solutions to ensure an environmentally and economically sustainable US dairy industry.

A cost effectiveness analysis of midwife psycho-education for fearful pregnant women - a health system perspective for the antenatal period.

BACKGROUND: Psycho-education can reduce childbirth fear and caesarean section numbers. This study determines the cost-effectiveness of a midwife-led psycho-education intervention for women fearful of birth. METHOD: One thousand four hundred ten pregnant women in south-east Queensland, Australia were screened for childbirth fear (W-DEQ A ≥ 66). Women with high scores (n = 339) were randomised to the BELIEF Study (Birth Emotions and Looking to Improve Expectant Fear) to receive psycho-education (n = 170) at 24 and 34 weeks of pregnancy or to the control group (n = 169). Women in both groups were surveyed 6 weeks postpartum with total cost for health service use during pregnancy calculated. Logistic regression models assessed the odds ratio of having vaginal birth or caesarean section in the study groups. RESULT: Of 339 women randomised, 184 (54%) women returned data at 6 weeks postpartum (Intervention Group n = 91; Control Group n = 93). Women receiving psycho-education had a higher likelihood of vaginal birth compared to controls (n = 60, 66% vs. n = 54, 58%; OR 2.34). Mean 'treatment' cost for women receiving psycho-education was AUS$72. Mean cost for health services excluding the cost of psycho-education, was less in the intervention group (AUS$1193 vs. AUS$1236), but not significant (p = 0.78). For every five women who received midwife counselling, one caesarean section was averted. The incremental healthcare cost to prevent one caesarean section using this intervention was AUS$145. CONCLUSION: Costs of delivering midwife psycho-education to women with childbirth fear during pregnancy are offset by improved vaginal birth rates and reduction in caesarean section numbers. TRIAL REGISTRATION: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012 (retrospectively registered one week after enrolment of first participant).

Australian private midwives with hospital visiting rights in Queensland: Structures and processes impacting clinical outcomes.

BACKGROUND: Reporting the outcomes for women and newborns accessing private midwives with visiting rights in Australia is important, especially since this data cannot currently be disaggregated from routinely collected perinatal data. AIM: 1) Evaluate the outcomes of women and newborns cared for by midwives with visiting access at one Queensland facility and 2) explore private midwives views about the structures and processes contributing to clinical outcomes. METHODS: Mixed methods. An audit of the 'all risk' 529 women receiving private midwifery care. Data were compared with national core maternity variables using Chi square statistics. Telephone interviews were conducted with six private midwives and data analysed using thematic analysis. FINDINGS: Compared to national data, women with a private midwife were significantly more likely to be having a first baby (49.5% vs 43.6% p=0.007), to commence labour spontaneously (84.7% vs 52.7%, p<0.001), experience a spontaneous vaginal birth (79% vs 54%, p<0.001) and not require pharmacological pain relief (52.9% vs 23.1%, p<0.001). The caesarean section rate was significantly lower than the national rate (13% vs 32.8%, p<0.001). In addition fewer babies required admission to the Newborn Care Unit (5.1% vs 16%, p<0.001). Midwives were proud of their achievements. Continuity of care was considered fundamental to achieving quality outcomes. Midwives valued the governance processes embedded around the model. CONCLUSIONS: Private midwives with access to the public system is safe. Ensuring national data collection accurately captures outcomes relative to model of care in both the public and private sector should be prioritised.

Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey.

BACKGROUND: The health and wellbeing of midwives are important considerations for workforce retention and quality care. The occurrence and relationships among mental health conditions such as burnout and depression have received little attention. We investigated the prevalence of burnout, depression, anxiety and stress in Australian midwives. METHODS: An online survey was conducted in September 2014. Participants were recruited through the Australian College of Midwives and professional networks. The survey sought personal and professional details. Standard measures included the Copenhagen Burnout Inventory (CBI) (Personal, Work and Client subscales), and Depression, Anxiety, and Stress Scale (DASS). The sample was collapsed into two groups according to DASS clinical cut-offs (normal/mild versus moderate/severe/extreme). Effect size statistics were calculated and judged according to Cohen's guidelines. RESULTS: One thousand thirty-seven surveys were received. Respondents were predominantly female (98%), with an average age of 46.43 years, and 16.51 years of practice. Using a CBI subscale cut-off score of 50 and above (moderate and higher), 64.9% (n = 643) reported personal burnout; 43.8% (n = 428) reported work-related burnout; and 10.4% (n = 102) reported client-related burnout. All burnout subscales were significantly correlated with depression, anxiety and stress, particularly personal and work-related burnout with Spearman's rho correlations ranging from .51 to .63 (p < .001). Around 20% of midwives reported moderate/ severe/ extreme levels of depression (17.3%); anxiety (20.4%), and stress (22.1%) symptoms. Mann-Whitney U tests revealed significant differences between groups with depression (r = .43), anxiety (r = .41) and stress (r = 48) having a medium size effect on burnout. CONCLUSION: Prevalence of personal and work-related burnout in Australian midwives was high. The physical and psychological exhaustion associated with the different types of burnout were reflected in symptoms of depression, anxiety and stress symptoms. Further research is needed to support the personal well-being of midwives and minimize workplace burnout by developing short and long term strategies.

