Development and validation of a pregnancy symptoms inventory

BACKGROUND. Physical symptoms are common in pregnancy and are predominantly associated with normal physiological changes. These symptoms have a social and economic cost, leading to absenteeism from work and additional medical interventions. There is currently no simple method for identifying common pregnancy related problems in the antenatal period. A validated tool, for use by pregnancy care providers would be useful. AIM: The aim of the project was to develop and validate a Pregnancy Symptoms Inventory for use by healthcare professionals (HCPs). METHODS: A list of symptoms was generated via expert consultation with midwives and obstetrician gynaecologists. Focus groups were conducted with pregnant women in their first, second or third trimester. The inventory was then tested for face validity and piloted for readability and comprehension. For test-re-test reliability, it was administered to the same women 2 to 3 days apart. Finally, outpatient midwives trialled the inventory for 1 month and rated its usefulness on a 10cm visual analogue scale (VAS). The number of referrals to other health care professionals was recorded during this month. RESULTS: Expert consultation and focus group discussions led to the generation of a 41-item inventory. Following face validity and readability testing, several items were modified. Individual item test re-test reliability was between .51 to 1 with the majority (34 items) scoring .0.70. During the testing phase, 211 surveys were collected in the 1 month trial. Tiredness (45.5%), poor sleep (27.5%) back pain (19.5%) and nausea (12.6%) were experienced often. Among the women surveyed, 16.2% claimed to sometimes or often be incontinent. Referrals to the incontinence nurse increased > 8 fold during the study period. The median rating by midwives of the ‘usefulness’ of the inventory was 8.4 (range 0.9 to 10). CONCLUSIONS: The Pregnancy Symptoms Inventory (PSI) was well accepted by women in the 1 month trial and may be a useful tool for pregnancy care providers and aids clinicians in early detection and subsequent treatment of symptoms. It shows promise for use in the research community for assessing the impact of lifestyle intervention in pregnancy.

Transitioning to practice across the professions : some lessons from the teaching profession

Across the professions, there is strong interest in the transition between graduation and early stages of professional practice. Our initial literature search revealed that this period of transition is significant to professions that include nursing, vets, midwives, financial planners, lawyers, occupational therapists, doctors as well as our particular area of interest - teachers. This importance is easy to understand for in these applied fields new graduates need to be competent in applying and synthesizing their theoretical content knowledge on a daily basis, often with limited supervision and mentoring (Goetz, Tombs & Hampton, 2005). As such, this transition period is of critical importance to the individual and their feelings of competence and early profession learning. An added layer for graduates in these professions during this transition/probation period is that they are also expected to have well-developed 'soft skills' such as communication, problem solving, and teamwork (Oblinger & Verville, 1998; Rao & Sylvester, 2000) in order to be effective in their roles.

Women's perceptions of their healthcare experience when they choose not to breastfeed

Research Question How do women who choose not to breastfeed perceive their healthcare experience? Method This qualitative research study used a phenomenographic approach to explore the healthcare experience of women who do not breastfeed. Seven women were interviewed about their healthcare experience relating to their choice of feeding, approximately four weeks after giving birth. Six conceptions were identified and an outcome space was developed to demonstrate the relationships and meaning of the conceptions in a visual format. Findings There were five unmet needs identified by the participants during this study. These needs included equity, self sufficiency, support, education and the need not to feel pressured. Conclusion Women in this study who chose not to breastfeed identified important areas where they felt that their needs were not met. In keeping with the Code of Ethics for Nurses and Midwives, the identified needs of women who do not breastfeed must be addressed in a caring, compassionate and just manner. The care and education of women who formula feed should be of the highest standard possible, even if the choice not to breastfeed is not the preferred choice of healthcare professionals.

