Trauma-Informed Pedagogy: Instructional Strategies to Support Student Success.

Over the past several years, the ongoing coronavirus disease 2019 pandemic has contributed to challenging working and life conditions. As a result, the midwifery and health care workforce has faced significant shortages due to burnout. Increased societal awareness of historical trauma and systemic racism embedded within US culture has also led to increased anxiety and signs of trauma among midwifery and health profession students. Now more than ever, innovative teaching strategies are needed to support students, reduce the risks of burnout, and increase diversity in the workforce. One strategy is to adopt a trauma-informed pedagogy within midwifery education. Trauma-informed pedagogy is founded on core assumptions of trauma-informed care and thus supports student success by recognizing that the student cannot be separated from their own life experiences. Faculty and preceptors can develop empathetic, flexible supports that communicate care and concern regarding students' personal and social situations, and emotions. Empathetic behavior from teachers also increases student learning motivation, making it easier for students to actively engage in learning thereby reducing their distress. The purpose of this State of the Science review, therefore, was to describe the literature surrounding trauma-informed pedagogy and to offer concrete educational strategies that faculty members and educational programs can employ to increase the success of a diverse student body. This can be accomplished through flexibility in curriculum design and outcome measurement to ensure attainment of end of program learning outcomes. Institutional and administrative support are essential to develop a faculty who realize the benefit and value of trauma-informed pedagogy underpinning student success.

Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector.

BACKGROUND: The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public. METHODS: This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum. RESULTS: The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified. CONCLUSION: Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.

Clinical Implications for Women of a Low-Carbohydrate or Ketogenic Diet With Intermittent Fasting.

Obesity in the United States is pervasive and associated with morbidity, mortality, and increased health care costs. For women, obesity may affect stages of life including early menarche, fertility, pregnancy, and menopause as a result of hormonal imbalances and insulin resistance. The insulin-carbohydrate model of obesity has been proposed as an explanation for growing obesity rates and can be used to target weight loss strategies by increasing insulin sensitivity. Together, low-carbohydrate dietary patterns along with intermittent fasting may help individuals with insulin resistance not only lose weight but also increase their insulin sensitivity. The purpose of this article is to review the epidemiology and physiology of obesity and the indicators for health while outlining strategies for nurses and other clinicians to use when counseling women who are following a low-carbohydrate or ketogenic diet with intermittent fasting for weight management.

The experience of sleep deprivation for midwives practicing in the united states.

INTRODUCTION: Midwives in the United States who work shifts longer than 12 h have higher rates of excessive daytime sleepiness than midwives who work shifts of 12 h or less. Increased levels of excessive daytime sleepiness can lead to negative life impacts and may increase the risk for accidents and professional burnout. OBJECTIVE: To describe midwives' experiences related to sleep and sleep deprivation as a result of their work and call-shift schedules. METHODS: A survey designed to explore the experience and impact of work on sleep and sleepiness among midwives in the United States was sent to members of the American College of Nurse-Midwives (N = 4358). The survey included an open-ended question about midwives' experiences related to sleep or sleep deprivation. This analysis of the qualitative data was conducted using qualitative description and qualitative content analysis by two of the authors. RESULTS: There were a total of 753 midwife respondents (response rate = 17%); of those 268 responded to the qualitative question about sleep. Three main themes were identified: barriers and challenges contributing to sleep deprivation; negative consequences of sleep deprivation; and strategies that helped midwives cope with or reduce sleep deprivation. DISCUSSION: Midwives reported suffering health and safety consequences as a result of insufficient sleep, including impacts to their personal health, clinical errors, and errors in driving after an extended period awake. Nurses, midwives, physicians, and administrators are encouraged to work together to develop strategies and policies to ameliorate the risks and impacts of sleep deprivation for all clinicians, including midwives.

Consolidation of Guidelines of Postpartum Care Recommendations to Address Maternal Morbidity and Mortality.

Rates of maternal morbidity and mortality in the United States represent an urgent crisis. The purpose of this article is to consolidate current postpartum care guidelines to provide a comprehensive approach to care in the postpartum period. We include a critical examination of the reasons for some women's lack of attendance at postpartum visits, the current state of postpartum care, and the unmet needs of women. We review several postpartum care programs and suggest possible solutions for the postpartum period, including clinical implications for continuity of care for women with comorbidities including gestational diabetes, hypertension, and depression.

Client-Centered Mobile Health Care Applications: Using the Mobile Application Rating Scale Instrument for Evidence-Based Evaluation.

