Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial.

BACKGROUND: Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. METHODS: We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. FINDINGS: 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. INTERPRETATION: A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. FUNDING: Canadian Institutes of Health Research (CIHR, MOP-142448).

Tools for Screening and Measuring Anxiety Among Women Living with HIV of Reproductive Age: A Scoping Review.

Emerging evidence suggests that women living with HIV (WLWH) may experience higher rates of anxiety than men living with HIV and women living without HIV. To date, relatively little knowledge exists on valid anxiety screening and diagnostic tools and how they are used among WLWH, specifically WLWH of reproductive age. Thus, the purpose of this scoping review was to describe what is known in the published literature about anxiety among WLWH and the tools used to measure and screen for anxiety in clinical and research contexts. The Arksey and O'Malley methodological framework was used to guide a scoping review of published articles in PsycINFO, Scopus, Sociological Abstracts, and PubMed databases. Twenty-one measures of anxiety were used across the 52 articles identified in the search. Most measures used were self-report. Inconsistencies in standardized screening tools and cutoff scores were observed across studies. Further, measures to assess anxiety varied among studies focused on WLWH. Based on the results from this review, there is a need for consistent, valid measures of anxiety to advance research and clinical practice to support the well-being of WLWH.

Incubating Collaboration for a Neonatal Scholars Writing Group.

One method to improve writing and scholarship is through the formation of writing teams. While not new, we will present our innovative strategy for creating an effective neonatal writing team for faculty and students. Tuckman's Model of Team Development was used to guide our group through the five stages of effective teams including forming, storming, norming, performing, and adjourning to develop an effective writing group. The application of this model facilitated a strong foundation for our writing group, the Neonatal Scholars Interest Group, through the intentional movements through developmental stages and the ability to sustain our writing group. Furthermore, the impact of our writing group, as a model, resulted in several other specialized writing groups within our school. Our writing group improved the knowledge and skills of nurse faculty and students in sustained writing efforts through successful scholarship dissemination, mentoring students, and advancing nursing education and practice.

Factors influencing birth setting decision making in the United States: An integrative review.

BACKGROUND: The United States has the highest perinatal morbidity and mortality (M&M) rates among all high-resource countries in the world. Birth settings (birth center, home, or hospital) influence clinical outcomes, experience of care, and health care costs. Increasing use of low-intervention birth settings can reduce perinatal M&M. This integrative review evaluated factors influencing birth setting decision making among women and birthing people in the United States. METHODS: A search strategy was implemented within the CINAHL, PubMed, PsycInfo, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the review, and the Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate methodological quality and appraisal of the evidence. The Whittemore and Knafl integrative review framework informed the extraction and analysis of the data and generation of findings. RESULTS: We identified 23 articles that met inclusion criteria. Four analytical themes were generated that described factors that influence birth setting decision making in the United States: "Birth Setting Safety vs. Risk," "Influence of Media, Family, and Friends on Birth Setting Awareness," "Presence or Absence of Choice and Control," and "Access to Options." DISCUSSION: Supporting women and birthing people to make informed decisions by providing information about birth setting options and variations in models of care by birth setting is a critical patient-centered strategy to ensure equitable access to low-intervention birth settings. Policies that expand affordable health insurance to cover midwifery care in all birth settings are needed to enable people to make informed choices about birth location that align with their values, individual pregnancy characteristics, and preferences.

Improving Quality in Neonatal Care Through Competency-Based Simulation.

Approximately 440,000 patients die each year due to preventable errors. Although human error is inevitable, we can mitigate this risk by enhancing skills and clinical competencies by improving the quality of neonatal care through competency-based simulation. Clinical skills are learned activities necessary to function within an environment. Skills gained during pre-licensure nursing education, on-site clinical training, and experience as a clinical care provider, collectively demonstrate a clinician's overall competence to function within a clinical setting. Simulation is a method of supporting nurses to establish, maintain, and remediate competency-based skills for safe and effective healthcare. Evidence suggests that simulation improve clinical skills and maintain patient safety. With this knowledge, many professional organizations have adopted and set standards for the use of simulation, as an educational methodology, to improve clinician skills and competence providing only the highest quality care to neonates within the Neonatal Intensive Care Unit.

"I had to fight for my VBAC": A mixed methods exploration of women's experiences of pregnancy and vaginal birth after cesarean in the United States.