Screening for alcohol and drug use in pregnancy

Objective - this study examined the clinical utility and precision of routine screening for alcohol and other drug use among women attending a public antenatal service. Study design - a survey of clients and audit of clinical charts. Participants and setting - clients attending an antenatal clinic of a large tertiary hospital in Queensland, Australia, from October to December 2009. Measurements and findings - data were collected from two sources. First, 32 women who reported use of alcohol or other drugs during pregnancy at initial screening were then asked to complete a full substance use survey. Second, data were collected from charts of 349 new clients who attended the antenatal clinic during the study period. Both sensitivity (86%, 67%) and positive predictive value (100%, 92%) for alcohol and other drug use respectively, were high. Only 15% of surveyed women were uncomfortable about being screened for substance use in pregnancy, yet the chart audit revealed poor staff compliance. During the study period, 25% of clients were either not screened adequately or not at all. Key conclusions and implications for practise - despite recommended universal screening in pregnancy and the apparent acceptance by our participants, alcohol and other drug (A&OD) screening in the antenatal setting remains problematic. Investigation into the reasons behind, and ways to overcome, the low screening rate could improve health outcomes for mothers and children in this at-risk group. Targeted education and training for midwives may form part of the solution as these clinicians have a key role in implementing prevention and early intervention strategies.

Pregnancy as public property: The experience of couples following diagnosis of a foetal anomaly

Background: Pregnant women find themselves subject to comments and questions from people in public areas. Normally, becoming ‘public property’ is considered friendly and is relatively easy for pregnant women to deal with. However, following diagnosis of a fetal anomaly, the experience of being public property can exacerbate the emotional turmoil experienced by couples. Original research question: What is the experience of couples who continue pregnancy following the diagnosis of a fetal anomaly? Method: The study used an interpretive design informed by Merleau-Ponty and this paper reports on a subset of findings. Thirty-one interviews with pregnant women and their partners were undertaken following the diagnosis of a serious or lethal fetal anomaly. Women were between 25 and 38 weeks gestation at the time of their first interview. The non-directive interviews were audiotaped, transcribed verbatim and the transcripts were thematically analysed. Findings: A prominent theme that emerged during data analysis was that pregnancy is embodied therefore physically evident and ‘public’. Women found it difficult to deal with being public property when the fetus had a serious or lethal anomaly. Some women avoided social situations; others did not disclose the fetal condition but gave minimal or avoidant answers to minimise distress to themselves and others. The male participants were not visibly pregnant and they could continue life in public without being subject to the public’s gaze, but they were very aware and concerned about its impact on their partner. Conclusion: The public tend to assume that pregnancy is normal and will produce a healthy baby. This becomes problematic for women who have a fetus with an anomaly. Women use strategies to help them cope with becoming public property during pregnancy. Midwives can play an important role in reducing the negative consequences of a woman becoming public property following the diagnosis of a fetal anomaly.

Delineating the practice profile of advanced practice nursing : a cross-sectional survey using the modified strong model of advanced practice

AIMS: To test a model that delineates advanced practice nursing from the practice profile of other nursing roles and titles. BACKGROUND: There is extensive literature on advanced practice reporting the importance of this level of nursing to contemporary health service and patient outcomes. Literature also reports confusion and ambiguity associated with advanced practice nursing. Several countries have regulation and delineation for the nurse practitioner, but there is less clarity in definition and service focus of other advanced practice nursing roles. DESIGN: A statewide survey. METHODS: Using the modified Strong Model of Advanced Practice Role Delineation tool, a survey was conducted in 2009 with a random sample of registered nurses/midwives from government facilities in Queensland, Australia. Analysis of variance compared total and subscale scores across groups according to grade. Linear, stepwise multiple regression analysis examined factors influencing advanced practice nursing activities across all domains. RESULTS: There were important differences according to grade in mean scores for total activities in all domains of advanced practice nursing. Nurses working in advanced practice roles (excluding nurse practitioners) performed more activities across most advanced practice domains. Regression analysis indicated that working in clinical advanced practice nursing roles with higher levels of education were strong predictors of advanced practice activities overall. CONCLUSION: Essential and appropriate use of advanced practice nurses requires clarity in defining roles and practice levels. This research delineated nursing work according to grade and level of practice, further validating the tool for the Queensland context and providing operational information for assigning innovative nursing service.

Preceptorship : making a difference

A preceptor project at the Royal Brisbane and Women's Hospital in Queensland, Australia, explored existing levels of preceptorship support during the transition processes of newly employed or transferred nurses and midwives. Initiatives adopted have enhanced the implementation and maintenance of preceptorship principles and communication processes and defined accountability and responsibilities. Outcomes have contributed to enhanced role clarity, improved communication, increased support for teaching and learning, and infrastructure processes to facilitate the preceptor-preceptee relationship and increased retention.

