Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: A scoping review and thematic analysis.

PROBLEM: Whistleblowing, which involves raising concerns about wrongdoing, carries risks yet can be crucial to ensuring the safety of health service users in maternal and newborn healthcare settings. Understanding of the experiences of health care professionals that enact whistleblowing in this context is currently limited. BACKGROUND: Notable inquiries involving maternity services such as those reported upon by Ockenden and Kirkup and the Lucy Letby case in the United Kingdom have shone an international spotlight on whistleblowing failures. AIM: To identify and synthesise available literature addressing the experiences of healthcare professionals enacting whistleblowing in maternal and newborn care settings. METHODS: This scoping review followed Arksey and O'Malley's framework. Five academic databases were systematically searched for documents published between January 2013 and October 2023 with additional searches of Google Scholar and related reference lists. FINDINGS: Whilst 35 papers from international sources were identified, the majority originated from the United Kingdom, where recent high-profile incidents have occurred. Thematic analysis identified three main themes: 'Structural Power', 'Perfectionism' and 'Bravery, Hope and Disappointment', each with sub-themes. DISCUSSION: Whistleblowing is frequently an altruistic act in a hierarchical system. It exposes poor practices and disrupts power dynamics, especially in challenging workplace cultures. Open disclosure, however, requires psychological safety. Obstacles persist, emphasising the need for a culture of trust and transparency led by individuals who embody the desired values. CONCLUSION: Primary research on whistleblowing in maternal and newborn healthcare settings is limited. This study sheds light on power dynamics and factors that affect whistleblowing.

Midwives' recognition and response to maternal deterioration: A national cross-sectional study.

BACKGROUND: Early warning systems (EWS) are used across health care settings as a tool for the early identification of clinical deterioration and to determine the need to escalate care. Early detection of clinical deterioration and appropriate escalation of care in maternity settings is critical to the safety of pregnant women and infants; however, underutilization of EWS tools and reluctance to escalate care have been consistently reported. Little is known about midwives' use of EWS in the Australian context. METHODS: Using a cross-sectional approach, we elicited the attitudes, beliefs, and behaviors of a purposive sample of Australian midwives (n = 87) with respect to the Maternal Early Warning Trigger Tool (MEWT). Participants answered a 25-question Likert scale survey and one open-ended question. Qualitative answers were analyzed using consensus coding. RESULTS: Midwives reported positive attitudes toward the MEWT, describing it as a valuable tool for identifying clinical deterioration, especially when used as an adjunct to clinical judgment. However, midwives also identified training gaps; 25% had received no training, and only half of those who had received training felt it was effective. In addition, professional tension can create a significant barrier to the effective use of the MEWT. Midwives also reported feeling influenced by their peers in their decision-making with respect to use of the MEWT and being afraid they would be chastised for escalating care unnecessarily. CONCLUSIONS: Although the MEWT is valued by Australian midwives as a useful tool, barriers exist to its effective use. These include a lack of adequate, ongoing training and professional tension. Improving interdisciplinary collaboration could enhance the use of this tool for the safety of birthing women and their infants.

The grounded theory of Coalescence of Perceptions, Practice and Power: An understanding of governance in midwifery practice.

AIMS: This study aimed to understand midwifery care during labour, particularly decision-making processes, within Australian health systems. BACKGROUND: Midwifery, founded on a wellness model of motherhood, is at risk of being medicalized. Whilst medical intervention is lifesaving, it requires judicious use. Governance provides oversight to care. Exploring decision-making contributes to understanding governance of practices. METHOD: Straussian grounded theory using semi-structured interviews. Eighteen Australian registered midwives were interviewed about their practice when caring for women during labour. RESULTS: Midwives were caught between divergent positions; birth as natural versus birth as risk. Experienced midwives discussed focussing on the woman, yet less experienced were preoccupied with mandatory protocols like early warning tools. Practice was governed by midwives approach within context of labour. The final theory: The Coalescence of Perceptions, Practice and Power, comprising three categories: perceptions and behaviour, shifting practice and power within practice, emerged. CONCLUSIONS: Coalescence Theory elucidates how professional decision making by midwives during care provision is subject to power within practice, thereby governed by tensions, competing priorities and organizational mandates. IMPLICATIONS FOR MIDWIFERY MANAGERS: Midwifery managers are well positioned to negotiate the nuanced space that envelopes birthing processes, namely, expert knowledge, policy mandates and staffing capability and resources, for effective collaborative governance. In this way, managers sustain good governance.

