Characteristics and Outcomes of Postgraduate Midwifery Fellowships: A Mixed Methods Study.

INTRODUCTION: Postgraduate fellowships are growing in midwifery and yet are poorly understood by the profession. These fellowships are optional for midwives interested in developing advanced skills, transitioning to specialty practice, or entering or re-entering professional practice. The purpose of this study was to explore the characteristics and outcomes of US postgraduate midwifery fellowships as described by midwifery fellowship program directors. METHODS: Postgraduate midwifery fellowship programs in the United States were identified through an environmental scan and snowball sampling. Directors of these fellowship programs were invited to complete a survey and an open-ended interview to determine their program's characteristics and outcomes. Quantitative data were summarized, and thematic analysis was used to explore the qualitative data. RESULTS: An environmental scan and snowball sampling identified 17 postgraduate midwifery fellowship programs. Thirteen fellowship program directors completed a survey (76.5%), and 11 completed an interview (64.7%). The findings identified program characteristics, including location, structure, funding, and educational offerings, of midwifery fellowship programs. The thematic analysis revealed the emergence of 3 themes highlighting the creation of support for midwives in transition, including new graduates and practicing midwives returning to practice after a hiatus or shifting to specialty practice: (1) stepping stones, (2) empowered and equipped, and (3) innovative future. Community birth practice was defined as specialty practice by these directors. DISCUSSION: The results of this study inform the profession of the availability of fellowships and the development of future high-quality midwifery fellowships. Postgraduate midwifery fellowships should not be required for entry to practice but have a place in the work-study opportunities available to US midwives.

Approaches for improving sexuality and sexual health care in mental health settings: A qualitative study exploring clinicians' own perspectives.

There is an acknowledged professional practice gap regarding sexuality and sexual health related needs within mental health settings in Australia and internationally. Yet little is known about how clinicians can be best supported or enabled to improve sexuality-related practice, from their own perspective. This is important, given the sensitive and complex nature of sexuality and sexual health within the context of mental distress and service provision. This article reports a follow-up study, where mental health clinicians who participated in an initial study were invited to reflect on and discuss the (finalized) results and recommendations generated. The aim was to generate insights into the tools, strategies, and approaches participants felt would best equip and support clinicians to better incorporate sexuality and sexual health into their work. Six clinicians from three disciplines (mental health nursing, psychology, and psychiatry) participated in in-depth interviews to reflect on a plain language summary of the initial study. Three interconnected themes were generated via reflexive thematic analysis: (1) access to knowledge and information; (2) support from peers, senior colleagues, and workplaces; and (3) enacting a focus on sexuality-related care. These findings provide valuable insights into how clinicians may want to be supported in relation to (improving) their sexuality-related practice. The analysis also demonstrates the importance of a multifaceted approach to improving sexuality-related care in mental health and other health settings. This knowledge will contribute to directing future research and development of interventions, tools, strategies, or other approaches to this end.

Anorexia of aging: An international assessment of healthcare providers' knowledge and practice gaps.