The use of mobile devices and applications (apps) to monitor or assist in health behaviors is rapidly expanding in many areas of society. Clinicians desire evidence-based app recommendations for their clients to increase self-care and wellness management in such areas as mindfulness, weight loss and activity tracking, glycemic control, and consumer medication information. Given the constant influx of new apps into the major app repositories, clinicians need to be able to ensure the quality of information and interaction that occurs within the mobile health (mHealth) marketplace. The Mobile Application Rating Scale (MARS) and the user version of the scale are valid and reliable instruments used to examine the engagement, functionality, aesthetics, and quality of information in mHealth apps. MARS-rated apps can be readily available resources for busy clinicians to make app suggestions to assist clients on a variety of topics that promote improved outcomes. This article reviews the MARS instrument and utilization of the instrument by clinicians and summarizes several primary care and wellness apps that have been evaluated using this tool.

Factors That Contribute to Excessive Sleepiness in Midwives Practicing in the United States.

INTRODUCTION: Excessive daytime sleepiness is defined as difficulty maintaining wakefulness and alertness during normal waking hours. Excessive daytime sleepiness can lead to clinical errors in health care workers and is associated with dangerous driving. Little is known about the level of daytime sleepiness in midwives in the United States. The purposes of this study, conducted by the American College of Nurse-Midwives (ACNM) Sleep and Safety Taskforce, were first to identify the sleepiness level of US certified nurse-midwives (CNMs) and certified midwives (CMs) by calculating Epworth Sleepiness Scale scores for CNM/CMs in full-scope practice, and then to determine factors that significantly contribute to elevated Epworth Sleepiness Scale scores (>10). METHODS: Participants in this descriptive, correlational survey study were active ACNM members in full-scope midwifery practice. Descriptive statistics, bivariate analysis, and logistic regression were used for data analysis. Surveys were emailed to all active members of ACNM (N = 4358). RESULTS: A total of 753 (17.3%) survey responses were returned, of which 639 (14.7%) were eligible for analysis. Within this group, 639 (84.9%) self-identified as being in full-scope midwifery practice, and one-fourth (n = 164; 25.7%) had elevated Epworth Sleepiness Scale scores. Duration of work shifts was the only variable found to significantly contribute to differences in Epworth Sleepiness Scale scores, with midwives working shifts longer than 12 hours having higher rates of excessive daytime sleepiness compared with midwives who worked shifts of 12 hours or less. DISCUSSION: Midwives, midwifery services, and maternity care centers can work together to ensure that clinicians obtain adequate sleep. Reducing excessive sleepiness will contribute to increased safety for midwives, women, newborns, and the general public.

Mobile Applications for Women's Health and Midwifery Care: A Pocket Reference for the 21st Century.

Midwives and other women's health care providers are charged with providing high-quality care to women based on the most current available evidence. Quick, reliable, and accurate access to evidence-based information is essential. Numerous smartphone and mobile device applications (apps) are available to assist clinicians in providing care for women. This article discusses clinical reference apps, including those for evidence-based care guidelines, women's health care, pharmacologic reference, laboratory and diagnostic guides, as well as apps for information storage and management, electronic health records, and client education. Midwives and other clinicians are encouraged to thoughtfully integrate mobile apps into their clinical practices to improve client outcomes and clinician and client satisfaction. Although the thousands of health care apps that are available may seem daunting, this article highlights key apps that may help clinicians improve their care of women. By adding one app at a time, midwives and other women's health care providers can successfully integrate mobile apps into clinical practice.

Educational Strategies to Help Students Provide Respectful Sexual and Reproductive Health Care for Lesbian, Gay, Bisexual, and Transgender Persons.

Graduate medical, nursing, and midwifery curricula often have limited amounts of time to focus on issues related to cultural competency in clinical practice, and respectful sexual and reproductive health care for all individuals in particular. Respectful health care that addresses sexual and reproductive concerns is a right for everyone, including those who self-identify as lesbian, gay, bisexual, or transgender (LGBT). LGBT persons have unique reproductive health care needs as well as increased risks for poor health outcomes. Both the World Health Organization and Healthy People 2020 identified the poor health of LGBT persons as an area for improvement. A lack of educational resources as well as few student clinical experiences with an LGBT population may be barriers to providing respectful sexual and reproductive health care to LGBT persons. This article offers didactic educational strategies for midwifery and graduate nursing education programs that may result in reducing barriers to the provision of respectful sexual and reproductive health care for LGBT clients. Specific ideas for implementation are discussed in detail. In addition to what is presented here, other educational strategies and clinical experiences may help to support students for caring for LGBT persons prior to entrance into clinical practice.

Preconception Care: Improving the Health of Women and Families.

