Midwifery knowledge of equitable and culturally safe maternity care for Aboriginal women.

BACKGROUND: The Birthing on Noongar Boodjar project (NHMRC Partnership Project #GNT1076873) investigated Australian Aboriginal women and midwives' views of culturally safe care during childbearing. This paper reports on midwifery knowledge of Aboriginal women's cultural needs, their perceptions of health systems issues, and their ability to provide equitable and culturally safe care. METHOD: A qualitative study framed by an Indigenous methodology and methods which supported inductive, multilayered analyses and consensus-driven interpretations for two clinical midwife data groups (n = 61) drawn from a larger project data set (n = 145) comprising Aboriginal women and midwives. FINDINGS: Midwives demonstrated limited knowledge of Aboriginal women's cultural childbearing requirements, reported inadequate access to cultural education, substituted references to women-centered care in the absence of culturally relevant knowledge and consistently expressed racialized assumptions. Factors identified by midwives as likely to influence the midwifery workforce enabling them to provide culturally safe care for Aboriginal women included more professional development focused on improving understandings of cultural birth practices and health system changes which create safer maternal health care environments for Aboriginal women. CONCLUSIONS: Individual, workforce, and health systems issues impact midwives' capability to meet Aboriginal women's cultural needs. An imperative exists for effective cultural education and improved professional accountability regarding Aboriginal women's perinatal requirements and significant changes in health systems to embed culturally safe woman-centered care models as a means of addressing racism in health care.

Personalising haemodialysis treatment with incremental dialysis for incident patients with end-stage kidney disease: an implementation study protocol.

INTRODUCTION: Incremental dialysis is a personalised dialysis prescription based on residual kidney function that allows for the initial use of shorter duration, less frequent and less intense dialysis. It has been associated with enhanced quality of life and decreased healthcare costs when compared with conventional dialysis. While nephrologists report prescribing incremental dialysis, few dialysis programmes offer a systematic approach in offering and evaluating its use. To move evidence into practice, and in order to improve the safety and quality of providing incremental dialysis care, we have designed an implementation study. This study aims to evaluate the systematic assessment of patients starting facility-based haemodialysis for eligibility for incremental dialysis, and the prescription and monitoring of incremental dialysis treatment. METHODS AND ANALYSIS: A hybrid effectiveness and implementation study design is being used to evaluate the implementation of the programme at dialysis sites in Alberta, Canada. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to capture individual-level and organisational-level impact of the project. Clinical outcomes related to kidney function will be monitored on an ongoing basis, and patient-reported outcomes and experience measures will be collected at baseline and then quarterly throughout the first year of dialysis. ETHICS AND DISSEMINATION: The study was approved by the Health Research Ethics Board of the University of Alberta. The study is funded by the Strategic Clinical Networks of Alberta Health Services. The study will help answer important questions on the effectiveness of incremental dialysis, and inform the acceptability, adoption, feasibility, reach and sustainability of incremental dialysis within provision of haemodialysis care.

Development of a Standardized Bone Marrow Procedure Training and Competency Toolkit for Advanced Practice Providers in a Large Community Oncology Practice.

Bone marrow procedures are a common diagnostic tool utilized in hematology/oncology and can be completed in the office by trained clinicians. Currently, there are limited guidelines for appropriate training and competency for bone marrow procedures performed by advanced practice providers (APPs) in a community oncology practice setting. The need to create a standardized training and competency protocol for APPs in this setting was recognized. A comprehensive, standardized educational and procedural toolkit was created. The creation of a comprehensive training toolkit for APPs in the community oncology practice setting helps to ensure a high standard of procedural proficiency and consistency among individual providers and practices. The creation of such an extensive toolkit is time consuming. By adopting and standardizing toolkits such as this one, community hematology/oncology practices can ensure the delivery of high-quality patient care by highly trained and proficient APPs.

A multi-stage process to develop quality indicators for community-based palliative care using interRAI data.

