The state of professionalisation of midwifery in Belgium: A discussion paper.

AIM: To describe the state of the professionalisation of midwifery in Belgium, and to formulate recommendations for advancing the midwifery profession. METHODS: A descriptive overview of maternity care in Belgium and the professionalisation of midwifery through an analysis of relevant policy and academic texts, underpinned by Greenwood's sociological criteria for a profession: (1) own body of knowledge, (2) recognised authority, (3) broader community sanctions, (4) own code of ethics and (5) professional culture sustained by formal professional associations. From these insights, recommendations for advancing the midwifery profession in Belgium are formulated. FINDINGS: Current strengths of the professionalisation of midwifery in Belgium included unified midwifery education programmes, progress in midwifery research and overarching national documents for guiding midwifery education, practice and regulation. In contrast however challenges, such as the limited recognition of midwives' roles by its clientele, limitations of midwives' competencies and autonomy, lacking development of advanced roles in maternity care practice and a lack of unity of the organisation and its members, were also identified. Based on these, recommendations are made to strengthen Belgian midwifery. CONCLUSIONS: Recommendations for advancing the midwifery profession in Belgium includes in particular increasing public awareness of midwives' roles and competencies, implementing the full scope of midwifery practice and monitoring and advancing this practice. Thus, professional autonomy over both midwifery practice and working conditions should be enhanced. United midwifery organisations, together with women's groups, other maternity care professionals and policy-makers as equal partners are key to bring about changes in the Belgian maternity care landscape.

Expansion of the interprofessional clinical practice of Primary Care nurses.

OBJECTIVE: To analyze the clinical practice of nurses in the interprofessional context of the Family Health Strategy. METHOD: Case study in a basic health unit of the city of São Paulo with a professional team of the Family Health Strategy and of the Family Health Support Center. Direct observation and interviews with thematic analysis and triangulation were conducted. RESULTS: Four empirical categories were identified: interprofessional actions guided by the logic of the user's health needs; interprofessional actions guided by the logic of expediting service; interprofessional actions with a biomedical approach and interprofessional actions with an integral/holistic approach. Six interprofessional actions that indicated the expansion of the clinical practice of the Family Health Strategy's nurses were also identified. CONCLUSION: The results express the world trend of interprofessional practice and expansion of the scope of practice of different professions, particularly that of nurses, which requires consolidation based on the population's health needs.

The doctorate of nursing practice and entry into midwifery practice: Issues for consideration and debate.

The American College of Nurse-Midwives represents two cadres of midwifery professionals: certified nurse-midwives who are educated in both midwifery and nursing, and certified midwives who are educated in the discipline of midwifery. Certified nurse-midwives are designated by nursing professional organizations as advanced practice nurses. The United States nursing profession is advancing toward adoption of the Doctor of Nursing Practice degree, as the entry into practice credential for advanced practice nursing. There is no evidence to date to demonstrate differences in clinical practice outcomes between certified nurse-midwives and certified midwives. A secondary analysis of data from a series of compensation and benefits surveys did not demonstrate differences in salaries between respondents who held a practice-focused doctoral degree compared to a master's degree. The requirement of the practice-focused nursing doctoral degree for entry into midwifery practice for certified nurse-midwives would require additional evidence to support both a professional and a business case for such a change in policy. It would also require consideration of the professional and business impact that such a policy would have on certified midwives who do not hold the nursing credential. Equivalent entry into practice pathways would need to be developed.

