Alice Kiger

Models of intrapartum care and women’s trade‐offs in remote and rural Scotland: a mixed‐methods study

Objective  To explore women’s preferences for, and trade‐offs between, key attributes of intrapartum care models.

Treatment of minor illness in primary care: a national survey of patient satisfaction, attitudes and preferences regarding a wider nursing role

Background  This study investigated patient opinion about the provision of nurse‐led vs. doctor‐led primary health care in the treatment of minor illness.

“Choice” and place of delivery: a qualitative study of women in remote and rural Scotland

Objective: To explore women’s perceptions of “choice” of place of delivery in remote and rural areas where different models of maternity services are available. Setting and methods: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. Results: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from “acceptors” to “active choosers.” The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in “choice.” Conclusions: Provision of different models of maternity services may not be sufficient to convince women they have “choice.” The paper raises fundamental questions about the meaning of “choice” within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training

Objectives: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. Design: Interview and postal survey. Setting: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). Participants: Staff proportionally representative of professional groups involved in maternity care. Results: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for “generalists” in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. Conclusions: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

Being and doing politics: An outdated model or 21st century reality?

AIM This paper presents a discussion of how critical social theory can be used as a tool for research, reflection and exploration of the political role of the nurse. BACKGROUND Sociological theory can be used to examine ideologies within nursing systems in order to contribute to the future development of the profession. The importance of critical social theory has been identified in the literature as being directly relevant to holism which is central to the nature of nursing. DATA SOURCES Texts published in English were identified from 1990 to 2008 using the keywords critical social theory, community nursing, political advocacy, social justice, sociological theory, health inequalities, health democracy, equity and inequality. DISCUSSION Critical social theory can be used as a tool to highlight ethical ways to practise nursing. One reason for examination of the community nurses political role is a shift in focus from the individual as patient to communities experiencing health inequalities. Nursing needs to decide whether the profession will work at the political level, and where advocacy and citizenship are located within a community role. CONCLUSION Nurse educators must prepare nurses for political participation, and nurse managers need to focus on national and local contexts in order to encourage policy analysis and community engagement within nursing practice. An understanding of critical social theory can aid decision-making in relation to global and local policy, enable the nursing profession to respond to social injustice, and permit nurses to work with communities in the pursuit of community health.

The buck stops here: Midwives and maternity care in rural Scotland

OBJECTIVE To explore and understand what it means to provide midwifery care in remote and rural Scotland. DESIGN Qualitative interviews with 72 staff from 10 maternity units, analysed via a case study approach. SETTING Remote and rural areas of Scotland. PARTICIPANTS Predominantly midwives, with some additional interviews with paramedics, general surgeons, anaesthetists and GPs. FINDINGS Remote and rural maternity care includes a range of settings and models of care. However, the impact of rural geographies on decision-making and risk assessment is common to all settings. Making decisions and dealing with the implications of these decisions is, in many cases, done without onsite specialist support. This has implications for the skills and competencies that are needed to practice midwifery in remote and rural settings. Whereas most rural midwives reported that their skills in risk assessment and decisions to transfer were well developed and appropriate to practising in their particular settings, they perceived these decisions to be under scrutiny by urban-based colleagues and felt the need to stress their competence in the face of what they imagined to be stereotypes of rural incompetence. CONCLUSIONS This study shows that skills in risk assessment and decision-making are central to high quality remote and rural midwifery care. However, linked to different perspectives on care, there is a risk that these skills can be undermined by contact with colleagues in large urban units, particularly when staff do not know each other well. There is a need to develop a professional understanding between midwives in different locations. IMPLICATIONS FOR PRACTICE It is important for the good working relationships between urban and rural maternity units that all midwives understand the importance of contextual knowledge in both decisions to transfer from rural locations and the position of midwives in receiving units. Multiprofessional CPD courses have been effective in bringing together teams around obstetric emergencies; we suggest that a similar format may be required in considering issues of transfer.

