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.

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.

Birth choices after caesarean in Taiwan: A mixed methods pilot study of a decision aid for shared decision making.

BACKGROUND: Taiwan has a high national caesarean rate coupled with a low vaginal birth after caesarean (VBAC) rate. Studies suggest that women do not receive sufficient information about birth choices after caesarean in Taiwan and shared decision making (SDM) is not an expectation. This pilot study aimed to test the feasibility of using a birth choices decision aid to improve women's opportunity for engagement in SDM about birth after cesarean. METHODS: A two-phase sequential mixed methods pilot study was conducted in a regional hospital in northern Taiwan. Phase I involved a randomized pre-test and post-test experimental design. Participants with one previous caesarean section (CS) were recruited at 14-24 weeks. A total of 65 women completed a baseline survey and were randomly allocated to either the intervention (birth choice decision aid booklet) or usual care (general maternal health booklet) group. A follow up survey at 37-38 weeks measured change in decisional conflict, knowledge, and birth mode preference. Birth outcomes and satisfaction were assessed one month after birth. Phase II consisted of postnatal interviews with women at one month after birth, to explore women's decision making experiences, using a constant comparative analytic technique and thematic analysis. RESULTS: Decisional conflict was relatively low at baseline for all women. Although there were reductions in decisional conflict at follow up, differences between groups were not statistically significant. Women's early preferences regarding mode of birth influenced their knowledge-seeking behaviors and expectations or intention for engaging in SDM during pregnancy. Improvements in knowledge for the decision aid group were larger than for the usual care group, although differences between groups were not statistically significant. Four themes related to key factors in decision making were clarity, safety and risk, consistency, and support. CONCLUSION: A cultural shift is needed to align expectations and relationships towards SDM for birth in Taiwan. Simulation-based strategies and tailored communication skills should be explored to enhance skills in decision coaching for providers. Use of interactive multimedia technology may provide opportunities to increase engagement with tools and support women during decision consultations. Midwife-led continuity of care models may also be beneficial in empowering women to actively share decisions and achieve the birth that is best for them.

A Shared Decision-Making Toolkit for Mode of Birth After Cesarean.

This study evaluated a shared decision-making (SDM) Toolkit (decision aid, counseling guide, and provider scripts) designed to prepare and engage racially diverse women in shared decision-making discussions about the mode of birth after cesarean. The pilot study, involving 27 pregnant women and 63 prenatal providers, assessed women's knowledge, preferences, and satisfaction with decision making, as well as provider perspectives on the Toolkit's acceptability. Most women experienced knowledge improvement, felt more in control and that providers listened to their concerns and supported them. Providers reported that the Toolkit helped women understand their options and supported their counseling. The SDM Toolkit could be used to help women and providers improve their SDM regarding mode of birth after cesarean.

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.

A Study to Assess the Feasibility of Implementing a Web-Based Decision Aid for Birth after Cesarean to Increase Opportunities for Shared Decision Making in Ethnically Diverse Settings.

INTRODUCTION: Decision aids are central to shared decision making and are recommended for value-sensitive pregnancy decisions, such as birth after cesarean. However, effective strategies for widespread decision aid implementation, with interactive web-based platforms, are lacking. This study tested the feasibility and acceptability of implementing a Health Insurance Portability and Accountability Act-secure, web-based decision aid to support shared decision making about birth choices after cesarean, within urban, ethnically diverse outpatient settings. METHODS: A before-and-after design was used to assess feasibility and acceptability for decision aid implementation. Measures included women's knowledge, decisional conflict, birth preferences, birth outcomes, decision aid use, decision aid acceptability ratings (content, features, and functions), and views on how the decision aid supported shared decision making. RESULTS: Of the 68 women who participated, most were black (46.2%) or Hispanic (35.4%). Their knowledge scores increased by 2.58 points out of 15 (P < .001; d = 0.87), and decisional conflict score reduced by 0.45 points out of 5 points (P < .001; d = 0.69). Forty-four women (65.9%) attempted a vaginal birth after cesarean, of whom 29 (65.7%) succeeded. Women rated decision aid content, features, and functions as good or excellent. Most indicated they would recommend it to others. Health care providers recommended additional strategies to simplify decision aid access and integration into routine care. DISCUSSION: Implementing web-based decision aids within ethnically diverse practice settings is potentially feasible and worthwhile. However, strategies are needed to improve women's access and to encourage timely decision aid usage to prepare them for decision discussions with health care providers. Sustained implementation will require seamless integration into clinic workflow, which could include health care provider tools (counselling guides) embedded within the electronic health record, along with continuing education to support and engage health care providers in their use.

Development of a "Patient Rights" Subscale to Measure Informed Decision-Making Within the Dyadic Decisional Conflict Scale for Obstetric Care.