Expansion of the interprofessional clinical practice of Primary Care nurses / Ampliación de la práctica clínica de la enfermería de Atención Básica en el trabajo interprofesional / Ampliação da prática clínica da enfermeira de Atenção Básica no trabalho interprofissional

ABSTRACT Objective: To analyze the clinical practice of nurses in the interprofessional context of the Family Health Strategy. Method: Case study in a basic health unit of the city of São Paulo with a professional team of the Family Health Strategy and of the Family Health Support Center. Direct observation and interviews with thematic analysis and triangulation were conducted. Results: Four empirical categories were identified: interprofessional actions guided by the logic of the user's health needs; interprofessional actions guided by the logic of expediting service; interprofessional actions with a biomedical approach and interprofessional actions with an integral/holistic approach. Six interprofessional actions that indicated the expansion of the clinical practice of the Family Health Strategy's nurses were also identified. Conclusion: The results express the world trend of interprofessional practice and expansion of the scope of practice of different professions, particularly that of nurses, which requires consolidation based on the population's health needs.

RESUMEN Objetivo: Analizar la ampliación de la práctica clínica de la enfermera en el contexto interprofesional de la Estrategia de Salud de la Familia. Método: Estudio de caso en una unidad básica de salud de la ciudad de São Paulo con un equipo de profesionales de la estrategia de salud de la familia y el núcleo de apoyo a la salud de la familia. Se realizaron observación directa y entrevista con análisis temáticos y triangulación. Resultados: Se identificaron cuatro categorías empíricas: acciones interprofesionales orientadas por la lógica de las necesidades de salud del usuario; acciones interprofesionales orientadas por la lógica de agilizar la atención; acciones interprofesionales con enfoque biomédico, y acciones interprofesionales con enfoque integral/holístico. También se identificaron seis acciones interprofesionales en las que la enfermera participa, que evidenciaron la ampliación de la práctica clínica de la enfermera de la Estrategia de Salud de la Familia. Conclusión: Los resultados expresan la tendencia mundial de trabajo interprofesional y de ampliación del alcance de la práctica de las profesiones, en especial, de la práctica clínica de la enfermera, que requiere la consolidación a partir de las necesidades de salud de la población.

RESUMO Objetivo: Analisar a ampliação da prática clínica da enfermeira no contexto interprofissional da Estratégia Saúde da Família. Método: Estudo de caso em unidade básica de saúde do município de São Paulo com profissionais de uma equipe da Estratégia Saúde da Família e do Núcleo de Apoio à Saúde da Família. Realizaram-se observação direta e entrevista com análise temática e triangulação. Resultados: Foram identificadas quatro categorias empíricas: ações interprofissionais orientadas pela lógica das necessidades de saúde do usuário; ações interprofissionais orientadas pela lógica de agilizar o atendimento; ações interprofissional com abordagem biomédica e ações interprofissionais com abordagem integral/holística. Também foram identificadas seis ações interprofissionais nas quais a enfermeira participa, que evidenciaram a ampliação da prática clínica da enfermeira da Estratégia Saúde da Família. Conclusão: Os resultados expressam a tendência mundial de trabalho interprofissional e de ampliação do escopo de prática das profissões, em especial, da prática clínica da enfermeira, que requer a consolidação a partir das necessidades de saúde da população.

Australian midwives' experiences of implementing practice change.

OBJECTIVE: The introduction of the best available evidence into health care practice is a complicated and uncertain process. Attempts to translate even highly reliable evidence into care provision are known to flounder. The objective of this study was to investigate midwives' experiences of leading practice change. DESIGN: This study was conducted using Glaserian Grounded Theory methodology. SETTING: Australian midwifery practice contexts provided the setting for this study. PARTICIPANTS: Midwives who had led practice change initiatives. FINDINGS: Sixteen Australian midwife change leaders participated in this study. Each had sought to implement a workplace practice change. The core problem experienced by the participants was labelled 'So many barriers on so many levels'. KEY CONCLUSIONS: Although some participants were encouraged, supported and enabled to enact change to some degree, even when the change was initiated by the practice site, all participants experienced a number of obstacles at many levels in their implementation efforts. For most, this meant that their endeavours to move the best available evidence into practice took many years or did not progress at all. IMPLICATIONS FOR PRACTICE: The findings of this study will be of interest to midwives, midwifery leaders and midwifery educators. Understanding the factors in midwifery care environments that support or limit the uptake of best evidence into practice will help to inform and develop midwifery context-specific mechanisms to expedite sustained practice innovation.