Promoting nurses' and midwives' ethical responsibilities towards vulnerable people: An alignment of research and clinical practice.

AIM: To stimulate discussion and debate about the inclusion of vulnerable populations in primary research to inform practice change and improve health outcomes. BACKGROUND: Current research practices to safeguard vulnerable people from potential harms related to power imbalances may in fact limit the generation of evidence-based practice. EVALUATION: The authors draw on their experience working and researching with a recognized group of vulnerable people, incarcerated pregnant women, to provide insight into the application of ethics in both research and clinical practice. In a novel approach, the ethical principles are presented in both contexts, articulating the synergies between them. Suggestions are presented for how individuals, managers and organizations may improve research opportunities for clinical practitioners and enhance the engagement of vulnerable people to contribute to meaningful practice and policy change. KEY ISSUES: Ethical practice guidelines may limit the ability to create meaningful change for vulnerable populations, who need authentic system change to achieve good health outcomes. CONCLUSION: Inclusive research and practice are essential to ensuring a strengths-based approach to healthcare and addressing health needs of the whole population. Health systems and models of care recognizing the diverse lives and health needs of the broader population demand practical, sustainable support from clinical managers. IMPLICATIONS FOR NURSING MANAGEMENT: Practical suggestions for clinical managers to support point of care research is provided, embedding vulnerable voices in policy, practice development and care provision.

P2/N95 respirators & surgical masks to prevent SARS-CoV-2 infection: Effectiveness & adverse effects.

BACKGROUND: Millions of people have acquired and died from SARS-CoV-2 infection during the COVID-19 pandemic. Healthcare workers (HCWs) are required to wear personal protective equipment (PPE), including surgical masks and P2/N95 respirators, to prevent infection while treating patients. However, the comparative effectiveness of respirators and masks in preventing SARS-CoV-2 infection and the likelihood of experiencing adverse events (AEs) with wear are unclear. METHODS: Searches were carried out in PubMed, Europe PMC and the Cochrane COVID-19 Study Register to 14 June 2021. A systematic review of comparative epidemiological studies examining SARS-CoV-2 infection or AE incidence in HCWs wearing P2/N95 (or equivalent) respirators and surgical masks was performed. Article screening, risk of bias assessment and data extraction were duplicated. Meta-analysis of extracted data was carried out in RevMan. RESULTS: Twenty-one studies were included, with most having high risk of bias. There was no statistically significant difference in respirator or surgical mask effectiveness in preventing SARS-CoV-2 infection (OR 0.85, [95%CI 0.72, 1.01]). Healthcare workers experienced significantly more headaches (OR 2.62, [95%CI 1.18, 5.81]), respiratory distress (OR 4.21, [95%CI 1.46, 12.13]), facial irritation (OR 1.80, [95%CI 1.03, 3.14]) and pressure-related injuries (OR 4.39, [95%CI 2.37, 8.15]) when wearing respirators compared to surgical masks. CONCLUSION: The existing epidemiological evidence does not enable definitive assessment of the effectiveness of respirators compared to surgical masks in preventing infection. Healthcare workers wearing respirators may be more likely to experience AEs. Effective mitigation strategies are important to ensure the uptake and correct use of respirators by HCWs.

Be careful where you aim: craniomaxillofacial trauma from the utility of metal hammers.

