Responding to catastrophe: A case study of learning from perinatal death in midwifery practice.

PROBLEM/BACKGROUND: Perinatal death has far reaching emotional effects for all involved in this devastating event. The opportunity for learning as a result of this catastrophe, however, remains unexplored. AIM: To explore midwives' experiences of caring through, and learning from, perinatal death, to better inform the effective planning and delivery of education that optimises both midwifery and self-care. METHODS: A naturalistic interpretive multiple case study design. Seventeen midwives, located in Australia, participated in an online group activity hosted as a blog, followed by telephonic focus groups and in-depth email interviews. FINDINGS: Thematic data analysis revealed seven major themes: Grappling with the reality of perinatal death; Struggling with personal and professional heartache; Seeking the space to grieve as a professional; Being with the woman and her family; Finding a new purpose; Strengthened through support; and Developing the courage to care. DISCUSSION: The initial turmoil and impact of loss reflected the catastrophic nature of perinatal death. Midwives uncovered a journey to acceptance and learning, realising a determination to enhance expertise and discovering value in experiential knowledge. Insecurity regarding competence and confidence to manage perinatal death and bereavement care was highlighted. However, sharing their stories revealed professional fulfilment, personal strength, and solidarity amongst midwives who have endured similar experiences. CONCLUSION: A coordinated approach to support and the dissemination of experiential knowledge and learning could be developed within an online model of narrative sharing and discussion. Debriefing, support and sharing of expertise in this way may foster engagement within and beyond the workplace.

How do we facilitate international clinical placements for nursing students: A cross-sectional exploration of the structure, aims and objectives of placements.

BACKGROUND: International clinical placements provide undergraduate students with a unique and complex clinical learning environment, to explore cultural awareness, experience different health care settings and achieve clinical competencies. Higher education institutions need to consider how to structure these placements to ensure appropriate and achievable aims and learning outcomes. OBJECTIVES: In this study we described the structure, aims and learning outcomes associated with international clinical placement opportunities currently undertaken by Australian undergraduate nursing students in the Asia region. PARTICIPANTS: Forty eight percent (n = 18) of the institutions invited responded. Eight institutions met the inclusion criteria, one of which offered three placements in the region, resulting in 10 international placements for which data were provided. METHODS: An online survey tool was used to collect data during August and September 2015 on international clinical placements conducted by the participating universities. Descriptive data on type and numbers of placements is presented, along with results from the content analysis conducted to explore data from open ended questions on learning aims and outcomes. RESULTS: One hundred students undertook 10 International Clinical Placements offered in the Asian region by eight universities. Variations across placements were found in the length of placement, the number of students participating, facilitator to student ratios and assessment techniques used. Five categories related to the aims of the programs were identified: 'becoming culturally aware through immersion', 'working with the community to promote health', 'understanding the role of nursing within the health care setting', 'translating theory into professional clinical practice', and 'developing relationships in international learning environments'. Four categories related to learning outcomes were identified: 'understanding healthcare and determinants of health', 'managing challenges', 'understanding the role of culture within healthcare' and 'demonstrating professional knowledge, skills and behaviour'. CONCLUSIONS: International clinical placements in the Asia region appear to vary greatly from one education institution to the next with no clear consensus from either this study's findings or the literature on which structure, support and assessments lead to greater student learning.

Aggression and violence in healthcare and its impact on nursing students: A narrative review of the literature.

Aggression and violence is a significant social problem in many countries and an increasing problem in healthcare settings in which nurses are particularly vulnerable. The literature suggests that aggression and violence has a significant negative impact upon nurses and potentially upon nursing students and can result in these staff members experiencing stress as a direct result of these adverse events. The literature suggests that there is confusion over what constitutes aggression and violence in the workplace and therefore a true lack of understanding of the scale of the problem relating to nursing students. This review proposes that nursing students are indeed at significant risk of aggression and violence in the clinical setting which has the potential to significantly impact their role as a novice carer. Furthermore, aggression and violence can manifest negative stress responses in individuals, therefore, the potential for nursing students to cope with stressful situations shall be presented.

International clinical placements for Australian undergraduate nursing students: A systematic thematic synthesis of the literature.

OBJECTIVES: International clinical placements provide undergraduate nursing students with the opportunity to experience or practice nursing care in diverse countries, settings, and cultures. This systematic review aims to ascertain the current knowledge on international clinical placements offered by undergraduate nursing programs in Australia. It seeks to explore three questions: (1) How have previous experiences of nursing students' international clinical placements been described? (2) How have participants and stakeholders determined if the placement has been successful? And (3) What benefits or challenges have been identified by stakeholders as a result of participating in international clinical placements? DESIGN: A systematic thematic synthesis was undertaken. DATA SOURCES: A search of electronic databases including CINAHL, Proquest Central, Scopus, PubMed, and Health Collection was undertaken between September and October 2014. REVIEW METHODS: Key terms including 'international clinical placement', 'study abroad', 'international exchange', 'nursing', and 'Australia' were used to identify articles that appeared in peer-reviewed English language journals and that explored international clinical placements offered to undergraduate nursing students by Australian universities. RESULTS: Eight studies were identified that meet the inclusion criteria, and through thematic analysis, five key themes were identified including developing cultural awareness and competence, providing a global perspective on health care, translation of theory to practice, growing personally through reflection, and overcoming apprehension to successfully meet the challenge. A comparison search of literature from Canada and the United Kingdom revealed that similar themes occurred internationally. CONCLUSIONS: Although personal successes were identified by students undertaking international clinical placement, further research is required to identify all stakeholder experiences including those of the educators, the educational institutions, and travel providers supporting these placements and the communities where the placements take place.