The use of drama within midwifery education to facilitate the understanding of professional behaviour and values.

OBJECTIVE: to develop student midwife understanding of professional values and the application of these in clinical practice, prior to commencing their first clinical placement. DESIGN: an action research project. SETTING: a Simulation Suite environment within a University setting. PARTICIPANTS: 6 year 3 drama students and a cohort of 36 midwifery students. FINDINGS: the students were supportive of the idea of collaborative projects as this permitted the facilitation of student understanding of key professional values and their application in the clinical setting. KEY CONCLUSIONS: the students felt that the move away from a didactic approach to learning and teaching towards a more experiential model of teaching, enabled a more in depth reflection on the importance of professional standards and behaviour when providing care to pregnant women.

"A Naturologia não pode se acomodar ou estagnar" / "Naturology can not accommodate or stagnate"

Entrevista com a naturóloga Luana Wedekin realizada pelo Nat. Daniel Maurício de Oliveira Rodrigues

Complementary and alternative medicine's occupational closure in Portuguese healthcare: Contradictions and challenges.

This article analyses strategies of closure recently enacted by complementary and alternative medicine practitioners in order to achieve occupational control over work domains in healthcare, taking Portugal as an example. A combination of the neo-Weberian occupational closure theory of the professions and Abbott's jurisdictional vacancy theory is proposed as the framework for analysis. Acupuncture and homeopathy will be presented as case studies. Data are derived from in-depth interviews with 10 traditional acupuncturists and 10 traditional homeopaths. Data analysis suggests that (1) professionalisation, (2) alignment with biomedical science and (3) expressing 'legitimating values' of a countervailing nature have been three significant strategies complementary and alternative medicine practitioners have used in an attempt to achieve market closure. It is argued that these strategies are contradictory: some involve allegiances, while others involve demarcation from biomedical science. A further outcome of these strategies is the promotion of complementary and alternative medicine treatments and solutions in everyday life. The success of these strategies therefore, although helping to reinforce the biomedical model, may simultaneously help complementary and alternative medicine to demarcate from it, posing thus challenges to mainstream healthcare.

Regulation of Certified Nurse-Midwife Scope of Practice: Change in the Professional Practice Index, 2000 to 2015.

INTRODUCTION: Certified nurse-midwives (CNMs) across the United States are educated in the same core competencies, yet scope of practice varies with state regulation. The Health Resources and Services Administration (HRSA) funded studies published in 1994 and 2004 on the professional practice environment of CNMs, nurse practitioners, and physician assistants, and developed the Certified Nurse-Midwife Professional Practice Index (CNMPPI), a 100-point scoring system of state regulation focusing on 3 domains: legal status, reimbursement, and prescriptive authority. The purpose of this study was to examine changes to CNM regulation between 2000 and 2015 by updating scores to the CNMPPI. METHODS: Individual state CNMPPI scores from 2000 were updated for every year through 2015 by reviewing data published in the American College of Nurse-Midwives (ACNM) quarterly publication Quickening, the annual advanced practice registered nurse legislative updates in the journal Nurse Practitioner, and the ACNM State Legislative and Regulatory Guidance. RESULTS: Mean state scores increased 18%, from 69.7 in 2000 to 79.8 in 2015, and variation between state scores fell. Increases were seen in all 3 domains, with the greatest increase in the domain of prescriptive authority and the smallest in the legal domain. Individual state CNMPPI scores tend to be correlated with scores of adjacent states. DISCUSSION: The CNMPPI can be used to document changes in practice authority of CNMs. The increase in state CNMPPI scores and decrease in variance across states can be interpreted as indicating growth of professional authority and increasing consensus regarding the CNM role. The scoring system needs to be updated to reflect the current health systems environment and to include certified midwives and other midwives meeting the International Confederation of Midwives definition of a midwife. Applications of the CNMPPI to future research are discussed.