PURPOSE: A hammer is a popular tool among the "do it yourself" (DIY) population who pursue home-improvement projects. While we are aware that hammers have health hazards, no study has yet to explore the craniomaxillofacial injuries that could arise from the use of hammers. The purpose of this study is to describe the characteristics of craniomaxillofacial injuries from hammers. MATERIALS AND METHODS: This is a 20-year cross-sectional study conducted using the National Electronic Injury Surveillance System (NEISS). Injuries from hammers were included in this study if they involved the head, face, eyeball, mouth, or ear. The study predictor was the mechanism of injury. The study outcome was the admission rate from the emergency department (ED) and anatomical site injured. Patient and injury characteristics were compared using chi-squared and independent sample tests. RESULTS: Our final sample had a total of 2967 hammer-induced injuries. Most of the sample consisted of white (55.3%) males (80.2%). Summer was the most injury-congested season (30.1%). The majority of the patients were over the age of 18 (65.6%). Laceration (47.3%) was the most common primary diagnosis, followed by contusion/abrasion (21.9%). The head (42.9%) was the most commonly injured craniomaxillofacial region followed by the face (29.0%). Craniomaxillofacial injury most frequently transpired at the patient's home (63.6%). Concerning the mechanism of injury, accidentally self-induced injuries with a hammer were the most common (32.4%). Patients who were injured from the debris were more likely (P < 0.01) to be admitted (7.6%) relative to patients who were not (2.5%). The head was most likely to get injured from a falling hammer (P < 0.01). The face was most likely to get injured through accidental self-injury (P < 0.01). The eyeball was most likely to get injured from debris (P < 0.01). The mouth was, similar to the face, most likely to get injured through accidental self-injury (P < 0.01). CONCLUSIONS: Craniomaxillofacial injuries secondary to hammers illustrated a predilection to the head. Hammer falling from a height was most likely to injure the head. Debris from hammer strikes was the most dangerous mechanism of injury and was most likely to injure the eyeball. Hence, the authors urge the use of protective gear for the head (i.e., helmet) and eyeball (i.e., glasses) when handling hammers for constructive purposes.

A qualitative descriptive inquiry into factors influencing early weaning and breastfeeding duration among first-time mothers in Papua New Guinea's rural eastern highlands.

BACKGROUND: Exclusive breastfeeding confers multiple maternal and child health benefits. Although breastfeeding initiation following birth is common in Papua New Guinea, many first-time mothers may not achieve optimal breastfeeding duration. AIM: This study aims to explore and describe factors influencing early weaning and breastfeeding duration among first-time mothers in Papua New Guinea's rural eastern highlands. METHODS: A qualitative descriptive approach was adopted in this study. Data were collected through semi-structured in-depth interviews with 20 first-time mothers. The interviews transcripts were then thematically analysed. RESULTS: Three key themes identified were: source of breastfeeding information and support; social networks and breastfeeding communication; and balancing perceived gender and maternal roles. The study further identified a lack of fathers' involvement in supporting breastfeeding. CONCLUSION: Social and relational networks, and maternal factors need to be considered to better understand breastfeeding practices. Efforts to achieve optimal breastfeeding outcomes entail targeted and culturally appropriate programs, including fathers' involvement as they play important roles in breastfeeding and infant feeding practices.

COVID-19 Pandemic and its Impact on Dentistry: A Cross-sectional Survey of Practicing Dentists.

AIM AND OBJECTIVE: The purpose of this study was to evaluate the economic impact and the dental practice changes associated with the coronavirus disease-2019 (COVID-19). MATERIALS AND METHODS: This was a cross-sectional survey conducted at the peak of the COVID-19 pandemic (May 2020). The study sample was derived from the Columbia University College of Dental Medicine Alumni network, which included the graduating classes between 1975 and 2015. Active dental practitioners were surveyed regarding changes to their current operations and protective safety measures through a 22 closed-ended questionnaire-based survey. RESULTS: The response rate was 17%. Nearly 70.92% of respondents laid off at least one staff member during the COVID-19 pandemic, 51.80% expressed fear of permanent closure, and 79.43% applied for a small business administration loan. There were no significant associations between the amount of time in practice and the need to lay off staff members, the fear of going out of business, or the rates of application for the small business administration loan. Many practitioners bought at least one device geared toward reducing COVID-19 transmission, such as ultraviolet (UV) lights (26.21%), extraoral suctions (37.31%), and high-efficiency particulate air (HEPA) air filters (54.55%). CONCLUSION: At the peak of the pandemic, the majority of dental providers had to reduce staff and seek financial assistance. Concurrently, many of these practices also invested in new safety equipment with the intention of reducing viral transmission. CLINICAL SIGNIFICANCE: External mouth suctions, commercial air purifiers, and air exchange devices might be useful in the private practice setting. However, financially strained practitioners should recognize that these devices have not currently been proven to be effective against the COVID-19 virus. How to cite this article: Cimilluca JJ, Lee KC, Halepas S et al. COVID-19 Pandemic and its Impact on Dentistry: A Cross-sectional Survey of Practicing Dentists. J Contemp Dent Pract 2021;22(5):473-478.