Advanced practice nursing role development : factor analysis of a modified role delineation tool

Aim his study reports the use of exploratory factor analysis to determine construct validity of a modified advanced practice role delineation tool. Background Little research exists on specific activities and domains of practice within advanced practice nursing roles, making it difficult to define service parameters of this level of nursing practice. A valid and reliable tool would assist those responsible for employing or deploying advanced practice nurses by identifying and defining their service profile. This is the third paper from a multi-phase Australian study aimed at assigning advanced practice roles. Methods A postal survey was conducted of a random sample of state government employed Registered nurses and midwives, across various levels and grades of practice in the state of Queensland, Australia, using the modified Advanced Practice Role Delineation tool. Exploratory factor analysis, using principal axis factoring was undertaken to examine factors in the modified tool. Cronbach’s alpha coefficient determined reliability of the overall scale and identified factors. Results There were 658 responses (42% response rate). The five factors found with loadings of ≥.400 for 40 of the 41 APN activities were similar to the five domains in the Strong model. Cronbach’s alpha coefficient was .94 overall and for the factors ranged from 0.83 to 0.95. Conclusion Exploratory factor analysis of the modified tool supports validity of the five domains of the original tool. Further investigation will identify use of the tool in a broader healthcare environment.

Aromatherapy for postoperative nausea and vomiting

Background: Postoperative nausea and vomiting is one of the most common adverse reactions to surgery and all types of anaesthesia and despite the wide variety of available antiemetic and anti-nausea treatments, 20-30% of all patients still suffer moderate to severe nausea and vomiting following general anaesthesia. While aromatherapy is well-known and is used personally by nurses, it is less well utilised in the healthcare setting. If aromatherapy is to become an accepted adjunct treatment for postoperative nausea and vomiting, it is imperative that there is both an evidence base to support the use of aromatherapy, and a nursing workforce prepared to utilise it. Methods: This involved a Cochrane Systematic Review, a Delphi process to modify an existing tool to assess beliefs about aromatherapy to make it more relevant to nursing and midwifery practice, and a survey to test the modified tool in a population of nurses and midwives. Findings: The systematic review found that aromatherapy with isopropyl alcohol was more effective than placebo for reducing the number of doses of rescue antiemetics required but not more effective than standard antiemetic drugs. The Delphi panel process showed that the original Beliefs About Aromatherapy Scale was not completely relevant to nursing and midwifery practice. The modified Nurses' Beliefs About Aromatherapy Scale was found to be valid and reliable to measure nurses' and midwives' beliefs about aromatherapy. Factor analysis supported the construct validity of the scale by finding two sub-scales measuring beliefs about the 'usefulness of aromatherapy' and the 'scientific basis of aromatherapy'. Survey respondents were found to have generally positive beliefs about aromatherapy, with more strongly positive beliefs on the 'usefulness of aromatherapy' sub-scale. Conclusions: From the evidence of the systematic review, the use of isopropyl alcohol vapour inhalation as an adjunct therapy for postoperative nausea and vomiting is unlikely to be harmful and may reduce nausea for some adult patients. It may provide a useful therapeutic option, particularly when the alternative is no treatment at all. Given the moderately positive beliefs expressed by nurses and midwives particularly about the usefulness of aromatherapy there is potential for this therapy to be implemented and used to improve patient care.

Well-being, satisfaction and commitment : the substitutable nature of resources for maternity hospital nurses