Culturally capable and culturally safe: Caseload care for Indigenous women by Indigenous midwifery students.

BACKGROUND: Evidence is emerging of the benefits to students of providing continuity of midwifery care as a learning strategy in midwifery education, however little is known about the value of this strategy for midwifery students. AIM: To explore Indigenous students' perceptions of providing continuity of midwifery care to Indigenous women whilst undertaking a Bachelor of Midwifery. METHODS: Indigenous Bachelor of Midwifery students' experiences of providing continuity of midwifery care to Indigenous childbearing women were explored within an Indigenous research approach using a narrative inquiry framework. Participants were three Indigenous midwifery students who provided continuity of care to Indigenous women. FINDINGS: Three interconnected themes; facilitating connection, being connected, and journeying with the woman. These themes contribute to the overarching finding that the experience of providing continuity of care for Indigenous women creates a sense of personal affirmation, purpose and a validation of cultural identity in Indigenous students. DISCUSSION AND CONCLUSIONS: Midwifery philosophy aligns strongly with the Indigenous health philosophy and this provides a learning platform for Indigenous student midwives. Privileging Indigenous culture within midwifery education programs assists students develop a sense of purpose and affirms them in their emerging professional role and within their community. The findings from this study illustrate the demand for, and pertinence of, continuity of care midwifery experiences with Indigenous women as fundamental to increasing the Indigenous midwifery workforce in Australia. Australian universities should provide this experience for Indigenous student midwives.

Being a young midwifery student: A qualitative exploration.

BACKGROUND: undergraduate midwifery programmes offer opportunities for school leavers and young people (aged less than 21 years) to enter the profession. There is limited research exploring this age groups experience of their Bachelor of Midwifery programme. In order to retain these students we need to ensure that their experiences of undertaking a Bachelor of Midwifery program are positive and barriers and challenges are minimised. AIM: this study explored young midwifery students' experience of their Bachelor of Midwifery program. METHOD: a descriptive exploratory qualitative approach was used to explore the experiences of eleven students aged 20 years or less on enrolment. Data was collected using face-to-face or telephone-recorded interviews. Thematic analysis was used to analysis the data set. FINDINGS: three major themes described the young students' experiences. The first labelled 'The challenges of being young' presented a number of age related challenges including transport issues with on-call commitments as some students had not gained a driver's license. Students experienced some degree of prejudice relating to their age from their older student peers and some clinical staff during placements. 'Finding your way' was the second theme and described the strategies students used to build confidence and competence both in the university and clinical environment. The young students reported a strong commitment to the profession. They demonstrated high levels of connection with women and found the continuity of care experiences invaluable to their learning. The final theme 'Making the transition from teenager to midwife' demonstrated some unique insights into how studying to become a midwife impacted upon their personal and professional growth. CONCLUSION: the young students in this study encountered some unique issues related to their age. However as they progressed through the program they developed confidence in themselves and visualised themselves as having a long midwifery career. They were strongly motivated towards providing woman-centred maternity care and considered their continuity of care experiences fundamental to them developing a strong sense of themselves as midwives. Attracting and retaining young students is essential if the profession is to realise its goal of ensuring all women have access to a known midwife.

Women's experiences of having a Bachelor of Midwifery student provide continuity of care.