Understanding the impact and causes of 'failure to attend' on continuity of care for patients with chronic conditions.

AIM: To understand the impact and causes of 'Failure to Attend' (FTA) labelling, of patients with chronic conditions. BACKGROUND: Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended. METHOD: The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation. RESULTS: Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient's capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap. CONCLUSION: The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase 'Failure to Attend' has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase "appointment did not proceed" to replace FTA. IMPLICATIONS FOR NURSING MANAGEMENT: This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term 'appointment did not proceed.'

Examining the hurdles in defining the practice of Nurse Navigators.

BACKGROUND: Nurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care. PURPOSE: A critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident. DISCUSSION: Nurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance. CONCLUSION: Nurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.

Exploring the nurse navigator role: A thematic analysis.

BACKGROUND: Patients with complex chronic conditions experience fragmentation of care, unnecessary hospitalization and reduced quality of life, with an increased incidence of poor health outcomes. AIM(S): The aim of this paper was to explore how nurse navigators manage client care. This was achieved through an examination of narratives provided by the nurse navigator that evaluated their scope of practice. METHOD(S): All nurse navigators employed by Queensland Health were invited to participate in a study evaluating the effectiveness of the service. Eighty-four self-reported vignettes were thematically analysed to understand the work from the nurses' perspectives. RESULTS: Two themes emerged from the vignettes. Theme 1, the layers of complexity, is comprised of three sub-themes: the complex patient, the complex system and patient outcomes. Theme 2, professional attributes, has two sub-themes: person-centred care and clinical excellence. CONCLUSION: Navigators innovatively integrate services and address the fragmented nature of the health system. They apply expert clinical and social skills, through consistent and robust communication, to meet the needs of those with multiple chronic conditions. IMPLICATIONS FOR NURSING MANAGEMENT: Results provide insight into the new role, illuminating the work they achieve, despite system complexities.

The evaluation of nurse navigators in chronic and complex care.

AIM: With increasing age and chronicity in populations, the need to reduce the costs of care while enhancing quality and hospital avoidance, is important. Nurse-led co-ordination is one such model of care that supports this approach. The aim of this research was to assess the impact that newly appointed Navigators have on service provision; social and economic impact; nurses' professional quality of life and compassion fatigue; and analysis of the change that has occurred to models of care and service delivery. DESIGN: A concurrent mixed-method approach was selected to address the research aims. METHODS: The research project was funded in July 2018 and will conclude in December 2020. Several cohorts will be studied including; patients assigned to a navigator, patients not assigned to a navigator, family members of patients assigned a navigator; and a sample sized estimated at 140 navigators. DISCUSSION: This study provides a comprehensive international longitudinal and mixed method framework for evaluating the impact of nurse navigators on quality of care outcomes for patients with chronic conditions. IMPACT-WHAT PROBLEM WILL THE STUDY ADDRESS?: Even with specialty focused co-ordinated care, patients get lost in the system, increasing the incidence of non-compliance and exacerbation of condition. Navigators work with patients across service boundaries allowing for care that is patient responsive, and permitting variables in clinical, social and practical elements of care to be addressed in a timely manner. This novel nurse-led approach, supports hospital avoidance and patient self-management, while encouraging expansion and opportunity for the nursing and midwifery workforce.