Prevalence and characteristics of aggression and violence experienced by Western Australian nursing students during clinical practice.

AIM: To identify the prevalence and characteristics of aggression and violence experienced by undergraduate nursing students in the clinical setting. METHOD: A cross sectional survey of second (N = 97) and third (N = 56) year nursing students in a Western Australian University was conducted. Data were analysed using frequencies, percentages and means (standard deviation) and independent samples t-test for between group differences. RESULTS: Over 58% (N = 55) of second year and 57% (N = 32) of third year nursing students experienced some kind of non-physical violence. Various forms of physical violence were also reported by over a third (N = 33) of the second year and 25% (N = 18) of the third year nursing students. CONCLUSION: This study has identified nursing students are exposed to, and feel at significant risk of, aggression and violence in the clinical setting. Providing them with an appropriate level of knowledge and self-confidence to assist in the management of the threat and actuality of such incidents is essential.

Perceived changes in the knowledge and confidence of doctors and midwives to manage obstetric emergencies following completion of an Advanced Life Support in Obstetrics course in Australia.

BACKGROUND: The Advanced Life Support in Obstetrics (ALSO) course is an internationally recognised interprofessional course to support health professionals to develop and maintain the knowledge and skills to manage obstetric emergencies. AIMS: This study investigated changes in confidence and perceived changes in the knowledge of doctors and midwives to manage specific obstetric emergency situations following completion of an ALSO course in Australia. METHODS: A prospective repeated-measures survey design was used to survey 165 course attendees from four Australian states pre- and postcourse and at six weeks (n = 101). Data were analysed using a Friedman two-way repeated-measures analysis of variance and the Wilcoxon signed rank test. RESULTS: There was a significant improvement in confidence and perceived knowledge of the recommended management of all 17 emergency situations immediately postcourse (P < 0.001) and at six weeks postcourse (P < 0.001) when compared to precourse levels for both groups of health professionals. However, a significant decrease in knowledge and confidence for many emergency situations from immediately postcourse to six weeks postcourse (P < 0.05) was also observed in both groups. CONCLUSIONS: Completion of the Australian ALSO course in Australia has a positive effect on the confidence and perceived knowledge of doctors and midwives to manage obstetric emergencies. However, there needs to be some means of reinforcing the effects of the course for longer term maintenance of knowledge and confidence.

Analysis of the ethical issues in the breastfeeding and bedsharing debate.

Recommendations advising against mothers and their infants sharing a bed during sleep (bedsharing) have sparked heated debate in recent years, the effects of which are that bedsharing is now most often only considered in the polarised contexts of being either 'the norm' or 'inherently unsafe'. This has resulted in significant tensions between supporters of bedsharing and public health bodies who seek to eliminate the risks associated with SIDS. This paper considers the issues surrounding this debate by examining the evidence associated with bedsharing, SIDS and breastfeeding. This is undertaken using Baum's six-step framework for analysing potential ethical tensions in public health policy, which includes the principles of utility, evidence base and effectiveness of action, fairness, accountability, costs and burdens, and community acceptance. This framework has allowed us to examine the competing principles involved in the bedsharing and breastfeeding debate, and arrive at a position constructed using ethical considerations.

Relationships between post operative pain management and short term functional mobility in total knee arthroplasty patients with a femoral nerve catheter: a preliminary study.

BACKGROUND: Effective pain management following total knee arthroplasty (TKA) is fundamental in achieving positive rehabilitation outcomes. The purpose of our study was to investigate post operative pain management in relation to short term functional mobility in an intervention group receiving concomitant use of an IV narcotic PCA and a continuous infusion of local anaesthetic via a femoral nerve catheter (CFNC), compared to a group receiving narcotic PCA alone. This was a preliminary study conducted to establish an appropriate design for a larger investigative study. METHODS: A prospective design was used to measure the effect of a CFNC on post operative pain management and functional mobility prior to hospital discharge. The amount of fentanyl used, pain and nausea scores, timed up and go (TUG) tests and active range of knee movement (AROM) were used to compare a CFNC and supplemental narcotic patient controlled analgesia (PCA) group (n = 27) with a PCA only group (n = 25). RESULTS: The CFNC group used significantly less fentanyl than the PCA only group (p < .001) but there was no significant difference in TUG times between the two groups. There was however a significantly lower AROM reported for both extension (p < .04) and flexion (p < .006,) in the FNC group. Women had significantly slower TUG times (p < .005,) and there were moderate to strong positive correlations between post operative TUG times and the preoperative TUG time (r(s) = .505 p < .001), the time since oral analgesia (r(s) = .529 p < .014), and pain scores (r(s) = .328, p = .034) CONCLUSIONS: In this small preliminary study improved TUG performance at Day 4 post op was not influenced by the use of a CFNC but was positively correlated with male gender, preoperative performance, time elapsed since last oral analgesia and pain score. However AROM was decreased in the CFNC group suggesting further research on the relationship between CFNCs, local anaesthetic concentration and quadriceps strength should be incorporated in the follow up study's design.