BACKGROUND: Anorexia of aging is a common geriatric syndrome that includes loss of appetite and/or reduced food intake, with associated undernutrition, unintended weight loss, sarcopenia, functional decline, loss of independence and other adverse health outcomes. Anorexia of aging can have multiple and severe consequences and is often overlooked by healthcare professionals (HCPs). Even more concerningly, clinicians commonly accept anorexia of aging as an inevitable part of 'normal' aging. The aim of this assessment was to identify current gaps in professional knowledge and practice in identifying and managing older persons with anorexia. Results may guide educational programmes to fill the gaps identified and therefore improve patient outcomes. METHODS: This international assessment was conducted using a mixed-methods approach, including focus group interviews with subject matter experts and an electronic survey of practicing HCPs. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in-country collaborating organizations. RESULTS: A quantitative survey of 26 multiple-choice questions was completed by physicians, dietitians and other HCPs (n = 1545). Most HCPs (56.8%) recognize a consistent definition of anorexia of aging as a loss of appetite and/or low food intake. Cognitive changes/dementia (91%) and dysphagia (87%) are seen as the biggest risk factors. Most respondents were confident to give nutritional (62%) and physical activity (59.4%) recommendations and engaged caregivers such as family members in supporting older adults with anorexia (80.6%). Most clinicians assessed appetite at each visit (66.7%), although weight is not measured at every visit (41.5%). Apart from the Mini-Nutritional Assessment Short Form (39%), other tools to screen for appetite loss are not frequently used or no tools are used at all (29.4%). A high number of respondents (38.7%) believe that anorexia is a normal part of aging. Results show that treatment is focused on swallowing disorders (78%), dentition issues (76%) and increasing oral intake (fortified foods [75%] and oral nutritional supplements [74%]). Nevertheless, the lack of high-quality evidence is perceived as a barrier to optimal treatment (49.2%). CONCLUSIONS: Findings from this international assessment highlight the challenges in the care of older adults with or at risk for anorexia of aging. Identifying professional practice gaps between individual HCPs and team-based gaps can provide a basis for healthcare education that is addressed at root causes, targeted to specific audiences and developed to improve individual and team practices that contribute to improving patient outcomes.

Current Practice, Barriers to, and Facilitators of Exercise Testing and Training by Physiotherapists in Cystic Fibrosis Specialized Centres in Canada.

Purpose: This study surveyed physiotherapists working at Canadian cystic fibrosis (CF) specialized centres to investigate the current practice, barriers to, and facilitators of exercise testing and training. Method: Physiotherapists were recruited from 42 Canadian CF centres. They responded to an e-questionnaire regarding their practice. The data were analyzed using descriptive statistics. Results: Eighteen physiotherapists responded (estimated response rate of 23%); median years of clinical experience was 15 (range, min-max, 3-30) years. Aerobic testing was administered by 44% of respondents, strength testing by 39%, aerobic training by 78%, and strength training by 67%. The most frequently reported barriers across all four types of exercise testing and training were insufficient funding (reported by 56%-67% of respondents), time (50%-61%) and staff availability (56%). More late career than early career physiotherapists reported utilizing aerobic testing (50% vs. 33% of respondents), strength testing (75% vs. 33%), aerobic training (100% vs. 67%), and strength training (100% vs. 33%). Conclusions: Exercise testing and training is underutilized in Canadian CF centres. Experienced physiotherapists reported utilizing exercise testing and training more than less-experienced physiotherapists. Post-graduate education and mentorship, especially for less-experienced clinicians, are recommended to emphasize the importance of exercise testing and training. Barriers of funding, time, and staff availability should be addressed to further improve quality of care.

Objectif :sondage auprès de physiothérapeutes qui travaillent dans des centres canadiens spécialisés en fibrose kystique (FK) pour examiner les pratiques, les obstacles et les incitations actuels liés aux épreuves et aux entraînements à l'exercice. Méthodologie: les physiothérapeutes ont été recrutés dans 42 centres canadiens spécialisés en FK. Ils ont répondu à un questionnaire en ligne au sujet de leur pratique. Les données ont été analysées au moyen de statistiques descriptives. Résultats: les 18 physiothérapeutes qui ont répondu (taux de réponse estimatif de 23 %) avaient une médiane de 15 années d'expérience clinique (plage minimale-maximale de trois à 30 ans). Ainsi, 44 % des répondants effectuaient des épreuves d'endurance aérobique, 39 %, des épreuves en résistance, 78 %, un entraînement aérobique et 67 %, un entraînement en résistance. Les obstacles les plus signalés dans les quatre types d'épreuves et d'entraînement à l'exercice étaient un financement insuffisant (par 56 % à 67 % des répondants), le manque de temps (50 % à 61 %) et le peu de disponibilité du personnel (56 %). Plus de physiothérapeutes en fin de carrière qu'en début de carrière ont déclaré utiliser les épreuves d'endurance aérobique (50 % par rapport à 33 % des répondants), les épreuves de résistance (75 % par rapport à 33 %), l'entraînement aérobique (100 % par rapport à 67 %) et l'entraînement en résistance (100 % par rapport à 33 %). Conclusions:  l'épreuve et l'entraînement à l'exercice sont sous-utilisés dans les centres canadiens spécialisés en FK. Les physiothérapeutes d'expérience étaient plus nombreux à avoir déclaré utiliser l'épreuve et l'entraînement à l'exercice que les physiothérapeutes moins expérimentés. Les études supérieures et le mentorat, particulièrement chez les cliniciens moins expérimentés, sont recommandés pour insister sur l'importance de l'épreuve et de l'entraînement à l'exercice. Il faut corriger les obstacles au financement, au temps et à la disponibilité du personnel pour améliorer encore davantage la qualité des soins.