Elderly man with mandibular pain.

CLINICAL INTRODUCTION: A 77-year-old man presented to the ED with a history of fevers, purulent drainage and right mandibular pain. He had been diagnosed with multiple myeloma 2 years previously and was receiving treatment with pamidronate. On presentation, the lower right lip and chin were anaesthetic, tooth number 31 had grade 2 mobility and a 15 mm long ulceration was present on the lingual aspect of the mandible (figure 1). Antibiotics were administered, and a maxillofacial CT without contrast was performed (figure 2).emermed;36/1/17/F1F1F1Figure 1Clinical examination revealing a 15 mm long ulceration (arrow mark) associated with the lingual aspect of tooth number 31.emermed;36/1/17/F2F2F2Figure 2CT maxillofacial (coronal) demonstrating osseous destruction (arrow mark) of the right mandibular body. QUESTION: What is your diagnosis?Odontogenic abscessBenign fibro-osseous lesionMedication-related osteonecrosis of the jaw (MRONJ)Metastatic malignancy.

Transitioning across professional boundaries in midwifery models of care: A literature review.

BACKGROUND: High-risk pregnancy, or one with escalating complexities, requires the inclusion of numerous health professions in care provision. A strategy of midwife navigators to facilitate the smooth transition across models of care and service providers has now been in place in Queensland, Australia, for over twelve months, and a formal review process will soon begin. Navigators are experienced nurses or midwives who have the expertise and authority to support childbearing women with chronic or complex problems through the health system so that it is co-ordinated and they can transition to self-care. This includes ensuring a logical sequence in tests and procedures, providing education, or facilitating access to specialist care. The navigator evaluation included a review of existing models of care that support women with chronic and complex needs during their pregnancy. This paper describes the integrative literature review that explored the transitioning of care models. METHODS: The review followed formal Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, utilised the Critical Appraisal Skills Program tools and analysed a final 33 papers, published from 2000 onwards in professional, peer-reviewed journals and databases. RESULTS/CONCLUSIONS: Four key themes of communication, context, visibility and frames were identified, discussed in depth, and considered in the current body of knowledge. The outcomes refer clearly to 'property rights' or turf protected by invisible fences and gatekeeping by midwives and other health professionals. This review may inform development of future frameworks and practice review to better address the needs of pregnant women.

Proficient global nucleotide excision repair in human keratinocytes but not in fibroblasts deficient in p53.

The p53 tumor suppressor protein is important for many cellular responses to DNA damage in mammalian cells, but its role in regulating DNA repair in human keratinocytes is undefined. We compared the nucleotide excision repair (NER) response of human fibroblasts and keratinocytes deficient in p53. Fibroblasts expressing human papillomavirus 16 E6 oncoprotein had impaired repair of UV radiation-induced cyclobutane pyrimidine dimers in association with reduced levels of p53 and XPC, which is involved in DNA damage recognition. In contrast, keratinocytes expressing E6 alone or concurrently with the E7 oncoprotein, while possessing reduced levels of p53 but normal levels of XPC, continued to repair pyrimidine dimers as efficiently as control cells with normal p53 levels. Despite preservation of DNA repair, E6 and E6/E7 keratinocytes were hypersensitive to UV radiation. E6 fibroblasts exhibited markedly reduced basal and induced levels of mRNA encoding DDB2, another protein implicated in early events in global NER. In contrast, E6 or E6/E7 keratinocytes possessed basal DDB2 mRNA levels that were not significantly altered relative to control cells, although little induction occurred following UV radiation. Intact global NER was also confirmed in SCC25 cells possessing inactivating mutations in p53 as well as in cells treated with pifithrin-alpha, a chemical inhibitor of p53 that decreased sensitivity of cells to UV radiation. Collectively, these results indicate that human keratinocytes, unlike fibroblasts, do not require p53 to maintain basal global NER activity, but p53 may still be important in mediating inducible responses following DNA damage.