BACKGROUND: Vaginal birth after cesarean (VBAC) is safe, cost-effective, and beneficial. Despite professional recommendations supporting VBAC and high success rates, VBAC rates in the United States (US) have remained below 15% since 2002. Very little has been written about access to VBAC in the United States from the perspectives of birthing people. We describe findings from a mixed methods study examining experiences seeking a VBAC in the United States. METHODS: Individuals with a history of cesarean and recent subsequent birth were recruited through social media groups. Using an online questionnaire, we collected sociodemographic and birth history information, qualitative accounts of participants' experiences, and scores on the Mothers on Respect Index, the Mothers Autonomy in Decision Making Scale, and the Generalized Self-Efficacy Scale. RESULTS: Participants (N = 1711) representing all 50 states completed the questionnaire; 1151 provided qualitative data. Participants who planned a VBAC reported significantly greater decision-making autonomy and respectful treatment in their maternity care compared with those who did not. The qualitative theme: "I had to fight for my VBAC" describes participants' accounts of navigating obstacles to VBAC, including finding a supportive provider and traveling long distances to locate a clinician and/or hospital willing to provide care. Participants cited support from providers, doulas, and peers as critical to their ability to acquire the requisite knowledge and power to effectively self-advocate. DISCUSSION: Findings highlight the difficulties individuals face accessing VBAC within the context of a complex health system and help to explain why rates of attempted VBAC remain low.

Academic service-learning nursing partnerships in the Americas: a scoping review.

BACKGROUND: Academic service-learning nursing partnerships (ASLNPs) integrate instruction, reflection, and scholarship with tailored service through enriched learning experiences that teach civic responsibility and strengthen communities, while meeting academic nursing outcomes. OBJECTIVE: This scoping review aimed to identify, appraise, and synthesize evidence of community focused ASLNPs that promote primary health care throughout the Americas region. METHODS: A systematic search of PubMed, CINAHL, Scopus, Google Scholar, and LILACS English-language databases was performed in accordance with PRISMA guidelines. Full-text articles published since 2010 were reviewed using an inductive thematic approach stemming from the "Advancing Healthcare Transformation: a New Era for Academic Nursing Report" and the Pan American Health Organization "Strategic Directions for Nursing." RESULTS: A total of 51 articles were included with the vast majority 47 (92.1 %) representing North America. Structured, established relationships between an academic nursing institution or program and one or more community serving entities resulted in high levels of effectiveness and innovation across settings. Five themes emerged: (a) sustaining educational standards and processes - improving academic outcomes (25.5 %), (b) strengthening capacity for collaborative practice and interprofessional education (13.7 %), (c) preparing nurses of the future (11.8 %), (d) enhancing community services and outcomes (21.6 %), and (e) conceptualizing or implementing innovative academic nursing partnerships (27.4 %). A synthesis of conceptual frameworks and models revealed six focus areas: communities/populations (26.2 %), nursing (26.2 %), pedagogy (19 %), targeted outreach (14.3 %), interprofessional collaboration (11.9 %), and health determinants (9.5 %). A proliferation in US articles, triggered by nursing policy publications, was confirmed. CONCLUSIONS: ASLNPs serve as mechanisms for nurses and faculty to develop and lead change across a wide variety of community settings and healthcare systems, develop scholarship, as well as for students to apply the knowledge and skills learned. Given the lack of geographically broad evidence, successes and challenges across U.S. partnerships should be viewed cautiously. Nevertheless, ASLNPs can play a critical role towards meeting the goal of universal health access and coverage through partnering with the education sector. Further investigation of grey literature as well as Spanish and Portuguese language literature from Latin American and Caribbean countries is highly recommended.

Highlighting Simulation Practices in the Neonatal Environment.

Simulation is an effective teaching methodology to enhance clinical thinking and reasoning skills among nursing students and practicing nurses. The opportunity to practice in a safe environment maintains a structure that promotes learning at all levels. There are various levels of fidelity as well as cost to facilitate simulation in the neonatal setting. This at times hinders the ability to incorporate simulation into educational practices. The purpose of this article is to provide a discussion on simulation practices in the neonatal setting, an overview of low-cost neonatal simulation exemplars, and implications for practice.

Birth choices for women in a 'Positive Birth after Caesarean' clinic: Randomised trial of alternative shared decision support strategies.

BACKGROUND: Systematic approaches to information giving and decision support for women with previous caesarean sections are needed. AIM: To evaluate decision support within a 'real-world' shared decision-making model. METHODS: A pragmatic comparative effectiveness randomised trial in the Positive Birth After Caesarean Clinic. Women with one previous caesarean and singleton pregnancy <25 weeks were randomly allocated to standard Positive Birth After Caesarean care, or standard Positive Birth After Caesarean care plus a decision aid booklet. Main outcome measure was mode of birth, with secondary measures of knowledge, decisional conflict, birth choice, adherence to birth choice, perception of decision support, and satisfaction. RESULTS: Of 297 participants, rate of attempted vaginal birth after caesarean increased and was similar for both groups (61% vs 57%, P = 0.5). Knowledge scores increased more for women in the additional decision aid group (2.0 vs 1.6 points, P = 0.2). Decisional conflict score reduction was similar between groups (P = 0.5). Women initially unsure of their birth preference who received the additional decision aid had greater reduction in decisional conflict score (P = 0.04) and were more likely to plan vaginal birth after caesarean (49% vs 33%, P = 0.2). Adherence to birth choice and birth satisfaction was similar between groups. Women in the additional decision aid group rated their decision support tool higher (P < 0.01). CONCLUSIONS: In a 'real world' shared decision-making model, an additional decision aid conferred some benefits in factors associated with preparation for shared decision-making. Decision aids may provide particular benefit for women who are initially unsure and need assistance in the deliberation phase.