Improving Practice for Urinary Continence Care on Adult Acute Medical and Rehabilitation Wards: A Multi-Site, Co-Created Implementation Study.

Many adult inpatients experience urinary continence issues; however, we lack evidence on effective interventions for inpatient continence care. We conducted a before and after implementation study. We implemented our guideline-based intervention using strategies targeting identified barriers and evaluated the impact on urinary continence care provided by inpatient clinicians. Fifteen wards (acute = 3, rehabilitation = 7, acute and rehabilitation = 5) at 12 hospitals (metropolitan = 4, regional = 8) participated. We screened 2298 consecutive adult medical records for evidence of urinary continence symptoms over three 3-month periods: before implementation (T0: n = 849), after the 6-month implementation period (T1: n = 740), and after a 6-month maintenance period (T2: n = 709). The records of symptomatic inpatients were audited for continence assessment, diagnosis, and management plans. All wards contributed data at T0, and 11/15 wards contributed at T1 and T2 (dropouts due to COVID-19). Approximately 26% of stroke, 33% acute medical, and 50% of rehabilitation inpatients were symptomatic. The proportions of symptomatic patients (T0: n = 283, T1: n = 241, T2: n = 256) receiving recommended care were: assessment T0 = 38%, T1 = 63%, T2 = 68%; diagnosis T0 = 30%, T1 = 70%, T2 = 71%; management plan T0 = 7%, T1 = 24%, T2 = 24%. Overall, there were 4-fold increased odds for receiving assessments and management plans and 6-fold greater odds for diagnosis. These improvements were sustained at T2. This intervention has improved inpatient continence care.

Audiologists' perceived value of ototoxicity management and barriers to implementation for at-risk cancer patients in VA: the OtoMIC survey.

PURPOSE: Platinum-based chemotherapies used to treat many types of cancers are ototoxic. Ototoxicity management (OtoM) to mitigate the ototoxic outcomes of cancer survivors is recommended practice yet it is not a standard part of oncologic care. Although more than 10,000 patients each year are treated with platinum-based chemotherapies at the US Veterans Health Administration (VA), the current state of OtoM in VA is not well-defined. This study reports on a national survey of VA audiologists' perceptions regarding OtoM in cancer patients. METHODS: A 26-item online survey was administered to VA audiologists and service chiefs across the VA's 18 regional systems of care. Descriptive statistics and deductive thematic analysis were used to analyze the data. RESULTS: The 61 respondents included at least one from each VA region. All reported they felt some form of OtoM was necessary for at-risk cancer patients. A pre-treatment baseline, the ability to detect ototoxicity early, and management of ototoxic effects both during and after treatment were considered high value objectives of OtoM by respondents. Roughly half reported routinely providing these services for patients receiving cisplatin and carboplatin. Respondents disagreed regarding appropriate hearing testing schedules and how to co-manage OtoM responsibilities with oncology. They identified barriers to care that conformed to three themes: care and referral coordination with oncology, audiology workload, and lack of protocols. CONCLUSIONS: Although VA audiologists value providing OtoM for cancer patients, only about half perform OtoM for highly ototoxic treatment regimens. The OtoMIC survey provides clinician perspectives to benchmark and address OtoM care gaps. IMPLICATIONS FOR CANCER SURVIVORS: Collaboration between oncology and audiology is needed to improve current OtoM processes, so that cancer survivors can have more control over their long term hearing health.