BACKGROUND: Individuals receiving palliative care (PC) are generally thought to prefer to receive care and die in their homes, yet little research has assessed the quality of home- and community-based PC. This project developed a set of valid and reliable quality indicators (QIs) that can be generated using data that are already gathered with interRAI assessments-an internationally validated set of tools commonly used in North America for home care clients. The QIs can serve as decision-support measures to assist providers and decision makers in delivering optimal care to individuals and their families. METHODS: The development efforts took part in multiple stages, between 2017-2021, including a workshop with clinicians and decision-makers working in PC, qualitative interviews with individuals receiving PC, families and decision makers and a modified Delphi panel, based on the RAND/ULCA appropriateness method. RESULTS: Based on the workshop results, and qualitative interviews, a set of 27 candidate QIs were defined. They capture issues such as caregiver burden, pain, breathlessness, falls, constipation, nausea/vomiting and loneliness. These QIs were further evaluated by clinicians/decision makers working in PC, through the modified Delphi panel, and five were removed from further consideration, resulting in 22 QIs. CONCLUSIONS: Through in-depth and multiple-stakeholder consultations we developed a set of QIs generated with data already collected with interRAI assessments. These indicators provide a feasible basis for quality benchmarking and improvement systems for care providers aiming to optimize PC to individuals and their families.

Laboratory practices for manual blood film review: Results of an IQMH patterns of practice survey.

INTRODUCTION: Examination of a blood film is the second most common hematology test, after the complete blood count. Interpretation of a peripheral blood film by trained laboratory professionals provides valuable diagnostic information. The Institute for Quality Management in Healthcare (IQMH) Hematology Scientific Committee developed a questionnaire to gather information regarding current practices for manual blood film review and reporting from laboratories participating in IQMH Morphology proficiency testing (PT) surveys. METHODS: An online survey was distributed to 174 laboratories, 97% submitted results. RESULTS: Of the respondents, the majority (82%) indicated affiliation with small- or medium-sized hospitals (<500 beds). 80% of respondents had core laboratory technologists performing manual blood film reviews, while only 2% utilized dedicated hematology technologists with morphology expertise. All respondents had a policy for manual blood film review by a technologist, 70% did not have blood films reviewed by a senior/charge technologist prior to review by a physician. The majority (88%) of participants included morphological findings in their critical result list; of these, 98% include malaria and 88% include the first-time finding of blasts as critical results. 59% of participants indicated that they have a procedure in place to ensure that interpretation and confirmation of first-time potentially significant morphological findings are available from a physician at all times. CONCLUSION: This survey identified significant variation in blood film review and reporting practices across participating laboratories. The IQMH Hematology Scientific Committee will develop best practice recommendations to guide and standardize practice.

Advance care planning dashboard: quality indicators and usability testing.

OBJECTIVE: Advance care planning (ACP) and goals of care designation (GCD) performance indicators were developed and implemented across Alberta, Canada, and have been used to populate an electronic ACP/GCD dashboard. The study objective was to investigate whether users found the indicators and dashboard usable and acceptable. METHODS: This study employed a survey among a convenience sample of ACP/GCD community of practice members. The survey included questions on demographics, clinical practices and a validated usability questionnaire for the dashboard, System Usability Scale (SUS). RESULTS: Eighteen of 33 community of practice members (54.5%) answered the survey. Half of participants had a leadership or management role for ≥10 years. Most respondents (55.6%) had access to the ACP/GCD dashboard, and various ACP/GCD audit resources were used. Mean SUS was 70.83 (SD 19.72), which was above the threshold for acceptability (68). Approximately three-quarters of respondents (72.7%) found the indicators informative and meaningful for their practice, and over half (54.5%) were willing to use the dashboard and/or indicators to change their ACP/GCD practice. CONCLUSION: The nine indicators and dashboard were acceptable and usable for monitoring ACP/GCD performance. This set of indicators shows promise for describing and evaluating ACP/GCD uptake throughout a complex, multisector healthcare system.

