Healthcare Quality Received by Insured Patients in Two Indonesian Regional Public Hospitals.

Background: Hospitals are required to improve the quality of health services provided to patients. Purpose: Evaluating and comparing the healthcare quality received by insured patients hospitalized in two Indonesian regional public hospitals. Methods: Secondary data analysis used the 2019 and 2020 Indonesian National Health Insurance e-claim databases of Hospital A and Hospital B. Descriptive and crosstabs analyses were used to determine INA-CBGs diagnoses that were categorized as high volume, high risk, and high cost. Results: The admissions that caused financial loss at the Hospital A were 21.1% in 2019 and 19.8% in 2020, while 30.3% in 2019 and 27.5% at the Hospital B. More than 60% of these admissions were placed in the 3rd class of inpatient wards of the two hospitals. Of these admissions, < 5% at the Hospital A and >5% at the Hospital B were readmitted within 30 days, although more than 90% were previously discharged based on physicians' approval. Conclusions: Inadequate healthcare quality received by insured patients. Hence, an integrated clinical pathways based professional nursing practice model is highly recommended to increase patient outcomes and decrease 30 days hospital readmission rates.

Quality of complementary and alternative medicine information for type 2 diabetes: a cross-sectional survey and quality assessment of websites.

BACKGROUND: The global prevalence of diabetes mellitus is projected to reach approximately 700 million by the year 2045, with roughly 90-95% of all diabetes cases being type 2 in nature. Patients with type 2 diabetes mellitus (T2DM) frequently seek information about complementary and alternative medicine (CAM) online. This study assessed the quality of publicly accessible websites providing consumer health information at the intersection of T2DM and CAM. METHODS: An online search engine (Google) was searched to identify pertinent websites containing information specific to CAM for T2DM patients, and the relevant websites were then screened with an eligibility criteria. Consumer health information found on eligible websites were then assessed for quality using the DISCERN instrument, a 16-item standardized scoring system. RESULTS: Across the 480 webpages identified, 94 unique webpages remained following deduplication, and 37 eligible webpages belonged to and were collapsed into 30 unique websites that were each assessed using the DISCERN instrument. The mean overall quality score (question 16) across all 30 assessed websites was 3.55 (SD = 0.86), and the mean summed DISCERN score was 52.40 (SD = 12.11). Eighty percent of websites presented a wide range of CAM treatment options with the associated benefits/risks of each treatment, but in 56.7% of the websites, the sources used to collect information were unreliable. CONCLUSION: This study identified, assessed, and presents findings on the quality of online CAM information for T2DM. Although there were several high scoring websites, there was variability across most of the individual DISCERN items in the assessed websites. This study highlights the importance of awareness among healthcare providers regarding the reliability of online information about CAM treatment and management options for T2DM. Healthcare providers should be aware of patients' information seeking behaviour, guide them in navigating through the content they encounter online, and provide them with resources containing trustworthy and reliable information.

Headache and migraine clinical practice guidelines: a systematic review and assessment of complementary and alternative medicine recommendations.

BACKGROUND: Globally, 3 billion people suffer from either migraine or tension-type headache disorder over their lifetime. Approximately 50% of American adults suffering from headache or migraine have used complementary and alternative medicine (CAM), however, the quality and quantity of recommendations associated with such therapies across clinical practice guidelines (CPGs) for the treatment and/or management of these conditions are unknown. The purpose of this study was to identify the quantity and assess the quality of such CAM recommendations. METHODS: MEDLINE, EMBASE and CINAHL were systematically searched from 2009 to April 2020; the Guidelines International Network and the National Center for Complementary and Integrative Health websites were also searched for eligible CPGs. CPGs were included if they provided any therapy recommendations. Eligible CPGs included those written for adult patients with headache and migraine; CPGs containing CAM recommendations were assessed twice for quality using the AGREE II instrument, once for the overall CPG and once for the CAM sections. RESULTS: Of 486 unique search results, 21 CPGs were eligible and quality assessed; fifteen CPGs mentioned CAM, of which 13 CPGs made CAM recommendations. The overall CPG assessment yielded higher scaled domain percentages than the CAM section across all domains. The results from highest to lowest were as follows (overall, CAM): clarity of presentation (66.7% vs. 50.0%), scope and purpose (63.9% vs. 61.1%), stakeholder involvement (22.2% vs. 13.9%), rigour of development (13.5% vs. 9.4%), applicability (6.3% vs. 0.0%), and editorial independence (0.0% vs. 0.0%). CONCLUSIONS: Of the eligible CPGs, the CAM sections were of lower quality compared to the overall recommendations across all domains of the AGREE II instrument. CPGs that scored well could serve as a framework for discussion between patients and healthcare professionals regarding use of CAM therapies in the context of headache and migraine.