The Role of Physician Specialty in the Underutilization of Standard-of-Care Treatment Intensification in Patients With Metastatic Castration-sensitive Prostate Cancer.

PURPOSE: We evaluate utilization of treatment intensification of androgen deprivation therapy with androgen receptor pathway inhibitor/docetaxel for metastatic castration-sensitive prostate cancer patients across physician specialties. MATERIALS AND METHODS: This retrospective study identified patients with metastatic castration-sensitive prostate cancer in the Optum Research Database between 2014 and 2019. Adult men with ≥1 claim for metastatic disease within 90 days before or any time after the first prostate cancer claim who received androgen deprivation therapy were included. Physician specialty, determined from medical/pharmacy claims during each line of therapy, was categorized as urologist only, oncologist only, both (urologists and oncologists), or other (other specialties). Treatment intensification and patient characteristics were analyzed descriptively. RESULTS: Of 4,675 patients, 16% were treated by urologists only, 20% by oncologists only, 63% by both, and 1.1% by others. The most frequent first line of therapy was androgen deprivation therapy ± first-generation nonsteroidal antiandrogens (>50%). Androgen deprivation therapy + docetaxel use declined over time, while androgen deprivation therapy + androgen receptor pathway inhibitor use increased. Patients seen by oncologists or both were younger, had fewer comorbidities, and were likelier to receive treatment intensification compared to those treated by urologists. By 2019, however, treatment intensification remained <40% from oncologists only or both, and <15% from urologists only. In the second and third lines of therapy, androgen deprivation therapy + androgen receptor pathway inhibitor was the most prescribed regimen across specialties (>50%). CONCLUSIONS: Treatment intensification was underused in first lines of therapy across urology and oncology specialties despite evidence of improved survival. In subsequent lines, androgen deprivation therapy + androgen receptor pathway inhibitor was prescribed more frequently across specialties. These results underscore the need for earlier treatment intensification by urologists and oncologists.

Eating Disorder Screening and Treatment in a Medically Underserved Southern State: Data Collected by a Legislative Eating Disorder Council and Implications for Statewide Assessment.

Healthcare providers play a key role in early identification of eating disorders (EDs), especially in underserved states where ED treatment resources are lacking. Currently, there is little known about ED screening and treatment practices in underserved states. The current study assessed current ED screening and treatment practices among healthcare providers in an underserved state using data collected by a government-formed state ED council. Healthcare providers (N = 242; n = 209 behavioral health providers; n = 33 medical providers) practicing in Kentucky completed a brief, anonymous survey on ED screening and treatment practices, comfort with screening for EDs, and interest in continued education. Over half of healthcare providers indicated screening for EDs, with the majority using a clinical interview. After identification of ED symptoms, providers reported a combination of treating in-house, referring out, or seeking consultation. In bivariate analyses, medical providers were significantly more likely than behavioral health providers to use a screening tool specifically designed for EDs. The majority of medical providers indicated that they received education about EDs and feel knowledgeable about ED screening tools, though most reported infrequent use of these screening tools in their practice. Nearly all behavioral health and medical providers expressed interest in continuing education on ED screening and treatment. These findings indicate a need for, and interest in, education on evidence-based ED screening and treatment resources in underserved states and demonstrate the utility of a state ED council to collect these data to inform future education and treatment strategies.

Lack of Benefit of Adjusting Adaptively Daily Invitations for the Evaluation of the Quality of Anesthesiologists' Supervision and Nurse Anesthetists' Work Habits.