Midwifery and women's health.

EBN Perspectives bring together key issues from the commentaries in one of our nursing topic themes.

Complexities of choice after prior cesarean: a narrative analysis.

BACKGROUND: High rates of primary cesarean internationally continue to create decision dilemmas for women and practitioners about birth in subsequent pregnancies. This article explores values and expectations that guide women during decision making about the next birth after cesarean and identifies factors that influence consistency between women's choices and actual birth experiences. METHODS: Narrative analysis was used to identify key themes in decision-making experiences of women who were facing a choice about mode of birth after cesarean. A sample of 187 women provided qualitative data about their choices for birth at 36-38 weeks. At 6-8 weeks after the birth, 168 also wrote about their experiences of birth and the process of making the decision. RESULTS: Decision making about birth after cesarean was complex and difficult for many women; strong emotions were expressed as they weighed birth options. Fear and anxiety were articulated as women explained their choices and expectations. Avoidance of the previous cesarean experience, an expectation of a "better" or "faster" recovery, and issues around "safety" for the baby were common reasons given for wanting either vaginal or cesarean birth. Practitioner preferences were influential and women's need for information about their options underpinned their confidence or certainty about their decision. CONCLUSIONS: Strategies are needed to support practitioners to expand discussions beyond clinical algorithms about physical risks and benefits of birth options and to actively integrate women's values and preferences into decisions about birth.

Traveling the road toward academic promotion for faculty with a DNP degree.

There is a widely recognized need for nursing faculty in the United States. To prepare a practice-ready workforce, schools of nursing are hiring faculty with Doctor of Nursing Practice (DNP) preparation to ensure clinical expertise is embedded into curriculum by practice experts. However, nurses transitioning from clinical nursing to faculty positions require tailored support and guidance in navigating the academic environment. Preparation for academic promotion is essential to integration into an academic setting. Support in navigating the new environment is essential for building confidence, to lay a foundation for a successful transition, and ultimately retaining these qualified educators. This article provides strategies to support nursing faculty planning to embark on an academic career track and provides guidance on how to prepare these DNP-prepared faculty for career progression and future promotion along academic ranks. These strategies include school and institutional orientation, faculty development plans, mentorship, leadership development, and performance review processes.

Learning from women: Improving experiences of respectful maternity care during unplanned caesarean birth for women with diverse ethnicity and racial backgrounds.

PROBLEM: Women from diverse ethnicity and racial backgrounds have few opportunities to share birth experiences to inform improvements in care. BACKGROUND: Respectful maternity care is recognised as a global women's health priority. Integrating that framework into diverse care systems and models may help bridge care gaps for women who had unexpected birth experiences, including unplanned caesarean birth. AIM: To describe the experiences of women who had unplanned caesarean births and use knowledge gained to inform best practice recommendations that embody respectful maternity care. METHODS: Qualitative data were analysed from focus groups involving a convenience sample of 11 English speaking women, from diverse ethnic and racial backgrounds, with prior unplanned caesarean experience. Respectful maternity care was used as the lens for interpreting women's narratives using Thorne's interpretive description. The study site was an outpatient prenatal clinic within an urban academic, tertiary-care medical centre in the United States. FINDINGS: Two predominant, contrasting themes emerged: "not feeling well cared for" and "feeling well supported". Positive experiences included sources of support and strength from the midwifery practice, group prenatal care, and a doula program. Eight domains of respectful maternity care were applied to findings, highlighting current positive institutional practices and proposing areas for future quality improvement. CONCLUSION: Key practices promoting respectful maternity care include adequate communication and information sharing between pregnancy care providers and women, and a more robust informed consent process. Further emphasis on respectful maternity care is needed to support women to make shared decisions that best fit their circumstances and preferences.

Interprofessional team-based education: A comparison of in-person and online learner experiences by method of delivery and health profession.