Spectacular improvement in vitamin D status in elderly osteoporotic women: 8-year analysis of an osteoporotic population treated in a dedicated fracture liaison service.

UNLABELLED: In a population of postmenopausal women with a fragility fracture, we found a drastic reduction in the proportion of women with severe (<25 nmol/L) and moderate (25 to 75 nmol/L) hypovitaminosis D, especially from 2009 onwards. These results show that supplementation has been very widely integrated into current practice. INTRODUCTION: Vitamin D (25(OH)D) is essential for bone health. In institutionalised osteoporotic women, it reduces the risk of fragility fractures. Numerous articles suggesting the possibility of extraosseous effects have generated a growing number of publications and recommendations on more widespread administration, to limit the risks of moderate or severe hypovitaminosis D. We assessed the impact on clinical practice of these recommendations concerning 25(OH)D supplementation in elderly at-risk populations. METHODS: A total of 1486 postmenopausal osteoporotic women were seen in the context of a fracture liaison service (i.e. a rheumatology consultation following a peripheral fragility fracture), between May 2005 and December 2012. Of these, 1107 had a 25(OH)D assay (femur, n = 520; humerus, n = 207; wrist, n = 380). RESULTS: The average age of the total population was 76.7 ± 9.9 years, while for women with an available 25(OH)D assay, the average age was 75.1 ± 11.8 years. The average 25(OH)D (nmol/L) level was similar for the three fracture sites: femur, 30 ± 36.2; humerus, 27.5 ± 24; and wrist, 31 ± 26. A drastic reduction in the proportion of women with severe (<25 nmol/L) and moderate (25 to 75 nmol/L) hypovitaminosis D was observed, especially from 2009 onwards, with a mean prevalence of 69 and 30 % respectively before that year and 35 and 52 % thereafter. Conversely, the proportion of women with 25(OH)D at the threshold value of 75 nmol/L increased from 1.2 to 24 %. Overall, mean serum 25(OH)D levels were significantly higher when comparing the two periods 2005-2008 and 2009-1012 (17.6 ± 14.6 and 48.4 ± 39.2 nmol/L, respectively; p < 0.0001). CONCLUSION: These results show that supplementation has been very widely integrated into current practice. We can expect it to yield beneficial effects in osseous and extraosseous terms in osteoporotic women, particularly the very elderly.

Performing 'pragmatic holism': Professionalisation and the holistic discourse of non-medically qualified acupuncturists and homeopaths in the United Kingdom.

Complementary and alternative medicine practitioners have often utilised 'holism' as a key identification mark of their practice, distancing themselves from 'the reductionist biomedicine'. However, the past couple of decades have witnessed increased engagement of several complementary and alternative medicines in professionalisation, which includes a degree of biomedical alignment while 'reducing' holistic claims in order to provide practice with a 'credible outlook' and move closer to the mainstream, a development which challenges the role of holism in complementary and alternative medicine practices. This article explores the strategies by which two groups of complementary and alternative medicine practitioners, namely, non-medically qualified acupuncturists and homeopaths in the United Kingdom, pragmatically accommodate holistic notions as a professional resource, a process of negotiation between maintaining their holistic premise, on the one hand, and the drive to professionalise and enhance their societal status, on the other. Based on in-depth interviews with non-medically qualified acupuncture and homeopathy practitioners and school principals, textual analysis of practitioners' web sites and observation of practice, the findings demonstrate the dynamic approach to 'holism' in complementary and alternative medicine practice. This discourse, through which practitioners use a range of strategies in order to 'narrow' or 'expand' their holistic expression, can be described as 'pragmatic holism', by which they try to make gains from the formalisation/standardisation processes, without losing the therapies' holistic outlook and appeal.