Identification and operationalisation of indicators to monitor successful uptake of advance care planning policies: a modified Delphi study.

BACKGROUND: In 2014, the province of Alberta, Canada implemented a province-wide policy and procedures for advance care planning (ACP) and goals of care designation (GCD) across its complex, integrated public healthcare system. This study was conducted to identify and operationalise performance indicators for ACP/GCD to monitor policy implementation success and sustainment of ACP/GCD practice change. METHODS: A systematic review and environmental scan was conducted to identify potential indicators of ACP/GCD uptake (n=132). A purposive sample of ACP/GCD stakeholders was invited to participate in a modified Delphi study to evaluate, reduce and refine these indicators through a combination of face-to-face meetings and online surveys. RESULTS: An evidence-informed Donabedian by Institute of Medicine (IOM) framework was adopted as an organising matrix for the indicators in an initial face-to-face meeting. Three online survey rounds reduced and refined the 132 indicators to 18. A final face-to-face meeting operationalised the indicators into a measurable format. Nine indicators, covering 11 of the 18 Donabedian×IOM domains, were operationalised. CONCLUSIONS: Nine ACP/GCD evidence-informed indicators mapping to 11 of 18 Donabedian×IOM domains were endorsed, and have been operationalised into an online ACP/GCD dashboard. The indicators provide a characterisation of ACP/GCD uptake that could be generalised to other healthcare settings, measuring aspects related to ACP/GCD documentation, patient satisfaction and agreement between medical orders and care received. The final nine indicators reflect the stakeholders' expressed intent to strike a balance between comprehensiveness and feasibility within a large provincial healthcare system.

Guidance for quality control practices and precision goals for CBCs based on IQMH patterns-of-practice survey.

INTRODUCTION: Effective medical laboratory quality management systems ensure confidence in analyzing and reporting accurate and reliable patient results. To guarantee quality assurance, each laboratory needs appropriate internal quality control (IQC) procedures to monitor their test systems. The Institute for Quality Management in Healthcare (IQMH) Centre for Proficiency Testing conducted a survey on quality control (QC) practices in routine hematology. METHODS: An online survey was sent to 184 Ontario laboratories performing complete blood counts (CBC) and leukocyte differentials. RESULTS: All participants used three levels of commercial QC for test system monitoring. Eighty percent of laboratories supplement with in-house patient QC. The frequency of QC analysis was variable based on: Manufacturer recommendations (80%) Parameter stability (25%) Clinical impact of incorrect results (21%) Number of samples potentially requiring retesting if there is a QC failure (11%). All laboratories used established QC rules and limits to monitor results. They utilized various methods in establishing limits including: Standard deviation of QC results (60%) Manufacturer precision goals (55%) Published precision goals (24%) IQMH allowable performance limits (APLs) (37%). CONCLUSION: Considerable variation in QC practices of Ontario laboratories was identified, and consensus practice recommendations and precision goals were developed to guide and standardize QC practice.

Advance care planning discussions among residents of long term care and designated assisted living: experience from Calgary, Alberta.

OBJECTIVES: Patients, physicians and the healthcare system are faced with the challenge of determining, and respecting, the medical wishes of an aging population. Our study sought to describe who participates in advance care planning (ACP) and decision-making for patients in long-term care and designated assisted living. METHODS: In 2008, Alberta Health Services initiated its 'Advance Care Planning: Goals of Care Designation' (Adult) policy in the Calgary zone. This policy encouraged discussions about goals of care and used a tracking form to capture these conversations. A postpolicy implementation chart review was performed at 3 time points: at baseline, at 6 months and at 18 months post implementation in long term care (LTC) and designated assisted living sites. RESULTS: 166 charts were reviewed and 90% had a documented goals of care order. Less than half of residents (47%) were documented as participating in conversations and they were less likely to participate if they had cognitive impairment and were living in LTC. Documented family participation was more prevalent in LTC (51% vs 11%). Nurses participated in 67% of documented conversations with only 34% of discussions documenting physician involvement. CONCLUSIONS: This study identifies the lack of documented resident participation in ACP in LTC. While this finding may be explained by the high prevalence of cognitive impairment in our population, it raises questions about the optimal approach to ACP in LTC. In this setting, ACP appears to be more about relational autonomy than it is about patient autonomy.