Factors affecting revisit intention for medical services at dental clinics.

Recent changes in the medical paradigm highlight the importance of patient-centered communication. However, because of the lack of awareness of dental clinics and competency of medical personnel, the quality of medical services in terms of the communication between doctors and patients has not improved. This study analyzed the impact of health communication and medical service quality, service value, and patient satisfaction on the intention to revisit dental clinics. The study participants were outpatients treated at 10 dental clinics in Seoul. The research data were collected using a questionnaire during visits to these dental clinics from December 1 to December 30, 2016. A total of 600 questionnaires were distributed (60 copies to each clinics) and 570 valid questionnaires were used for the analysis. The influence of the factors was determined using structural equation modeling. The factors influencing service value were reliability (ß = 0.364, p < 0.001), expertise (ß = 0.319, p < 0.001), communication by doctors (ß = 0.224, p < 0.001), and tangibility (ß = 0.136, p < 0.05). In addition, the factors influencing patient satisfaction were reliability (ß = 0.258, p < 0.001), tangibility (ß = 0.192, p < 0.001), communication by doctors (ß = 0.163, p < 0.001), and expertise (ß = 0.122, p < 0.01). Further, service value (ß = 0.438, p < 0.001) raised patient satisfaction, which was found to influence the intention to revisit dental clinics (ß = 0.383, p < 0.001). Providing accurate medical services to inpatients based on smooth communication between doctors and patients improves patient satisfaction. In addition, doctors can build long-term relations with patients by increasing patients' intention to revisit through patient-oriented communication.

Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours.

BACKGROUND: Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women. PURPOSE: We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing. METHODS: This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest. DISCUSSION: While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

A qualitative study on midwives' identity and perspectives on the occurrence of disrespect and abuse in Maputo city.

BACKGROUND: Midwifery care plays a vital role in the reduction of preventable maternal and newborn mortality and morbidity. There is a growing concern about the quality of care during facility based childbirth and the occurrence of disrespect and abuse (D&A) worldwide. While several studies have reported a high prevalence of D&A, evidence about the drivers of D&A is scarce. This study aims to explore midwives' professional identity and perspectives on the occurrence of D&A in urban Mozambique. METHODS: A qualitative study took place in the central hospital of Maputo, Mozambique. Nine focus group discussions with midwives were conducted, interviewing 54 midwives. RQDA software was used for analysing the data by open coding and thematic analysis from a grounded theory perspective. RESULTS: Midwives felt proud of their profession but felt they were disrespected by the institution and wider society because of their inferior status compared to doctors. Furthermore, they felt blamed for poor health outcomes. The occurrence of D&A seemed more likely in emergency situations but midwives tended to blame this on women being "uncooperative". The involvement of birth companions was a protective factor against D&A together with supervision. CONCLUSION: In order to improve quality of care and reduce the occurrence of D&A midwives will need to be treated with more respect within the health system. Furthermore, they should be trained in handling obstetric emergency situations with respect and dignity for the patient. Systematic and constructive supervision might be another promising strategy for preventing D&A.

Health system affiliation of physician organizations and quality of care for Medicare beneficiaries who have high needs.

OBJECTIVE: To test the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system-affiliated and nonaffiliated physician organizations (POs) and to examine variability in quality across health systems. DATA SOURCES: 2015 Medicare Data on Provider Practice and Specialty linked physicians to POs. Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and IRS Form 990 data identified health system affiliations. Fee-for-service Medicare enrollment and claims data were used to examine quality. STUDY DESIGN: This cross-sectional analysis of beneficiaries with high needs, defined as having more than twice the expected spending of an average beneficiary, examined six quality measures: continuity of care, follow-up visits after hospitalizations and emergency department (ED) visits, ED visits, all-cause readmissions, and ambulatory care-sensitive hospitalizations. Using a matched-pair design, we estimated beneficiary-level regression models with PO random effects to compare quality of care in system-affiliated and nonaffiliated POs. We then limited the sample to system-affiliated POs and estimated models with system random effects to examine variability in quality across systems. PRINCIPAL FINDINGS: Among 2 323 301 beneficiaries with high needs, 52.3% received care from system-affiliated POs. Rates of ED visits were statistically significantly different in system-affiliated POs (117.5 per 100) and nonaffiliated POs (106.8 per 100, P < .0001). Small differences in the other five quality measures were observed across a range of sensitivity analyses. Among systems, substantial variation was observed for rates of continuity of care (90% of systems had rates between 70.8% and 89.4%) and follow-up after ED visits (90% of systems had rates between 56.9% and 73.5%). CONCLUSIONS: Small differences in quality of care were observed among beneficiaries with high needs receiving care from system POs and nonsystem POs. Health systems may not confer hypothesized quality advantages to patients with high needs.