Recorrido legislativo de la profesión de matrona / The regulatory journey of the midwife profession

A lo largo de la historia, las mujeres han sido las responsables de los cuidados de la embarazada y el parto. Los conocimientos eran transmitidos de madres a hijas, hasta que se inició el reconocimiento de la profesión en el siglo XIII. En este trabajo se describe la evolución de la legislación contemporánea que regula las competencias de las matronas españolas. Se ha llevado a cabo una revisión documental. Se han localizado documentos primarios, consulta del Boletín Oficial del Estado y revisión de las bases de datos CUIDEN y MEDLINE. No se han utilizado límites de tiempo. Formando parte de los resultados, se describen las diferentes disposiciones y leyes que han regulado la profesión desde 1973 hasta la actualidad. Hay una evolución favorable a lo largo de la historia de la profesión de matrona, en la que el reconocimiento de sus funciones ha aumentado, tanto en las ordenaciones jurídicas europeas como españolas. Actualmente, en nuestro entorno, la matrona es una figura reconocida y con unas competencias bien delimitadas

Throughout history, women have been responsible for pregnancy care and labour. Knowledge was transmitted from mothers to daughters, until the acknowledgement of the profession started in the XIII century. This article describes the evolution of contemporary legislation which regulates the responsibilities of Spanish midwives. A document review was conducted. Primary documents were located, the Official Gazette of the State (BOE) was consulted, and there was a review of the CUIDEN and MEDLINE databases. No time limitations were used. As part of the results, there is a description of the different regulations and laws which have ruled the profession from 1973 to our current day. There has been a favourable evolution along the history of the midwife profession, with an increase in the acknowledgement of its functions, both by European and Spanish legal systems. Currently, in our setting, the midwife is an acknowledged figure, with well-specified responsibilities

Midwifery Practice and Education: Current Challenges and Opportunities.

Midwifery clinical practice and education has changed significantly since Mary Breckinridge first introduced nurse-midwives to the United States in 1925. This article discusses current challenges in midwifery clinical practice and education and proposes possible solutions. Midwifery clinical challenges include restrictive legislation and business-related barriers, including but not limited to physician supervision restrictions, prescriptive authority, out-of-hospital birth legislation, and third party reimbursement. Educational challenges highlighted include the current healthcare climate's influence on midwifery education, the contribution of clinical sites and preceptors, and the benefits of midwifery education.

Anaemia management in patients with inflammatory bowel disease: routine practice across nine European countries.

BACKGROUND AND OBJECTIVES: Anaemia and iron deficiency (ID) are common complications in inflammatory bowel disease (IBD). In patients undergoing iron therapy, intravenous iron supplementation is recommended in preference to oral therapy. This study evaluated routine practice in the management of IBD-associated anaemia and ID to verify implementation of international treatment guidelines. MATERIALS AND METHODS: Gastroenterologists from nine European countries (n=344) were surveyed about their last five IBD patients treated for anaemia (n=1404). Collected information included tests performed at anaemia diagnosis, haemoglobin (Hb) levels and iron status parameters, the anaemia treatment given and, if applicable, the iron administration route. RESULTS: Selection of diagnostic tests and treatment for IBD-associated anaemia varied considerably across Europe. Anaemia and iron status were mainly assessed by Hb (88%) and serum ferritin (75%). Transferrin saturation was only tested in 25% of patients. At diagnosis of anaemia, 56% presented with at least moderate anaemia (Hb<10 g/dl) and 15% with severe anaemia (Hb<8 g/dl). ID (ferritin<30 ng/ml) was detected in 76%. Almost all patients (92%) received iron supplementation; however, only 28% received intravenous iron and 67% oral iron. Management practice was similar in 2009 and 2011. CONCLUSION: In clinical practice, most IBD patients received oral iron even though this administration route may aggravate the disease, and despite international guidelines recommending intravenous administration as the preferred route. The high frequency of ID suggests insufficient monitoring of iron status in IBD patients. There is a need to increase awareness and implementation of international guidelines on iron supplementation in patients with IBD.