Approximately 50% of the pregnancies in the United States are unintended. Most pregnancies are not diagnosed until after the period of organogenesis. Environmental exposures, chronic and acute illnesses, and ingestion of teratogens that can negatively affect the fetus may occur during these early weeks of pregnancy. Some chronic disease effects and lifestyle behaviors that affect the fetus can be adjusted prior to conception. Because of this, the health of a woman and her partner prior to pregnancy are of utmost importance. The Centers for Disease Control and Prevention and the Preconception Health and Health Care Initiative have established goals and evidence-based guidelines for preconception care. Preconception health care can be threaded into every visit with all women of reproductive age who are not pregnant. The guidelines focus on 3 main areas: screening, health promotion, and interventions. Screening is accomplished with women and couples via a thorough history and assessment of risks including a reproductive life plan; assessment of tobacco, alcohol and drug use; sexually transmitted infection (STI) testing and education; and assessment of environmental or teratogenic risk factors. Health promotion includes making sure the woman is current with regard to recommended vaccines, taking appropriate levels of folic acid, and maintaining a healthy weight and level of physical activity. The health care provider can intervene when indicated with management of chronic and acute illnesses, as well as provide assistance with tobacco, alcohol, and drug cessation as necessary. When a woman and her partner are healthy prior to pregnancy, unintended or planned, the woman and her fetus have a better chance at a healthy gestation and beyond. This article, via the use of case presentations, reviews how preconception health can be integrated into an office visit.

Innovative uses of technology in online midwifery education.

Women's health care in the United States is at a critical juncture. There is increased demand for primary care providers, including women's health specialists such as certified nurse-midwives/certified midwives, women's health nurse practitioners, and obstetrician-gynecologists, yet shortages in numbers of these providers are expected. This deficit in the number of women's health care providers could have adverse consequences for women and their newborns when women have to travel long distances to access maternity health care. Online education using innovative technologies and evidence-based teaching and learning strategies have the potential to increase the number of health care providers in several disciplines, including midwifery. This article reviews 3 innovative uses of online platforms for midwifery education: virtual classrooms, unfolding case studies, and online return demonstrations of clinical skills. These examples of innovative teaching strategies can promote critical and creative thinking and enhance competence in skills. Their use in online education can help enhance the student experience. More students, including those who live in rural and underserved regions and who otherwise might be unable to attend a traditional onsite campus, are provided the opportunity to complete quality midwifery education through online programs, which in turn may help expand the women's health care provider workforce. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Strategies to Promote Cultural Competence in Distance Education.

Cultural competence is a mainstay in health care and nursing education. With the expansion in the number of distance-based nursing programs across the country, innovative teaching methods for distance learning faculty are required to instill cultural competence in students. Faculty must be deliberate when planning distance-based learning activities that incorporate cultural experiences. This article describes several such strategies including the creative use of blogging, recorded lectures, the online synchronous classroom, social media, and cultural immersion projects. These methods capitalize on existing information technologies and offer distance-based students the opportunity to connect with one another, as well as develop the awareness, sensitivity, and respect that is required when providing culturally competent care. These teaching methods are modifiable to meet the teaching and learning needs of the faculty and the students, thereby allowing educators to support the integration of cultural competence into patient care for distance students.

Evidence-based nurse-driven interventions for the care of newborns with neonatal abstinence syndrome.

Neonatal abstinence syndrome (NAS) is a growing problem in the United States, related to increased maternal substance use and abuse, and a set of drug withdrawal symptoms that can affect the central nervous system and gastrointestinal and respiratory systems in the newborn when separated from the placenta at birth. Infants with NAS often require a significant length of stay in the neonatal intensive care unit (NICU). Pharmacologic treatments and physician-directed interventions are well researched, but nursing-specific interventions and recommendations are lacking. A thorough review and analysis of the literature and interviews with neonatal experts guided the development of a nursing clinical practice guideline for infants with NAS in a level IV NICU. Recommended nursing-specific interventions include methods for maternal drug-use identification, initiation and timing of the Finnegan Scoring System to monitor withdrawal symptoms, and bedside interventions to lessen the drug-withdrawal symptoms in the newborn with NAS.

Identification of the pregnant woman who is using drugs: implications for perinatal and neonatal care.

Neonatal abstinence syndrome (NAS) is a set of drug withdrawal symptoms that affect the central nervous, gastrointestinal, and respiratory systems in the newborn when separated from the placenta at birth. Maternal substance use of opioids, benzodiazepines, barbiturates, and alcohol can cause NAS. Universal drug screening via questioning pregnant women is recommended, but identification of drug use is incomplete with this method. This article provides resources for the identification and management of drug use during pregnancy for midwives who provide care not only during the prenatal period but also during the intrapartum and postpartum periods. The impact of drug use on newborns can be significant and may require pharmacologic assistance with the transition to extrauterine life. Challenges involved in caring for the woman who is using drugs during pregnancy include ordering toxicology screens on the newborn, alerting social services, and educating the woman about her newborn's progress. Several measures to comfort a newborn with NAS may help to enable a mother to provide the best care for her newborn.