Traditional practices during pregnancy and birth, and perceptions of perinatal losses in women of rural Pakistan.

OBJECTIVE: Understanding the sociocultural context and local practices during pregnancy and birth is imperative to identify factors related to perinatal mortality in countries where its burden is high. This study aims to explore the pregnancy and birth related cultural practices and the perceptions of women with a recent perinatal death in Sindh province, Pakistan. DESIGN: This qualitative exploratory study consisted of in-depth interviews with women who had experienced a perinatal death in the year preceding the study. Women were identified and recruited with the help of lady health workers. After consent, women were interviewed in their homes and in their own language (Sindhi) by a local female interviewer. SETTING AND PARTICIPANTS: Interviews were conducted with women from predominantly rural district of the southern province of Sindh in Pakistan between May and August 2018. The data were coded both inductively and deductively and then analysed using themes. FINDINGS: Twenty-five women were interviewed. Traditional home remedies were commonly used to alleviate pregnancy symptoms such as general aches and pains. The health providers often delayed the information about the perinatal deaths in health facilities, which saddened the women. Most women had fatalistic opinions about what caused their losses, and explained the cause based on their own interpretation, which were not necessarily consistent with known causes of perinatal death. The women also desired to use contraception and believed that it would prevent future pregnancy loss; however, many women were unable to make that decision themselves. CONCLUSIONS AND IMPLICATIONS: The high use of traditional home-based remedies may be a proxy measure for poor access to formal healthcare services. Many women described poor acknowledgement of their grief which may be harmful. Women's knowledge about the causes of perinatal mortality in general was very low, improving this knowledge may help women to seek appropriate healthcare services during pregnancy.

Newborn Clinic: A Novel Model to Provide Timely, Comprehensive Care to Newborns Following Nursery Discharge.

Ensuring safe and timely follow-up after well baby nursery (WBN) discharge is an ongoing challenge. This study demonstrates the efficacy of a novel model for follow-up, the Newborn Clinic (NBC), in reducing time to outpatient follow-up after WBN discharge. Our retrospective chart review of 17 952 newborns found that time to follow-up visit decreased significantly following NBC establishment. Emergency department visits, a marker of infant morbidity, were slightly increased in the post-establishment cohort. There was no difference, however, in hospital readmissions. Analysis within the post-establishment cohort showed that newborns with jaundice, a high-risk group, were much more likely to have early follow-up if their visit was scheduled with NBC. Our study demonstrates that NBC is an effective model for decreasing time from WBN discharge to follow-up visit. It should be considered as an initiative to run concurrently with expedited newborn discharge initiatives so that safe follow-up need not be sacrificed.

Quality of and barriers to routine childbirth care signal functions in primary level facilities of Tigray, Northern Ethiopia: Mixed method study.