Abstract Aims. To investigate the relationship between three types of organizational resources (job control, social support and organizational justice) and the impact of job demands on nurse’s well-being and attitudes towards their work. Background. The negative impact of work-related stress on nurse’s health and attitudes towards their work has been established. Increasingly, research is focusing on the role of organizational resources in reducing the impact of work related stress. Design. Cross-sectional survey. Method. Data collected in November 2008 from 226 Australian nurses and midwives were analysed using the full Job Strain Model with the addition of organizational justice variables. Multiple regression analyses explored the relationships among job control, job demands, three sources of social support and four types of organizational justice on well-being and work attitudes. Results. The overall regression models explained a significant amount of variance in well-being, job satisfaction and organizational commitment. Significant main effects were evident for support variables and organizational justice variables on well-being and job satisfaction. Interactions between job control and supervisor support and between job demands and supervisor support were evident for job satisfaction. Conclusions. Supervisor support and organizational justice have significant relationships with nurses’ well-being and job satisfaction. More broadly, the findings suggest that, in the triple-matching approach from a work-stressor to a resource to a work outcome, personal, supervisory and organizational resources may be substitutable. These findings provide nurse management with empirical endorsement for the development and delivery of the organization’s resources for nursing staff.

Relational regulation theory and the role of social support and organisational fairness for nurses in a general acute context

Aims and objectives. To present a novel approach to nurse stress by exploring the demand–control–support model with organisational justice through the lens of relational regulation theory. Background. Nursing is often stressful due to high demands and dissatisfaction with pay, which impacts the mental well-being and productivity of nurses. Design. A cross-sectional design. Methods. A validated questionnaire was sent to the work addresses of all nursing and midwifery staff in a medium-sized general acute hospital in Australia. A total of 190 nurses and midwives returned completed questionnaires for the analyses. Results. The multiple regression analyses demonstrated that the model applies to the prototypical context of a general acute hospital and that job control, supervisor support and outside work support improve the job satisfaction and mental health of nurses. Conclusions. Most importantly, supervisor support was found to buffer the impact of excessive work demands. Fairness of procedures, distribution of resources and the quality and consistency of information are also beneficial. Relational regulation theory is applied to these findings as a novel way to conceptualise the mechanisms of support and fairness in nursing. Relevance to clinical practice. The importance of nurses’ well-being and job satisfaction is a priority for improving clinical outcomes. Practically, this means nurse managers should be encouraging nurses in the pursuit of diverse relational activities both at work and outside work.

Development and validation of a pregnancy symptoms inventory

Background Physical symptoms are common in pregnancy and are predominantly associated with normal physiological changes. These symptoms have a social and economic cost, leading to absenteeism from work and additional medical interventions. There is currently no simple method for identifying common pregnancy related problems in the antenatal period. A validated tool, for use by pregnancy care providers would be useful. The aim of this study was to develop and validate a Pregnancy Symptoms Inventory for use by health professionals. Methods A list of symptoms was generated via expert consultation with health professionals. Focus groups were conducted with pregnant women. The inventory was tested for face validity and piloted for readability and comprehension. For test-re-test reliability, the tool was administered to the same women 2 to 3 days apart. Finally, midwives trialled the inventory for 1 month and rated its usefulness on a 10cm visual analogue scale (VAS). Results A 41-item Likert inventory assessing how often symptoms occurred and what effect they had, was developed. Individual item test re-test reliability was between .51 to 1, the majority (34 items) scoring ≥0.70. The top four “often” reported symptoms were urinary frequency (52.2%), tiredness (45.5%), poor sleep (27.5%) and back pain (19.5%). Among the women surveyed, 16.2% claimed to sometimes or often be incontinent. Referrals to the incontinence nurse increased > 8 fold during the study period. Conclusions The PSI provides a comprehensive inventory of pregnancy related symptoms, with a mechanism for assessing their effect on function. It was robustly developed, with good test re-test reliability, face validity, comprehension and readability. This provides a validated tool for assessing the impact of interventions in pregnancy.