Western Australia facing critical losses in its midwifery workforce: a survey of midwives' intentions.

OBJECTIVE: the ongoing attrition of the midwifery workforce frustrates future workforce planning and the provision of maternity services in Western Australia. This project determined factors contributing to the intention of the midwives to move jobs and/or leave the profession. DESIGN: a cross-sectional survey approach was taken for this descriptive research utilising a self-administered questionnaire developed by the Nursing and Midwifery Office, Department of Health, Western Australia. SETTING: public and private health sectors in Western Australia, April-May 2010. PARTICIPANTS: 1,600 midwives employed in the public and private health sectors throughout Western Australia were invited to participate: 712 responded (44.5%), one-fifth of the state's registered midwives. FINDINGS: most midwives worked part-time in a clinical role in public hospitals. Almost half intended moving jobs within 5 years and/or leaving midwifery. Excluding midwives of retirement age, the most common reasons for intending to move jobs were family commitments, working conditions and role dissatisfaction. Those intending to leave midwifery cited work-life balance, career change and family commitments. Midwives thought addressing the following issues would improve midwifery retention: flexible work arrangements, remuneration, staffing and caseload, workplace culture, professional development and models of care. KEY CONCLUSIONS: retaining the midwifery workforce requires attention to workforce practices particularly flexible work arrangements and workloads; models of care to strengthen midwives' relationships with clients and colleagues; and accessible professional development. IMPLICATIONS FOR PRACTICE: a review of workplace practices at unit and institution levels is urgently required in Western Australia so that midwives can achieve work-life balance and practice to the full extent of their professional role. These changes are necessary to forestall premature retirement of skilled and experienced midwives from the profession and workforce churn.

A qualitative analysis of the content of telephone calls made by women to a dedicated 'Next Birth After Caesarean' antenatal clinic.

BACKGROUND: The 'Next Birth After Caesarean' (NBAC) clinic is a dedicated service for women who have had a previous caesarean section. The midwifery-led clinic commenced at a tertiary hospital in Western Australia in 2008. As part of this service, access to a midwife via telephone is available. AIM: This paper aims to provide maternity health care providers with an increased understanding of, and insight into, the different information needs of this specific group of maternity care consumers. METHODS: A qualitative descriptive approach was used to analyse the content of 170 telephone calls made by women to the NBAC clinic over a period of 16 months (July 2008-November 2009). RESULTS: Six distinct categories of calls were elicited from the analysis process with the majority of calls related to women seeking information and support about the option of vaginal birth after caesarean (VBAC). These were labeled: 'Wanting and seeking a VBAC'; 'Is VBAC a possiblility?'; 'Seeking clarification and cross-checking information in the face of opposition'; 'Existing NBAC clients checking in/checking out'; 'Feeling distressed and disappointed; wanting to talk' and 'Professional inquiry about NBAC service'. DISCUSSION: It is acknowledged that women require access to non-biased information to be able to make informed decisions about birth after caesarean. However there remains limited evidence on the precise informational needs of these women. It appears from our findings that this particular group of maternity service consumers requires opportunities to discuss their particular needs within the context of their individual childbearing experiences. CONCLUSION: Preliminary evidence is provided that a telephone service led by midwives may be one effective strategy to meet women's informational needs and address decisional conflict in relation to options for birth after a caesarean section.

Message retrieval for survivors of traumatic brain injury.