BACKGROUND: Efforts to expand access to institutional delivery alone without quality of care do not guarantee better survival. However, little evidence documents the quality of childbirth care in Ethiopia, which limits our ability to improve quality. Therefore, this study assessed the quality of and barriers to routine childbirth care signal functions during intra-partum and immediate postpartum period. METHODS: A sequential explanatory mixed method study was conducted among 225 skilled birth attendants who attended 876 recently delivered women in primary level facilities. A multi stage sampling procedure was used for the quantitative phase whilst purposive sampling was used for the qualitative phase. The quantitative survey recruitment occurred in July to August 2018 and in April 2019 for the qualitative key informant interview and Focus Group Discussions (FGD). A validated quantitative tool from a previous validated measurement study was used to collect quantitative data, whereas an interview guide, informed by the literature and quantitative findings, was used to collect the qualitative data. Principal component analysis and a series of univariate and multivariate linear regression analysis were used to analyze the quantitative data. For the qualitative data, verbatim review of the data was iteratively followed by content analysis and triangulation with the quantitative results. RESULTS: This study showed that one out of five (20.7%, n = 181) mothers received high quality of care in primary level facilities. Primary hospitals (ß = 1.27, 95% CI:0.80,1.84, p = 0.001), facilities which had staff rotation policies (ß = 2.19, 95% CI:0.01,4.31, p = 0.019), maternal involvement in care decisions (ß = 0.92, 95% CI:0.38,1.47, p = 0.001), facilities with maternal and newborn health quality improvement initiatives (ß = 1.58, 95% CI:0.26, 3.43, p = 0.001), compassionate respectful maternity care training (ß = 0.08, 95% CI: 0.07,0.88, p = 0.021), client flow for delivery (ß = 0.19, 95% CI:-0.34, -0.04, p = 0.012), mentorship (ß = 0.02, 95% CI:0.01, 0.78, p = 0.049), and providers' satisfaction (ß = 0.16, 95% CI:0.03, 0.29, p = 0.013) were predictors of quality of care. This is complemented by qualitative research findings that poor quality of care during delivery and immediate postpartum related to: work related burnout, gap between providers' skill and knowledge, lack of enabling working environment, poor motivation scheme and issues related to retention, poor providers caring behavior, unable translate training into practice, mismatch between number of provider and facility client flow for delivery, and in availability of essential medicine and supplies. CONCLUSIONS: There is poor quality of childbirth care in primary level facilities of Tigray. Primary hospitals, facilities with staff rotation, maternal and newborn health quality improvement initiatives, maternal involvement in care decisions, training on compassionate respectful maternity care, mentorship, and high provider satisfaction were found to have significantly increased quality of care. However, client flow for delivery service is negatively associated with quality of care. Efforts must be made to improve the quality of care through catchment-based mentorship to increase providers' level of adherence to good practices and standards. More attention and thoughtful strategies are required to minimize providers' work-related burnout.

Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system.

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.

Missed Nursing Care in Pediatric and Neonatal Care Settings: An Integrative Review.

INTRODUCTION: Missed nursing care is required care that is delayed, incomplete, or left undone during a nurse's working shift. Missed nursing care is most often studied in adult populations; however, it may have significant consequences in pediatric and neonatal care settings. The purpose of this integrative review is to describe missed nursing care in pediatric and neonatal nursing care settings. METHODS: SCOPUS and PubMed were used in the literature search. Multiple combinations of the keywords and phrases "missed nursing care," "pediatric," "neonatal," "care left undone," or "nursing care rationing" were used for the literature search. Missed nursing care is a relatively new topic as the first article on the subject was published in 2006; therefore, inclusion criteria were set to English articles published between January 1, 2006 and October 11, 2019 that reported on missed nursing care in pediatric and neonatal inpatient care settings. RESULTS: Fourteen articles met inclusion criteria. Missed nursing care in pediatric and neonatal nursing care settings is associated with workload, patient acuity, work environment, and nurse characteristics, and is related to prolonged hospitalization of preterm infants. CLINICAL IMPLICATIONS: Providing nurses with an adequate amount of resources and tools to avoid missed nursing care will continue to improve care delivery. Missed nursing care and related patient and nurse outcomes in diverse pediatric and neonatal samples remains an area for future research.

Women's unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery.

OBJECTIVE: to analyse women's experiences of early labour care in caseload midwifery in Australia. DESIGN: this study sits within a multi-site randomised controlled trial of caseload midwifery versus standard care. Participant surveys were conducted at 6-weeks and 6-months after birth. Free-text responses about experiences of care were subject to critical thematic analysis in NVivo 11 software. SETTING: two urban Australian hospitals in different states. PARTICIPANTS: women 18 years and over, with a singleton pregnancy, less than 24 weeks' pregnant, not planning a caesarean section or already booked with a care provider; were eligible to participate in the trial. INTERVENTIONS: participants were randomised to caseload midwifery or standard care for antenatal, labour and birth and postpartum care. MEASUREMENTS AND FINDINGS: The 6-week survey response rate was 58% (n = 1,019). The survey included five open questions about women's experiences of pregnancy, labour and birth, and postnatal care. Nine-hundred and one respondents (88%) provided free text comments which were coded to generate 10 categories. The category of early labour contained data from 84 individual participants (caseload care n = 44; standard care n = 40). Descriptive themes were: (1) needing permission; (2) doing the 'wrong' thing; and (3) being dismissed. Analytic themes were: (1) Seeking: women wanting to be "close to those who know what's going on"; and (2) Shielding: midwives defending resources and normal birth. KEY CONCLUSIONS: Regardless of model of care, early labour care was primarily described in negative terms. This could be attributed to reporting bias, because women who were neutral about early labour care may not comment. Nevertheless, the findings demonstrate a gap in knowledge about early labour care in caseload midwifery models. IMPLICATIONS FOR PRACTICE: Maternity services that offer caseload midwifery are ideally placed to evaluate how early labour home visiting impacts women's experiences of early labour.