BACKGROUND: The Australian national midwifery education standards require students to complete a number of continuity of care (COC) experiences. There is increasing evidence outlining the value of this experience to the student, but there is limited research examining women's experiences of having a COC midwifery student. This study aimed to investigates the woman's experiences. METHODS: A retrospective descriptive cohort design was used. A paper-based survey was posted to all women cared for by a midwifery student in 2013 (n=698). Descriptive statistics were used to explore the proportion, mean score, standard deviation and range of the variables. Construct validity of the Satisfaction and Respect Scales was tested using exploratory factor analysis. Free text responses were analysed using latent content analysis. RESULT: One-third of women returned a completed survey (n=237/698, 34%). There was a significant positive correlation (p<0.05) between the number of AN/PN visits a midwifery student attended and women's levels of satisfaction. Women were very satisfied with having a student midwife provide continuity. The qualitative data provided additional insight demonstrating that most women had a positive relationship with the midwifery student that enhanced their childbearing experience. CONCLUSION: The women in this study valued continuity of midwifery care and were able to form meaningful relationships with their midwifery student. Programs leading to registration as a midwife should privilege continuity of care experiences. Not only does this benefit women but provides the future midwifery workforce with a clear understanding of models that best meet women's individual and the benefits of working in these models.

Young student's motivations to choose an undergraduate midwifery program.

BACKGROUND: Within the context of an ageing health workforce it is important to gain a greater understanding of the motivations of young people (aged less than 21 years) to choose a career in midwifery. AIM: To explore the reasons why young students decided to study midwifery and enrol in one Australian Bachelor of Midwifery program. METHOD: A descriptive exploratory qualitative design was used. Eleven midwifery students aged less than 21 years on enrollment participated in a semi-structured tape-recorded interview. The transcribed interviews were analysed using thematic analysis. FINDINGS: Direct and indirect exposure to positive constructions of childbirth as well as the midwives role fuelled young student's fascination with midwifery and drove their desire to enrol. While some young students entered midwifery studies as a result of their 'love of babies' others took a more pragmatic 'wait and see' approach about their career choice. Many young students however clearly distinguished midwifery from nursing demonstrating an intention to be a midwife rather than a nurse. This decision often took place within the context of opposition from within their family, school and social networks where the public discourse continued to reinforce nursing as the preferred pathway to midwifery. CONCLUSION: Creating opportunities for young people to be exposed to positive constructions of childbirth as well as midwifery role models may increase the number of young students entering midwifery. There is also a need for information to be provided to school careers officers to assist them to understand the distinction between midwifery and nursing.

Reforming maternity services in Australia: Outcomes of a private practice midwifery service.

BACKGROUND AND AIMS: recent legislative changes in Australia have enabled eligible midwives to provide private primary maternity care with fee rebates through Medicare. This paper (1) discusses these changes affecting midwifery practice; (2) describes Australia's first private midwifery service with visiting rights to hospital for labour and birth care since Medicare funding for midwives was introduced in 2010; and (3) compares outcomes with National Core Maternity Indicators. METHODS: an audit of all client records (n=323) for the survey period from September 2012 to February 2014 was undertaken. Data were extracted and compared with the 10 perinatal indicators using Chi square statistics. FINDINGS: this convenience sample of all-risk women was similar to the national birthing population for age and parity. Compared to national indicators, women were significantly more likely to have spontaneous commencement of labour (79.6% versus 54.8%) (χ(2)=79.88, p<.001), lower rates of induction (10.2% versus 26%) (χ(2)=79.88, p<.001), and not require pharmacological pain relief (54.8% versus 23.9%) (χ(2)=152.2, p<.001). The majority of women had a normal vaginal birth (70.3% versus 55.1%) (χ(2)=28.13, p<.001). The caesarean section rate (22% versus 32.3%) was significantly lower (χ(2)=15.64, p<.001) than the national rate. Average gestation of neonates was 39.3 weeks; average birth weight was 3525 gms, and fewer required transfer to the special care nursery (8.4% versus 15.3%) (χ(2)=11.89, p<.001). DISCUSSION: this is the first report of maternal and neonatal outcomes for a private midwifery service in Australia since the introduction of access to Medicare for midwives. Maternal and newborn outcomes were statistically better than national rates. Routinely reporting and publishing clinical outcomes needs to become the norm for private maternity care. CONCLUSIONS: this private midwifery caseload model has been instrumental in the ground-breaking change to primary maternity services that extends women׳s access to safe midwifery care in Australia. The potential impact of private practicing midwives to align maternity care with the best available evidence is significant.

Using the Five Senses of Success framework to understand the experiences of midwifery students enroled in an undergraduate degree program.