Introduction Whenever a department implements the evaluation of professionals, a reasonable operational goal is to request as few evaluations as possible. In anesthesiology, evaluations of anesthesiologists (by trainees) and nurse anesthetists (by anesthesiologists) with valid and psychometrically reliable scales have been made by requesting daily evaluations of the ratee's performance on the immediately preceding day. However, some trainees or nurse anesthetists are paired with the same anesthesiologist for multiple days of the same week. Multiple evaluations from the same rater during a given week may contribute little incremental information versus one evaluation from that rater for the week. We address whether daily evaluation requests could be adjusted adaptively to be made once per week, hopefully substantively reducing the number of evaluation requests. Methods Every day since 1 July 2013 at the studied department, anesthesia residents and fellows have been requested by email to evaluate anesthesiologists' quality of supervision provided during the preceding day using the De Oliveira Filho supervision scale. Every day since 29 March 2015, the anesthesiologists have been requested by email to evaluate the work habits of the nurse anesthetists during the preceding day. Both types of evaluations were made for interactions throughout the workday together, not for individual cases. The criterion for an electronic request to be sent is that the pair worked together for at least one hour that day. The current study was performed using evaluations of anesthesiologists' supervision and nurse anesthetists' work habits through 30 June 2023. Results If every evaluation request were completed by trainees on the same day it was requested, trainees would have received 13.5% fewer requests to evaluate anesthesiologists (9367/69,420), the maximum possible reduction. If anesthesiologists were to do the same for their evaluations of nurse anesthetists, the maximum possible reduction would be 7.1% fewer requests (4794/67,274). However, because most evaluations were completed after the day of the request (71%, 96,451/136,694), there would be fewer requests only if the evaluation were completed before or on the day of the next pairing. Consequently, in actual practice, there would have been only 2.4% fewer evaluation requests to trainees and 1.5% fewer to anesthesiologists, both decreases being significantly less than 5% (both adjusted P <0.0001). Among the trainees' evaluations of faculty anesthesiologists, there were 1.4% with very low scores, specifically, a mean score of less than three out of four (708/41,778). Using Bernoulli cumulative sum (CUSUM) among successive evaluations, 72 flags were raised over the 10 years. Among those, there were 36% with more than one rater giving an exceptionally low score during the same week (26/72). There were 97% (70/72) with at least one rater contributing more than one score to the recent cumulative sum. Conclusion Conceptually, evaluation requests could be skipped if a rater has already evaluated the ratee that week during an earlier day working together. Our results show that the opportunity for reductions in evaluation requests is significantly less than 5%. There may also be impaired monitoring for the detection of sudden major decreases in ratee performance. Thus, the simpler strategy of requesting evaluations daily after working together is warranted.

Implementation strategies to improve evidence-based practice for post-stroke dysphagia identification and management: A before-and-after study.

Objectives: Even though guidelines are available to guide dysphagia identification and management practice, there is still a gap between evidence and practice, which requires improvement. The purpose of this study was to determine the effect of using tailored, multifaceted strategies to improve evidence-based post-stroke dysphagia identification and management practice in a community hospital. Methods: Guided by the Knowledge to Action framework, the tailored, multifaceted strategies were developed and implemented for 5 months in a community hospital using a before-and-after study design. These strategies consisted of training intervention, policy intervention, and audit and feedback intervention. Nurses' level of knowledge and adherence, were collected in March 2019 and again in January 2020. Patients' quality of life and satisfaction were evaluated during the pre-intervention period (between February 2019 and April 2019) and the post-intervention period (between November 2019 and January 2020). Results: A total of 55 patients with post-stroke dysphagia (28 in the pre-intervention period and 27 in the post-intervention period) and 17 registered nurses were recruited. Following implementation, there were statistically significant improvements in patients' outcomes (quality of life and satisfaction) and nurses' outcomes (level of knowledge and adherence). Conclusions: This study assists in closing the research-practice gap by using tailored, multifaceted strategies to increase the use of evidence-based nursing care for dysphagia identification and management practices.