Quality of safety reporting for complementary and alternative therapies for dysmenorrhea.

OBJECTIVES: This study assessed the quality of safety reporting in complementary and alternative therapies randomized controlled trials for primary dysmenorrhea. METHODS: Methodologic systematic review of randomized controlled trials published until August 25, 2019 without language restrictions. The adequacies of safety reporting are reported as frequencies and percentages and their predictors were analyzed by multiple least-squares and logistic regressions. RESULTS: Thirty-nine trials were included in this review. Of 39 trials, 56% (22/39) reported that no harms were observed. Of the predictor variables, the percentage of words reporting safety in the body section of text increased significantly with sample sizes (effect size 0.14, 95% confidence interval 0.01-0.26, p = .041). CONCLUSIONS: No harms of included trials were well-reported in complementary and alternative therapy journals. These findings will serve as sound guidance to assess the quality of safety reporting in further complementary and alternative therapies for primary dysmenorrhea.

Can social accountability mechanisms using community scorecards improve quality of pediatric care in rural Cambodia?

OBJECTIVE: To determine the effect of social accountability strategies on pediatric quality of care. DESIGN AND SETTING: A non-randomized quasi experimental study was conducted in four districts in Cambodia and all operational public health facilities were included. PARTICIPANTS: Five patients under 5 years and their caretakers were randomly selected in each facility. INTERVENTIONS: To determine the effect of maternal and child health interventions integrating citizen voice and action using community scorecards on quality of pediatric care. OUTCOME MEASURES: Patient observations were conducted to determine quality of screening and counseling, followed by exit interviews with caretakers. RESULTS: Results indicated significant differences between intervention and comparison facilities; screening by Integrated Management of Childhood Illness (IMCI) trained providers (100% vs 67%, P < 0.019), screening for danger signs; ability to drink/breastfeed (100% vs 86.7%, P < 0.041), lethargy (86.7% vs 40%, P < 0.004) and convulsions (83.3 vs 46.7%, P < 0.023). Screening was significantly higher for patients in the intervention facilities for edema (56.7% vs 6.7%, P < 0.000), immunization card (90% vs 40%, P < 0.002), child weight (100 vs 86.7, P < 0.041) and checking growth chart (96.7% vs 66.7%, P < 0.035). The IMCI index, constructed from key performance indicators, was significantly higher for patients in the intervention facilities than comparison facilities (screening index 8.8 vs 7.0, P < 0.018, counseling index 2.7 vs 1.5, P < 0.001). Predictors of screening quality were child age, screening by IMCI trained provider, wealthier quintiles and intervention facilities. CONCLUSION: The institution of social accountability mechanisms to engage communities and facility providers showed some improvements in quality of care for common pediatric conditions, but socioeconomic disparities were evident.

Evaluation of a student-led midwifery group practice: A woman's perspective.