Survivors of traumatic brain injury often lose their ability to use natural speech to communicate and then rely on augmentative and alternative communication (AAC) devices. Survivors may also have concomitant cognitive communication disorders that negatively impact memory and organization skills. AAC devices need to incorporate a word retrieval organization strategy that is fast and effective. The current study compared the conditions of topic, place, and alphabet for message recognition. The participants were asked a delayed recall question to elicit a communicative response. Results showed that alphabet is significantly more accurate than place and significantly faster than place and topic. However, participants chose to retrieve words using all three strategies.

Post-choice information processing by pigeons.

In a conditional discrimination (matching-to-sample), a sample is followed by two comparison stimuli, one of which is correct, depending on the sample. Evidence from previous research suggests that if the stimulus display is maintained following an incorrect response (the so-called penalty-time procedure), acquisition by pigeons is facilitated. The present research tested the hypothesis that the penalty-time procedure allows the pigeons to review and learn from the maintained stimulus display following an incorrect choice. It did so by including a penalty-time group for which, following an incorrect choice, the sample changed to match the incorrect comparison, thus providing the pigeons with post-choice 'misinformation.' This misinformation group acquired the matching task significantly slower than the standard penalty-time group (that had no change in the sample following an error). Furthermore, acquisition of matching by a control group that received no penalty time fell midway between the other two groups, suggesting that the pigeons did not merely take more care in making choices because of the aversiveness of penalty-time. Thus, it appears that in the acquisition of matching-to-sample, when the stimulus display is maintained following an incorrect choice, the pigeons can review or acquire information from the display. This is the first time that such an effect has been reported for a nonhuman species.

Evidence for shared recognition of a peptide ligand by a diverse panel of non-obese diabetic mice-derived, islet-specific, diabetogenic T cell clones.

MHC class II-restricted autoreactive T cells play a major role in the development of autoimmune diabetes mellitus in both human and mouse. Two of our groups previously established panels of islet-reactive CD4+ T cell clones from prediabetic non-obese diabetic (NOD) mice. These clones express distinct sets of TCR V alpha , V beta , J alpha and J beta , and also differ in the structure of the junctional region of TCR. All of the T cell clones have been shown to cause insulitis and several induce diabetes when transferred to various recipients. The antigen specificities of these T cell clones have not been determined, but they do not react with defined islet cell antigens such as glutamic acid decarboxylase. To identify the peptide ligands recognized by these clones, we examined the reactivity of the T cell clones to peptide mixtures in which anchor residues for H2-A g7 were fixed. Most of the clones showed similar reactivity to the peptide mixtures. To further determine the peptide ligands of the T cell clones, we synthesized several peptides based on the favored amino acid motifs and examined clone reactivity to the synthetic peptides. Some of the peptides, e.g. HLAI-RM and HIPI-RM, could stimulate most of the T cell clones tested, even though the clones expressed different TCR. The results suggest that our islet-reactive T cell clones recognize in islet beta cells a natural ligand that is similar to these peptides.

The hph-1 mouse: a model for dominantly inherited GTP-cyclohydrolase deficiency.

Dominantly inherited guanosine triphosphate (GTP)-cyclohydrolase deficiency, otherwise known as Segawa's disease or dopa-responsive dystonia, has a wide spectrum of phenotypic expression ranging from asymptomatic to very severe. Penetrance is more frequent in women as compared with men, and there is a variable occurrence of diurnal variation in symptom intensity. Biochemical characterization of the disease has demonstrated lower cerebrospinal fluid levels of tetrahydrobiopterin (BH4), neopterin, and homovanillic acid and low levels of tyrosine hydroxylase protein in the striatum. To investigate the pathophysiology, we have begun to characterize biogenic amine and BH4 metabolism in the GTP cyclohydrolase deficient hph-1 mouse. The data show low brain levels of BH4, catecholamines, serotonin, and their metabolites together with low levels of tyrosine hydroxylase protein within the striatum. The hph-1 mouse therefore provides a good model system in which to study the human disease.