BACKGROUND: developing a student's sense of capability, purpose, resourcefulness, identity and connectedness (five-senses of success) are key factors that may be important in predicting student satisfaction and progression within their university program. AIM: the study aimed to examine the expectations and experiences of second and third year midwifery students enroled in a Bachelor of Midwifery program and identify barriers and enablers to success. METHOD: a descriptive exploratory qualitative design was used. Fifty-six students enroled in either year 2 or 3 of the Bachelor of Midwifery program in SE Queensland participated in an anonymous survey using open-ended questions. In addition, 16 students participated in two year-level focus groups. Template analysis, using the Five Senses Framework, was used to analyse the data set. FINDINGS: early exposure to 'hands on' clinical midwifery practice as well as continuity of care experiences provided students with an opportunity to link theory to practice and increased their perception of capability as they transitioned through the program. Students' sense of identity, purpose, resourcefulness, and capability was strongly influenced by the programs embedded meta-values, including a 'woman centred' approach. In addition, a student's ability to form strong positive relationships with women, peers, lecturers and supportive clinicians was central to developing connections and ultimately a sense of success. A sense of connection not only fostered an ongoing belief that challenges could be overcome but that students themselves could initiate or influence change. CONCLUSIONS: the five senses framework provided a useful lens through which to analyse the student experience. Key factors to student satisfaction and retention within a Bachelor of Midwifery program include: a clearly articulated midwifery philosophy, strategies to promote student connectedness including the use of social media, and further development of clinicians' skills in preceptorship, clinical teaching and facilitation. Program delivery methods and student support systems should be designed to enable maximum flexibility to promote capability and resourcefulness and embed sense of purpose and identity early in the program.

Jordanian women's dissatisfaction with childbirth care.

BACKGROUND: Dissatisfaction with childbirth care can have a negative impact on a woman's health and well-being, as well as her relationships with her infant. AIM: To investigate the prevalence and associated factors of dissatisfaction with intrapartum care by Jordanian women. METHOD: A descriptive cross-sectional study was used. Participants (n = 320) who were 7 weeks post-partum were recruited from five maternal and child health centres in Irbid city in northern Jordan. Participants provided personal and obstetric information, and completed the Satisfaction with Childbirth Care Scale. RESULTS: The majority of women (75.6%) were dissatisfied with their intrapartum care. Dissatisfaction was associated with the attendance of unknown and unwanted persons during childbirth, experiencing labour as more painful than expected, and perceptions of inadequate help from healthcare providers to manage pain during labour. LIMITATIONS: Findings are limited to Jordanian women accessing public sector perinatal health services. CONCLUSION: The high percentage of women reporting dissatisfaction with intrapartum care in this study is of concern. Women's perception of pain and expectations of staff during labour and birth need to be addressed through education and improved communication by staff. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Development of national evidence-based policies and quality assurance systems would help reduce the rate of obstetric interventions and give greater emphasis to respect for women's preferences during labour and birth.

Early childhood caries: recurrence after comprehensive dental treatment under general anaesthesia.

AIMS: This was to assess the recurrence of dental caries and the affecting factors after dental surgery for early childhood caries (ECC). STUDY DESIGN: A retrospective study completed in a private dental practice with surgical facilities. METHODS: Dental charts were reviewed for 269 patients under 6-years-old who had comprehensive dental care under general anaesthesia (GA) between January 1, 2005 and December 31, 2007. The rate of new caries was evaluated by recording the new carious lesions at each follow-up appointment up to 24 months after the original dental surgery. RESULTS: Of the 269 patients, 62% had at least one recall appointment within 12 months after the GA; 24% of these had at least one new carious lesion. Of the 36 patients who attended recalls at 13 to 24 months following the GA, 53% had new carious lesions. Demographics, defs/deft before the GA, and number of extractions, pulpotomies, and preformed metal crowns (PMC) at the GA were not associated with relapse. Patients who had a previous dental GA were less likely to relapse in the short term (1-6 months after GA), but more likely to relapse in the longer term (19-24 months), as compared with those who had not had another GA. CONCLUSION: A previous dental GA experience may have an immediate impact on parents to promote healthy behaviours, but the challenges that they face may eventually mean failure of maintaining good oral health in the long term. A comprehensive and frequent preventive approach is required to reduce the relapse rate following a dental surgery for ECC.

The challenge of patients' unmet palliative care needs in the final stages of chronic illness.