BACKGROUND: Building capacity for teamwork, communication, role clarification and recognition of shared values is essential for interprofessional healthcare workforce development. Requirements to demonstrate interprofessional practice competencies have coincided with pivots to online delivery. Comparison of in-person and online delivery models for interprofessional education is important for future curriculum design. PURPOSE: This article presents an evaluation of in-person and online delivery modes for interprofessional team-based education and compares learner experiences across different health professions. METHODS: Students from 13 health professions (n = 2236) participated between Spring 2020 and Fall 2021. In-person and online delivery models were compared, assessing learner perceptions of efficacy for interprofessional practice, using reflective pre-post responses to the Interprofessional Collaborative Competency Attainment Scale (ICCAS). RESULTS: Mean ICCAS scores improved for in-person and online delivery (0.79 vs 0.66), with strong effect (Cohen's D 2.03 and 1.31 respectively; p < 0.001). Statistically significant differences were observed across professions, although all experienced ICCAS score improvements. Logistical benefits were evident for online delivery. CONCLUSION: In-person and online interprofessional team-based education can provide valuable learner experiences for large student cohorts from multiple professions. ICCAS score differences should be weighed against potential logistical benefits of online delivery. Timing of delivery and determinants of differences in student response across professions warrant evaluation for future curriculum design.

An innovative web-based decision-aid about birth after cesarean for shared decision making in Taiwan: study protocol for a randomized control trial.

BACKGROUND: Taiwan has a high national caesarean rate coupled with a low vaginal birth after caesarean (VBAC) rate. This study aims to develop and evaluate a web-based decision-aid with communication support tools, to increase shared decision making (SDM) about birth after caesarean. METHODS: A quantitative approach will be adopted using a randomized pre-test and post-test experimental design in a medical centre in northern Taiwan. The web-based decision aid consists of five sections. Section 1 provides a two-part video to introduce SDM and how to participate in SDM. Section 2 presents an overview of functions and features of the birth decision-aid. Section 3 presents relevant VBAC information, including definitions, benefits and risks, and an artificial intelligence (AI) calculator for rate and likelihood of VBAC success. Section 4 presents the information regarding elective repeat caesarean delivery (ERCD), involving definitions, benefits, and risks. Section 5 comprises four steps of decision making to meet women's values and preferences. Pregnant women who have had one previous caesarean and are eligible for VBAC, will be recruited at 14-16 weeks. Participants will complete a baseline survey prior to random allocation to either the control group (usual care) or intervention group (usual care plus an AI-decision aid). A follow up survey at 35-38 weeks will measure change in decisional conflict, knowledge, birth mode preference, and decision-aid acceptability. Actual birth outcomes and satisfaction will be assessed one month after birth. DISCUSSION: The innovative web-based decision-aid with support tools will help to promote pregnant women's decision-making engagement and communication with their providers and improve opportunities for supportive communication about VBAC SDM in Taiwan. Linking web-based AI data analysis into the medical record will also be assessed for feasibility during implementation in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov identifier (NCT05091944), Registered on October 24, 2021.

Development and implementation of a virtual "collaboratory" to foster interprofessional team-based learning using a novel faculty-student partnership.

BACKGROUND: Safe and efficient healthcare demands interprofessional collaboration. To prepare a practice-ready workforce, students of health professions require opportunities to develop interprofessional competencies. Designing and delivering effective interprofessional learning experiences across multiple professions is often hampered by demanding course loads, scheduling conflicts, and geographical distance. To overcome traditional barriers, a case-based online interprofessional collaboratory course was designed for professions of dentistry, nursing, occupational therapy, social work and public health using a faculty-student partnership model. AIM: To build a flexible, web-based, collaborative learning environment for students to actively engage in interprofessional teamwork. METHODS: Learning objectives addressed Interprofessional Education Collaborative (IPEC) core competency domains of Teamwork, Communications, Roles/Responsibilities, and Values/Ethics. Four learning modules were aligned with developmental stages across the case patient's lifespan. Learners were tasked with producing a comprehensive care plan for each developmental life stage using interprofessional teamwork. Learning resources included patient and clinician interviews, discussion board forums, elevator pitch videos, and interprofessional role modelling. A mixed methods quality improvement approach integrated the pre and post IPEC Competency Self-Assessment Tool with qualitative student feedback. RESULTS: In total, 37 learners participated in the pilot. IPEC Competency Assessment Interaction domain mean scores increased from 4.17/5 to 4.33 (p = 0.19). The Values domain remained high (4.57/5 versus 4.56). Thematic analysis highlighted five core themes for success: active team engagement, case reality, clear expectations, shared team commitment, and enjoyment. CONCLUSIONS: A faculty-student partnership model was feasible and acceptable for designing and implementing a virtual, interprofessional team-based course. Using a quality improvement cycle fast-tracked improvements to course workflow, and highlighted strategies for engaging students in online team-learning.