Excretion of lactose in urine as a measure of increased permeability of the lactating breast during inflammation.

HYPOTHESIS: The increased excretion of lactose in urine will be an accurate predictor of increased breast permeability during inflammation of the breast and therefore could predict whether there is a relationship between the severity and type of symptoms suffered during mastitis and changes in breast permeability. METHODS: Twenty-six mothers were followed prospectively from Day 5 postpartum to the end of their lactation. Milk from each breast, blood, 24-hour urine samples, and data on breast and systemic pathologies were collected at reference intervals during the first three months postpartum, daily during the occurrence of any breast inflammation and 7 days after resolution of symptoms. RESULTS: The 24-h excretion of lactose in urine was higher during mastitis (p < 0.001), peaking at the commencement of the mastitis and decreasing over time until there was no significant difference at the time of follow-up when compared to mothers without mastitis (p < 0.25). The changes in lactose in urine were consistent with the changes in sodium, chloride, and lactose in milk, confirming milk expressed for sample analysis was representative of milk from the site of inflammation. Increased severity of breast symptoms experienced during mastitis was a significant predictor for an increased excretion of lactose in urine (p < 0.022). CONCLUSIONS: The use of 24-h excretion of lactose in urine provided a reliable marker of changes occurring in breast permeability and subsequently has shown that an increasing area of inflammation of the breast was predictive of an increase in breast permeability and associated changes in milk composition.

Severity of mastitis symptoms as a predictor of C-reactive protein in milk and blood during lactation.

OBJECTIVE: To investigate the presence of C-reactive protein (CRP) in breast milk and any relationship between changes in CRP in breast milk and blood, and the severity of systemic and breast symptoms experienced during mastitis. METHODS: Mothers (n = 26) were followed prospectively from day 5 postpartum to the end of their lactation. Milk from each breast, blood, 24-hour urine samples and data on breast and systemic pathologies were collected at reference intervals during the first 3 months postpartum, daily during the occurrence of any breast inflammation and at 7 days after resolution of symptoms. RESULTS: CRP in blood was significantly increased during mastitis (p < 0.001, df:1,81; F = 31) and severity of systemic symptoms was a significant predictor for changes of CRP in blood (p < 0.01; df:3,42; F = 9.6). During mastitis both the symptomatic breast (p < 0.001; df:1,79; F = 19) and the contralateral asymptomatic breast (p < 0.004; df:1,75; F = 8.7) had a significantly higher milk CRP when compared with women with no mastitis. CONCLUSIONS: Although an increasing severity of breast and systemic symptoms in mastitis was predictive of an increasing CRP in milk and blood, respectively, the presence of CRP in similar concentrations in the mastitis and asymptomatic breast suggests it is of little use in making a differential diagnosis between infective verses noninfective forms of mastitis.

Relationships between symptoms and changes in breast physiology during lactation mastitis.

OBJECTIVE: The objective was to investigate changes in milk composition that reflect variations in breast permeability, milk synthesis, and immune response in women before, during, and after mastitis. METHODS: Mothers (n = 26) were followed prospectively from day 5 postpartum to the end of their lactation. Milk from each breast, blood, 24-hour urine samples, and data on breast and systemic pathologies were collected at reference intervals during the first 3 months postpartum, daily during the occurrence of any breast inflammation, and 7 days after resolution of symptoms, and was analyzed using mixed-model analysis (repeated measures). RESULTS: There was a significant difference in sodium (p < 0.001), chloride (p < 0.001), serum albumin (p < 0.02) and lactose (p < 0.003) in the breast with mastitis when compared with both the contralateral asymptomatic breast and "healthy" breasts. Inflammation of the whole breast was a significant predictor for a decreased glucose (p < 0.01) and hyperacute systemic symptoms predicted a decrease in milk glucose (p < 0.03) and an increased lactoferrin (p < 0.05) and sIgA (p < 0.03). CONCLUSIONS: There is an increased breast permeability, reduced milk synthesis, and increased concentration of the immune components sIgA and lactoferrin with increasing severity of breast and systemic symptoms. The changes observed in milk composition during periods of increased breast permeability cannot be solely explained by the current theory of permeability of the paracellular pathway and further research in this area is required.