Mammary hypoplasia: not every breast can produce sufficient milk.

Breast milk is considered the optimal form of nutrition for newborn infants. Current recommendations are to breastfeed for 6 months. Not all women are able to breastfeed. Mammary hypoplasia is a primary cause of failed lactogenesis II, whereby the mother is unable to produce an adequate milk volume. Women with mammary hypoplasia often have normal hormone levels and innervation but lack sufficient glandular tissue to produce an adequate milk supply to sustain their infant. The etiology of this rare condition is unclear, although there are theories that refer to genetic predisposition and estrogenic environmental exposures in select agricultural environments. Women with mammary hypoplasia may not exhibit the typical breast changes associated with pregnancy and may fail to lactate postpartum. Breasts of women with mammary hypoplasia may be widely spaced (1.5 inches or greater), asymmetric, or tuberous in nature. Awareness of the history and clinical signs of mammary hypoplasia during the prenatal period and immediate postpartum increases the likelihood that women will receive the needed education and physical and emotional support and encouragement. Several medications and herbs demonstrate some efficacy in increasing breast milk production in women with mammary hypoplasia.

Racial differences in the health of childbearing-aged women.

UNLABELLED: The incidence of preterm birth in the United States varies by race/ethnicity and socioeconomic status. Given the unsatisfactory reduction in preterm birth with interventions directed at single risk factors, we examined the preconceptional health of childbearing-aged women of different racial/ethnic groups to understand the risk prior to pregnancy. PURPOSE: To evaluate the preconceptional health of childbearing-aged women by examining specific health factors implicated in preterm birth in light of racial/ethnic and socioeconomic factors. We tested the hypothesis that subgroups with historically high levels of preterm birth would have poorer preconceptional health compared to other groups and that the economic influence would be similar across groups. STUDY DESIGN AND METHODS: We performed a secondary analysis of cross-sectional population-based data from the National Health and Nutrition Examination Survey 2001-2002 and 2003-2004 data sets, including 1,497 of 2,108 eligible White, African American, and Mexican American women. We measured health using select indicators of cardiovascular and metabolic disorders, infectious disease, and sexual and substance-use behaviors associated with increased risk for preterm birth and conducted comparisons within and across racial groups. We used adjusted logistic regression by race. RESULTS: In addition to increased rates of preterm birth shown in the literature, childbearing-aged African American women have poorer overall preconceptional health than the other groups. Measures of socioeconomic status affect preconceptional health differently for each racial/ethnic group. CLINICAL IMPLICATIONS: Racial/ethnic subgroups with higher rates of preterm birth experience poorer health preconceptionally. Clinicians should address preconceptional health risks for preterm birth in all childbearing-aged women, paying attention to racial/ethnic-specific risks identified here.

Douching patterns in women related to socioeconomic and racial/ethnic characteristics.

OBJECTIVE: To examine whether socioeconomic and racial/ethnic characteristics contribute independently and in combination to influence douching behavior. DESIGN: A cross-sectional design. SETTING: United States. PARTICIPANTS: Women between 14 and 49 years of age who were both interviewed and examined as part of the National Health and Nutrition Examination Survey data collection process. MAIN OUTCOME MEASURES: Douching rates in women categorized on socioeconomic and racial and ethnic characteristics. RESULTS: Based on data from 3,522 women, 21% reported recent douching. Separated by race, Black women douche at much higher percentage (47%) than non-Hispanic White (17%), Mexico-born Mexican American women (12.5%), or U.S.-born Mexican American women (19%). Although increasing age and low socioeconomic status are both associated with increased douching, the effects of socioeconomic status on douching vary by race/ethnicity. CONCLUSIONS: Low income and minority racial status contribute both independently and together to influence douching behavior in women. These findings suggest cultural contributions to douching may be especially prevalent in the Black population while Mexican American women born in Mexico may be relatively immune to U.S. cultural influences.

Postpartum fatigue and evidence-based interventions.

The aim of this article is to review postpartum fatigue, especially as it relates to the occurrence and pathophysiology of three common postpartum conditions known to contribute to fatigue: anemia, infection/inflammation, and thyroid dysfunction. Fatigue is an unrelenting condition that affects physical and mental health, and it has implications for everyday activities, motivation, and social interactions. Although individuals of all ages and both genders are at risk for developing fatigue, postpartum fatigue is particularly challenging, because the new mother has demanding life tasks to accomplish during this period of time. Postpartum fatigue may impact postpartum maternal role attainment and may place a woman at increased risk for postpartum depression. Although several treatable physiological conditions common during the postpartum period are known to increase fatigue, none of these conditions is a part of the usual assessment of healthy postpartum women. For many women, subtle fatigue may develop, linger or worsen, and even lead to depression, with both the woman and her care provider unaware.