BACKGROUND: . OBJECTIVE: To evaluate women's experiences of a student-led midwifery group practice. DESIGN: A mixed methods design was used to examine women's experiences and level of satisfaction about a student-led midwifery model of care. An on-line survey elucidated women's levels of satisfaction and experiences with the student-led midwifery group practice. The online survey was sent to all women (n = 25) who were receiving care from third year Bachelor of Midwifery students in 2018 via email up to 6 weeks postnatally. The online survey was distributed in the first instance to obtain baseline information about the importance of this student-led midwifery group practice and so the survey information was linked to the in-depth interview in the analysis for the purpose of identifying if the women were primiparous or multiparous. Women (n = 9) were invited to participate in an in-depth interview by self-opting on the survey and this extra data provided a richer understanding about the level of satisfaction about woman-centred care led by midwifery students. Retrospective data were also collected from the Maternity database - E-Maternity about birth outcomes. SETTING: A tertiary teaching public hospital in New South Wales (NSW). PARTICIPANTS: Fifteen women participated in an online survey. Five primiparous and four multiparous women opted to be involved in the in-depth interviews on the online survey. MEASUREMENTS AND FINDINGS: Analysis in SPSS provided descriptive statistics including frequencies and percentages of data including birth outcomes. Simple correlations enabled associations to be established between levels of satisfaction, individualised care, quality of care, benefits and anxiety during pregnancy. The overarching themes from the qualitative findings identified the students' presence for the women as the most important component of the women's journey. The four main themes that emerged from the study included: familiarity of the caregiver, staying informed on the journey, feeling supported and reassured by their expertise, and control and decisions over birth events. KEY CONCLUSIONS: For a variety of reasons, women valued the presence of the students throughout their childbearing journey, including valuing the woman's private space during labour and her time with her partner. This combination of pedagogical approaches provides an alternative to the current placement approach, which includes working shifts in all areas of maternity. This approach will better support midwifery students to achieve the skills necessary to provide a continuity of care experience (CoCE) amongst a small team by a student-led midwifery group practice that is supported by a registered midwife in the antenatal clinic. The midwifery student is able to develop a relationship with the woman as a component of the CoCE under the guidance of a registered midwife and this is an important underpinning of the philosophy of woman-centred care. IMPLICATIONS FOR PRACTICE: This model of care provides evidence that women do value the students' support and presence throughout their experience and that the benefits of this model should be offered to all women as a normal component of their midwifery care.

Direct-to-Patient Telehealth: Opportunities and Challenges.

Provision of healthcare services through telehealth continues to increase. This rise is driven by the several factors, such as improved access, decreased cost, patient convenience and positive patient satisfaction. Direct-to-patient (DTP) care delivery is the most popular form of telehealth. However, barriers exist to its widespread use in practice, such as lack of reimbursement, concern that the convenience of these services may raise utilization to the point that spending increases without increasing quality of care, concern about quality of care provided and low uptake by underrepresented or at risk populations. DTP offers opportunities to improve population health and provide value-based care within integrated health systems, but requires thoughtful implementation strategies that address patient and provider barriers to its use.

Perception of care quality and ethical sensitivity in surgical nurses.

BACKGROUND: It is stated that high ethical sensitivity positively affects the quality of nursing care. However, the relationship between nursing care quality and ethical sensitivity has not been clearly demonstrated in researches. AIM: This study was carried out to determine the relationship between surgical nurses' care behaviors and their ethical sensitivity. METHOD: The sample of this cross-sectional, descriptive-correlational study consists of 308 nurses who worked at the surgical departments in four Turkish hospitals. The data were collected using the "Nurse Description Form" developed by the researcher, "Caring Behaviours Inventory-24" and "Ethical Sensitivity Questionnaire." Data were evaluated by the Mann Whitney U test, Kruskal Wallis one-way analysis of variance and Spearman correlation analysis. ETHICAL CONSIDERATIONS: The study was approved by the ethics committee. Verbal and written consent was received from the nurses. RESULTS: It was found in the study that nurses' Caring Behaviours Inventory-24 total score median was 5.25 (4.83-5.58), nurses' perception level of caring quality was high, median of Ethical Sensitivity Questionnaire total score was 89.00 (75.00-101.00) and nurses' ethical sensitivity was moderate. A negative significant relation was found between nurses' Caring Behaviours Inventory-24 total score and Ethical Sensitivity Questionnaire total score (r = -0.162; p = 0.009). A negative relation was also detected between nurses' working period at the current clinic and providing benefit (r = -0.147; p = 0.012), holistic approach (r = -0.139; p = 0.018) and orientation (r = -0.175; p = 0.003) scores of Ethical Sensitivity Questionnaire sub-scales. CONCLUSION: Nurses' perception levels of caring quality were high and their ethical sensitivity levels were moderate. It was found out that nurses' ethical sensitivity increased together with their perception of caring quality, and as their working period at the current clinic increased, the ethical sensitivity also increased in terms of the sub-scales of providing benefit, holistic approach, and orientation. The factors that adversely affect the quality of nursing care and ethical sensitivity should be examined and attempts should be made to improve the working environment.