BACKGROUND AND PURPOSE: A modified Dyadic Decisional Conflict Scale (D-DCS) and new Patient Rights subscale to measure perceptions of informed decision-making regarding use of epidural analgesia during childbirth are tested. METHODS: Thirty-five primiparous women and 52 providers from three hospitals tested the modified instrument. Cronbach's α coefficient assessed reliability. Mokken scale, principal components, and correlation analyses assessed unidimensionality of subscales. RESULTS: Internal reliability was demonstrated for the D-DCS-Patient (Cronbach's α = 0.846) and D-DCS-Provider (α = 0.888). Further analyses suggest the Patient Rightssubscale has potential to make a unique contribution to the D-DCS. CONCLUSIONS: The modified D-DCS and Patient Rights subscale allow for a more comprehensive study of informed healthcare decision-making that includes legal and ethical elements, which may aid development of targeted interventions to improve decision-making.

Trends in birth choices after caesarean section in Japan: A national survey examining information and access to vaginal birth after caesarean.

OBJECTIVES: in the context of a rising caesarean section (CS) rate in Japan, the objectives of this study were; to investigate the national situation for women's birth options after primary CS; to explore characteristics of institutions accepting planned vaginal birth after caesarean (VBAC); to identify the timing and type of information given to women about their birth options by health professionals. DESIGN: a national census study using a self-administered postal survey of nursing managers within obstetric departments in Japanese hospitals and clinics was conducted. Data were analyzed to explore characteristics of institutions accepting or not accepting VBAC and information given to women about planned VBAC and planned repeat CS. SETTING: institutions included hospitals and clinics providing childbirth services throughout Japan. PARTICIPANTS: nursing managers from hospitals (n=303) and clinics (n=196) completed surveys about their institutional policies and practices around birth after CS. FINDINGS: only 154 (30.9%) of 499 institutions examined, accepted planned vaginal birth as an option for birth after CS. The success rate of VBAC was 77.0% in these institutions. Availability of transport services for institutional transfer and existence of a Maternal Fetal Intensive Care Unit (MFICU) were significantly associated with acceptance of VBAC (OR=5.39, p<0.001; OR=2.96, p=0.04). Information about options for birth method was mostly provided in the form of consent documents, and doctors were the sole provider of information about method of childbirth in 55.7% of institutions. Nursing managers described challenges in caring for women who strongly desire VBAC when women did not have access to information or if institutional policies conflicted with women's wishes. They recommended evidence-based information for women regarding birth choices after CS and recognised the necessity of emotional support for women faced with decision dilemmas. KEY CONCLUSIONS: institutional policies and practices for birth after CS vary widely in Japan, with evidence of limited opportunities for women to make informed choices about planned VBAC. It was difficult for nurse managers to support women to choose VBAC when institutional policy conflicted with this choice and when women did not have consistent or balanced information. IMPLICATIONS FOR PRACTICE: strategies are needed to support women as well as pregnancy care providers to support women to consider VBAC as a possible birth option after CS and to expand the use of shared decision making in pregnancy care settings in Japan.

Timing the provision of a pregnancy decision-aid: temporal patterns of preference for mode of birth during pregnancy.

OBJECTIVE: To help identify the optimal timing for provision of pregnancy decision-aids, this paper examines temporal patterns in women's preference for mode of birth after previous cesarean, prior to a decision-aid intervention. METHODS: Pregnant women (n=212) with one prior cesarean responded to surveys regarding their preference for elective repeat cesarean delivery (ERCD) or trial of labor (TOL) at 12-18 weeks and again at 28 weeks gestation. Patterns of adherence or change in preference were examined. RESULTS: Women's preferences for birth were not set in early pregnancy. There was evidence of increasing uncertainty about preferred mode of birth during the first two trimesters of pregnancy (McNemar value=4.41, p=0.04), decrease in preference for TOL (McNemar value=3.79, p=0.05) and stability in preference for ERCD (McNemar value=0.31, p=0.58). Adherence to early pregnancy choice was associated with previous birth experience, maternal country of birth, emotional state and hospital site. CONCLUSION: Women's growing uncertainty about mode of birth prior to 28 weeks indicates potential readiness for a decision-aid earlier in pregnancy. PRACTICE IMPLICATIONS: Pregnancy decision-aids affecting mode of birth could be provided early in pregnancy to increase women's opportunity to improve knowledge, clarify personal values and reduce decision uncertainty.

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.

The importance of mode of birth after previous cesarean: success, satisfaction, and postnatal health.