Preventing infections following caesarean section

Surgical site infections following caesarean section are a serious and costly adverse event for Australian hospitals. In the United Kingdom, 9% of women are diagnosed with a surgical site infection following caesarean section either in hospital or post-discharge (Wloch et al 2012, Ward et al 2008). Additional staff time, pharmaceuticals and health supplies, and increased length of stay or readmission to hospital are often required (Henman et al 2012). Part of my PhD investigated the economics of preventing post-caesarean infection. This paper summarises a review of relevant infection prevention strategies. Administering antibiotic prophylaxis 15 to 60 minutes pre-incision, rather than post cordclamping, is probably the most important infection prevention strategy for caesarean section (Smaill and Gyte2010, Liu et al 2013, Dahlke et al 2013). However the timing of antibiotic administration is reportedly inconsistent in Australian hospitals. Clinicians may be taking advice from the influential, but out-dated RANZCOG and United States Centers for Disease Control and Prevention guidelines (Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2011, Mangram et al 1999). A number of other important international clinical guidelines, including Australia's NHMRC guidelines, recommend universal prophylactic antibiotics pre-incision for caesarean section (National Health and Medical Research Council 2010, National Collaborating Centre for Women's and Children's Health 2008, Anderson et al 2008, National Collaborating Centre for Women's and Children's Health 2011, Bratzler et al 2013, American College of Obstetricians and Gynecologists 2011a, Antibiotic Expert Group 2010). We need to ensure women receive preincision antibiotic prophylaxis, particularly as nurses and midwives play a significant role in managing an infection that may result from sub-optimal practice. It is acknowledged more explicitly now that nurses and midwives can influence prescribing and administration of antibiotics through informal approaches (Edwards et al 2011). Methods such as surgical safety checklists are a more formal way for nurses and midwives to ensure that antibiotics are administered pre-incision (American College of Obstetricians and Gynecologists 2011 b). Nurses and midwives can also be directly responsible for other infection prevention strategies such as instructing women to not remove pubic hair in the month before the expected date of delivery and wound management education (Ng et al 2013). Potentially more costly but effective strategies include using a Chlorhexidine-gluconate (CHG) sponge preoperatively (in addition to the usual operating room skin preparation) and vaginal cleansing with a povidone-iodine solution (Riley et al 2012, Rauk 2010, Haas, Morgan, and Contreras 2013).

Keeping our nursing and midwifery workforce : factors that support non-practising clinicians to return to practice

BACKGROUND: Within Australia and internationally (Health Workforce Australia, 2012) an increasing and on-going nursing workforce shortage is documented. Recent international estimates indicate that there will be ongoing and significant gaps in the supply of a nursing workforce; the United Kingdom is predicted to have a reduction of 12.12% nurses over the coming eight years if a current 'steady state' is maintained (Buchan and Seacombe, 2011); Canada is predicted to have a shortage of 60,000 nurses by 2022 (Tomblin et al., 2012) with Australia's anticipated nursing shortage reported as over 90,000 by the year 2025 (Health Workforce Australia, 2012). Queensland Health in response to their tracked emerging nursing and midwifery workforce shortages developed a nursing and midwifery refresher programme to return registered staff back to the workforce. A study was undertaken between 2008 and 2010 to provide an understanding of how non-practising nurses and midwives maybe supported back into the workforce. METHODS: Programme applicants (444) were invited to respond to an on-line survey designed to understand what aspects of the programme supported their learning and ability to return to the workforce. This number represents those who applied but not all completed or commenced the programme. Descriptive statistics (Polit and Beck, 2008) were used to collate quantifiable survey responses and free text and unsolicited responses were themed. RESULTS: The survey received a 35.5% response rate (n=158) with a return of 20% of unsolicited comments in the form of e-mail responses which were included in the themed results. Key themes supporting participants' learning and ability to return to the workforce were: Respondents were 94% female and 6% male, with 37.7% >51 years of age. Child rearing was the foremost reason for female staff relinquishing workforce roles (36.6%). The primary reason for returning to the workforce was maintenance of registration (40.5%). Both theory and clinical placement components were seen by participants as contributing to their confidence to return to the health workforce. CONCLUSION: The Queensland Nursing and Midwifery Refresher Programs provided a structured programme for registered, non-practising nurses and midwives to return to the Queensland Health workforce. Responses indicated that clinical supervision and contract learning should be central to a return to workforce induction programme for registered but non-practising nurses and midwives. The majority of nurses and midwives returning to the workforce were approaching retirement age in 10-15 years.

The concept of collaboration : a critical exploration of the care continuum

This thesis critically explored the concept of collaboration through an analysis of the experiences of midwives, child health nurses and women in the process of transition from hospital to community care and related policy documents. The research concluded that the concept serves an important social function in obscuring the complexity of social relations in healthcare. Rather than adopt an unquestioning attitude to what is represented as collaboration this thesis argues for a more critical examination of what is occurring, what is potentially hidden and how specific interests are served through its use.