Improving Uptake of Cardiac Rehabilitation: Using Theoretical Modelling to Design an Intervention

Background: Attendance rates at cardiac rehabilitation remain low with typically fewer than 35% of eligible patients attending. Much of the poor attendance stems from invited patients failing to attend. Aim: To design a theoretically based intervention to improve attendance at cardiac rehabilitation. Methods: Our methods followed recommendations that have been developed from the Medical Research Council (MRC) framework for the design of complex interventions. We conducted three processes that progressed simultaneously: 1) literature review for evidence on epidemiology, behavioural theory, and efficacy of interventions; 2) expert meetings on behavioural theory and to select target points for intervention; and 3) development and theoretical modelling of the intervention. Result: Our final interventions were a theoretically worded invitation letter and leaflet based on the Theory of Planned Behaviour and the Common Sense Model of Illness, designed to: a) motivate patients through professional recommendation; b) provide simple information on the contents of cardiac rehabilitation emphasising ease for participants; c) reassure participants that the programme is tailored to their personal needs in a safe supervised environment; and d) reinforce the benefits of attending cardiac rehabilitation. Conclusion: A theoretically worded letter and leaflet could be an inexpensive intervention to improve attendance at cardiac rehabilitation. The letters and leaflets will now be evaluated in a randomised trial.

Effectiveness of theory-based invitations to improve attendance at cardiac rehabilitation: a randomized controlled trial.

Background: Despite well-established evidence of benefit from cardiac rehabilitation, typically fewer than 35% of eligible patients attend. Objective: The purpose of this study was to evaluate whether theory-based invitations increase attendance at cardiac rehabilitation. Method: The study was a randomized controlled trial (RCT) with two by two factorial design. A total of 375 participants with acute myocardial infarction or coronary revascularization was recruited from medical and surgical cardiac wards at Aberdeen Royal Infirmary (ARI). They were randomly assigned to receive either the standard invitation letter or a letter with wording based on the ‘theory of planned behavior (TPB)’ and the ‘common sense model of illness perception’, and either a supportive leaflet with motivational messages or not. The primary outcome was one or more attendances at cardiac rehabilitation. Results: The theory-based letter increased attendance at cardiac rehabilitation compared to the standard letter (84% versus 74%, odds ratio (OR) 2.93, 95% confidence interval (CI) 1.54–5.56), independent of age, gender, working status, hypertension, identity and TPB constructs. The number needed to treat (NNT) was 9 (95% CI 7–12). The motivational leaflet had no significant effect on attendance at rehabilitation (OR 1.02, 95% CI 0.57–1.83). Conclusions: The use of theory-based wording in invitation letters is a simple method to improve attendance at cardiac rehabilitation. Our letter, reproduced in this paper, could provide a template for practitioners and researchers.

‘We are the ones that talk about difficult subjects’: nurses in schools working to support young people’s mental health

As health professionals in an educational setting, nurses in schools occupy a unique place in the spectrum of children’s services. Yet the service is often overlooked and has been described as invisible. This paper draws on findings from a study, funded by the Scottish Government’s National Programme for Improving Mental Health and Well‐being, which explored the role of school nurses in promoting and supporting the mental health of children and young people. The school nursing service throughout the United Kingdom is at a pivotal point as its role is being redefined to align with moves across the National Health Service towards a public health model. This paper therefore offers a timely overview of the mental health work of school nurses, and raises key issues for future work. Interviews were conducted with 25 school nurse managers across Scotland. Interviewees claimed that the contribution of nurses in schools was distinctive, owing to the quality and consistency of relationship that they could offer, and the autonomy that the service allowed young people. However, significant challenges were reported in making this contribution, and tensions were evident in the conceptualisation of their role. The framework of resilience is used to discuss the findings on the significance of building relationships in promoting mental health.

Clinical staff and the new student nurse: anticipating change

This article focuses on the feelings and perceptions of clinical staff who are about to encounter Project 2000 students. It makes use of selected findings from a small exploratory study in which interviews were used to gather qualitative data from such staff. There is a brief consideration of the historical context of nurse education from which Project 2000 has arisen and the legislation that has been instrumental in its development. Embodied within this change is the expectation that clinical staff will continue to contribute to the education of student nurses on clinical placements. The target population for this study was identified as clinical staff who would be working with Project 2000 students within a large general teaching hospital. Through means of taped informal interviews, the study explored the world of the clinical staff in relation to their expectations of Project 2000 students. It identified feelings of threat, lack of communication and issues of change and its implementation. For successful implementation and wide acceptance of such a radical change in nurse education, consistency of knowledge and communication was shown to be essential.