INTRODUCTION: The recent National Institutes of Health consensus conference on vaginal birth after cesarean (VBAC) recommended a focus on strategies that increase women's opportunities to make informed choices about VBAC. This study aimed to expand knowledge of women's experiences of planned VBAC by focusing on postnatal experiences of women who participated in an Australian birth-after-cesarean study. METHODS: At 6 to 8 weeks after birth, 165 women who experienced childbirth after a previous cesarean rated satisfaction with their birth experiences using a 10-point visual analogue scale, reported on postnatal health problems, and indicated whether they would make the same birth choice again. RESULTS: Significant differences were found in satisfaction scores by mode of birth. Mean scores out of a possible score of 10 ranged from 8.86 for spontaneous vaginal birth, 7.86 for elective repeat cesarean delivery, 6.71 for emergency cesarean delivery, to 6.15 for instrumental vaginal birth (F = 5.33; P = .002). Mean satisfaction scores for spontaneous vaginal birth and elective repeat cesarean delivery were statistically higher than for instrumental vaginal birth and emergency cesarean birth. Women who experienced instrumental vaginal birth and emergency cesarean birth also reported a higher number of postnatal health-related problems and were least likely to agree that they would make the same birth choice again. DISCUSSION: Mode of birth was the most important determinant of postnatal satisfaction, postnatal health, and whether women felt they would make the same birth choice again. Clinicians, researchers, and policymakers should identify effective labor management practices that enhance women's opportunities to achieve spontaneous vaginal birth during planned VBAC.

What happens when a private hospital comes to town? The impact of the 'public' to 'private' hospital shift on regional birthing outcomes.

PURPOSE: To examine the regional impact of a shift from public to private hospital care on birthing outcomes. PROCEDURES: A retrospective regional cohort study analysed the birth outcomes for 20,826 live singleton births of gestation >or=37 weeks, within one regional area in New South Wales between 1 January 1997 and 31 December 2003. Rates of intervention for induction of labour (IOL), epidural pain relief and operative mode of birth were established and analysed according to hospital type. A cascade model was then constructed for total births by hospital type. FINDINGS: Regional birthing outcomes were significantly affected by a shift from public to private hospital care. The introduction of a new private hospital birth facility in the region studied, led to 90% of all privately insured births within the region shifting to the private hospital. During the period 1997-2003, overall regional rates for IOL increased from 38 to 45%, epidural use in labour increased from 10.4 to 21.1% and the caesarean section rate increased from 14.1 to 24.75%. PRINCIPAL CONCLUSIONS: The introduction of a new private hospital birthing facility into the regional health area studied and the shift from public to private hospital birth had a profound impact on the overall birthing experiences of women in the region. This suggests that private hospital services are not a direct substitute for public hospital birthing services. The cascade effect was present for women regardless of risk category and more pronounced in the private hospital. Women who are privately insured require better information to assist them in choosing their birthing environment, rather than assuming that they are simply buying a comparable product through private insurance.

Making choices for childbirth: a randomized controlled trial of a decision-aid for informed birth after cesarean.

BACKGROUND: Decision-making about mode of birth after a cesarean delivery presents challenges to women and their caregivers and requires a balance of risks and benefits according to individual circumstances. The study objective was to determine whether a decision-aid for women who have experienced previous cesarean birth facilitates informed decision-making about birth options during a subsequent pregnancy. METHOD: A prospective multicenter randomized controlled trial of 227 pregnant women was conducted within 3 prenatal clinics and 3 private obstetric practices in New South Wales, Australia. Women with 1 previous cesarean section and medically eligible for trial of vaginal birth were recruited at 12 to 18 weeks' gestation; 115 were randomized to the intervention group and 112 to the control group. A decision-aid booklet describing risks and benefits of elective repeat cesarean section and trial of labor was given to intervention group women at 28 weeks' gestation. Main outcome measures included level of knowledge, decisional conflict score, women's preference for mode of birth, and recorded mode of birth. RESULTS: Women who received the decision-aid demonstrated a significantly greater increase in mean knowledge scores than the control group (increasing by 2.17 vs 0.42 points on a 15-point scale) (p < 0.001, 95% CI for difference = 1.15-2.35). The intervention group demonstrated a reduction in decisional conflict score (p < 0.05). The decision-aid did not significantly affect the rate of uptake of trial of labor or elective repeat cesarean section. Preferences expressed at 36 weeks were not consistent with actual birth outcomes for many women. CONCLUSION: A decision-aid for women facing choices about birth after cesarean section is effective in improving knowledge and reducing decisional conflict. However, little evidence suggested that this process led to an informed choice. Strategies are required to better equip organizations and practitioners to empower women so that they can translate informed preferences into practice. Further work needs to examine ways to enhance women's power in decision-making within the doctor-patient relationship.

Costing the ambulatory episode: implications of total or partial substitution of hospital care.

The Macarthur Health Service introduced an innovative Acute Ambulatory Care Service (MACS) in 2000. The service was designed to substitute patient care previously provided in hospital beds with care in the patient's home. The financial implications of complete or partial substitution of hospital care were explored using local data sources from the introduction of the service in 2001-2002. These data were analysed using the NSW Department of Health cost of care methodology. This study determined that episodes of care in MACS were less costly than equivalent episodes of inpatient care for selected diagnoses. The Macarthur cost of care data confirmed substantial savings (63%) in cases in certain diagnostic groups (cellulitis, pneumonia) with complete substitution, and lower savings (50%) for partial substitution of care when compared with hospital admission. Savings are likely to be greater as the level of substitution increases and are dependent on the choice of ambulatory sensitive diagnoses.