BACKGROUND: There is consensus in the literature that the end of life care for patients with chronic illness is suboptimal, but research on the specific needs of this population is limited. AIM: This study aimed to use a mixed methodology and case study approach to explore the palliative care needs of patients with a non-cancer diagnosis from the perspectives of the patient, their significant other and the clinical team responsible for their care. Patients (n = 18) had a diagnosis of either end-stage heart failure, renal failure or respiratory disease. METHODS: The Short Form 36 and Hospital and Anxiety and Depression Questionnaire were completed by all patients. Unstructured interviews were (n = 35) were conducted separately with each patient and then their significant other. These were followed by a focus group discussion (n = 18) with the multiprofessional clinical team. Quantitative data were analysed using simple descriptive statistics and simple descriptive statistics. All qualitative data were taped, transcribed and analysed using Colaizzi's approach to qualitative analysis. FINDINGS: Deteriorating health status was the central theme derived from this analysis. It led to decreased independence, social isolation and family burden. These problems were mitigated by the limited resources at the individual's disposal and the availability of support from hospital and community services. Generally resources and support were perceived as lacking. All participants in this study expressed concerns regarding the patients' future and some patients described feelings of depression or acceptance of the inevitability of imminent death. CONCLUSION: Patients dying from chronic illness in this study had many concerns and unmet clinical needs. Care teams were frustrated by the lack of resources available to them and admitted they were ill-equipped to provide for the individual's holistic needs. Some clinicians described difficulty in talking openly with the patient and family regarding the palliative nature of their treatment. An earlier and more effective implementation of the palliative care approach is necessary if the needs of patients in the final stages of chronic illness are to be adequately addressed.

Tea tree oil reduces the swelling associated with the efferent phase of a contact hypersensitivity response.

OBJECTIVE: To examine the anti-inflammatory activities of tea tree oil (TTO) in vivo. METHODS: Mice were sensitized to a chemical hapten, trinitrochlorobenzene, on their ventral skin and 7 days later challenged (or re-exposed) on their dorsal skin with the same hapten. RESULTS: TTO applied 30 min before or up to 7 h after to the same dorsal site as hapten challenge caused a significant reduction in skin swelling after 24 h. TTO reduced oedema but not the influx of inflammatory cells. This finding was supported by the inability of TTO to suppress TNFalpha-induced E-selectin expression by human umbilical vein endothelial cells. TTO did not suppress irritant- or ultraviolet B-induced oedema. CONCLUSION: Topical TTO, specifically the TTO components, terpinen-4-ol and alpha-terpineol can regulate the oedema associated with the efferent phase of a contact hypersensitivity response.

Mortality among three refinery/petrochemical plant cohorts. I. 1970 to 1982 active/terminated workers.

This study updates mortality rates for 19,075 active and terminated workers at three refinery/petrochemical plants. Mortality rates of the workers were compared with both national and state rates. The results indicated deficits of deaths for all causes, all malignant neoplasms, and respiratory and prostate cancer. The noteworthy finding was a statistically significant increase in leukemia among Louisiana male subjects (standardized mortality ratio [SMR], 181; 95% confidence interval [CI], 122 to 259), which showed suggestive trends of increasing SMRs with increasing tenure. This excess was largely due to increased chronic lymphocytic leukemia (SMR, 351; 95% CI, 168 to 645). The rate of kidney cancer remained elevated among Louisiana male subjects, but this finding was no longer significant, and there were no patterns in SMRs by tenure and latency. Mesothelioma was increased at the Louisiana (SMR, 198; 95% CI, 72 to 430) and Texas (SMR, 246; 95% CI, 99 to 507) locations. The leukemia findings have prompted a study of leukemia incidence at the Louisiana location.

Mortality among three refinery/petrochemical plant cohorts. II. Retirees.

This study updates mortality data for 6238 retirees from three refinery/petrochemical plants. Almost 90% of the cohort was deceased. Deaths from all causes (standardized mortality ratio, 104; 95% confidence interval, 102 to 107) and all cancers (standardized mortality ratio, 109; 95% confidence interval, 102 to 116) were elevated. Increased deaths due to kidney cancer, mesothelioma, and the category of other lymphohemopoietic cancers also were observed. The rate of leukemia was not increased. There was little internal or external consistency to support an occupational relationship for kidney cancer, but findings for mesothelioma and other lymphohemopoietic cancers are consistent with reports for other petroleum cohorts. Analyses by age indicated significantly higher all-cause mortality rates among persons retiring before age 65. The results suggest that continued surveillance of mesothelioma and lymphohemopoietic cancer malignancies in younger workers with more contemporary exposures may be warranted. Furthermore, age at retirement should be considered when analyzing occupational cohorts.