Meredith McIntyre

The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care

BACKGROUND the maternity services reforms announced by the Australian government herald a process of major change. The primary maternity care reforms requires maternity care professionals to work collaboratively as equals in contrast to the current system which is characterised by unequal relationships. AIM critical discourse analysis (CDA) using neoliberalism as an interpretive lens was employed to determine the positions of the respective maternity care professionals on the proposed reform and what purpose was served by their representations to the national review of maternity services. METHOD a CDA framework informed by Fairclough, linking textual and sociological analysis in a way that foregrounds issues of power and resistance, was undertaken. Data were collected from selected written submissions to the 2008 national review of maternity services representing the position of midwifery, obstetrics, general practitioners including rural doctors and maternity service managers. FINDINGS maternity care professionals yielded several discourses that were specific to the discipline with a number that were shared across disciplines. The rise in consumerism has changed historical positions of influence in maternity services policy. The once powerful obstetric position in determining the direction of policy has come under siege, isolated in the presence of a powerful alliance involving consumers, midwives, sympathetic maternity service managers and some medical professions. The midwifery voice has been heard, a historical first, supported by its presence as a member of the alliance. CONCLUSION the struggle for contested boundaries is entering a new phase as maternity care professionals struggle with different perceptions of what multidisciplinary collaboration means in the delivery of primary maternity care.

Exploration of the role of specialist nurses in the care of women with gynaecological cancer: a systematic review.

AIM AND OBJECTIVE To evaluate the role and interventions used by specialist nurses in caring for women with gynaecological cancer. BACKGROUND Evidence evaluating the efficacy of specialist nurses in the gynaecological-oncology setting is limited and fragmented. DESIGN Systematic review including both randomised controlled trials and nonrandomised studies. METHODS Nine major databases were accessed from their date of inception to April 2013 with search results limited to publications from 1993-2013. Inclusion criteria were applied to select studies for review. Studies were critically appraised and assessment of the risk of bias performed. Data were extracted and compiled, with a narrative analysis undertaken. RESULTS Nine studies (six randomised controlled trials and three nonrandomised studies) testing interventions by specialist nurses in the gynaecological-oncology setting were included in the systematic review. Results for the randomised controlled trials and nonrandomised studies were reported separately to enable distinction between evidence levels. Risk of bias assessment revealed that the quality of the randomised controlled trials was mixed and highlighted the inherent flaws of nonrandomised study designs. Studies varied greatly in the type of intervention provided and the tools used to measure outcomes, contributing to mixed results. The review demonstrated some positive effects of interventions by specialist nurses for women with gynaecological cancer, although these must viewed in conjunction with the assessment of evidence quality. CONCLUSIONS This systematic review has contributed to our understanding of the patient-centred aspects of the specialist nurse role in the gynaecological-oncology setting and further research is required to evaluate the role overall. RELEVANCE TO CLINICAL PRACTICE The review indicates that interventions that either encompassed all domains of care, involved telephone contact or were executed between diagnosis and the completion of treatment were the most successful.

Safety of non-medically led primary maternity care models: a critical review of the international literature

The Australian government has announced major reforms with the move to a primary maternity care model. The direction of the reforms remains contentious; with the Australian Medical Association warning that the introduction of non-medically led services will compromise current high standards in maternity services and threaten the safety of mothers and babies. The purpose of this paper is to conduct a critical review of the literature to determine whether there is convincing evidence to support the safety of non-medically led models of primary maternity care. Twenty-two non-randomised international studies were included representing midwifery-led care, birth centre care and home birth. Comparative outcome measurements included: perinatal mortality; perinatal morbidity; rates of medical intervention in labour; and antenatal and intrapartum referral and transfer rates. Findings support those of the three Cochrane reviews, that there is sufficient international evidence to support the conclusion of no difference in outcomes associated with low risk women in midwifery-led, birth centre and home birth models compared with standard hospital or obstetric care. These findings are limited to services involving qualified midwives working within rigorous exclusion, assessment and referral guidelines, limiting the number of urgent intrapartum transfers that come with increased risk of perinatal mortality.

Hidden costs associated with the universal application of risk management in maternity care

This paper presents a critical analysis of risk management in maternity care and the hidden costs associated with the practice in healthy women. Issues of quality and safety are driving an increased emphasis by health services on risk management in maternity care. Medical risk in pregnancy is known to benefit 15% or less of all pregnancies. Risk management applied to the remaining 85% of healthy women results in the management of risk in the absence of risk. The health cost to mothers and babies and the economic burden on the overall health system of serious morbidity has been omitted from calculations comparing costs of uncomplicated caesarean birth and uncomplicated vaginal birth. The understanding that elective caesarean birth is cost-neutral when compared to a normal vaginal birth has misled practitioners and contributed to over use of the practice. For the purpose of informing the direction of maternity service policy it is necessary to expose the effect the overuse of medical intervention has on the overall capacity of the healthcare system to absorb the increasing demand for operating theatre resources in the absence of clinical need.

Critical discourse analysis: understanding change in maternity services

This paper provides an example of the use of critical discourse analysis (CDA) in the area of maternity care policy and describes the process of CDA as an effective research method for understanding the influences of change in the context of Australian maternity services. CDA is a methodological approach that examines how discourse is formed and given power, as a result of how power is used, who uses it and the context within which this usage takes place. The application of CDA is described in this study for the purpose of examining key-stakeholder use of knowledge and power for the purpose of influencing the direction of the maternity services reform. The CDA theoretical framework guided discourse identification and analysis of the purpose behind the discourse through examination of power relationships between key stakeholders. The use of a theoretical lens in the form of neoliberalism to supplement the theoretical framework facilitated the exposure of forces intrinsic to the maternity care context driving change.

Australian rural maternity services: creating a future or putting the last nail in the coffin

[Extract] Nurses and midwives are the largest group of health providers in Australia (60%), and with increasing remoteness, this proportion increases substantially. The recruitment and retention of nurses, and more specifically midwives in rural health services, is at crisis point. Sustainable birthing services will be reliant on a stable, regenerative workforce. Key to this goal is the education of nurses, midwives and doctors, all of whom have stringent pre-service professional placement quotas in order to meet required competencies to practice.

Experiences of gynecological cancer patients receiving care from specialist nurses: a qualitative systematic review

Background The care needs of women with gynecological cancer are complex and change over the course of their cancer journey. Specialist nurses are well positioned to play a role in meeting the needs of women with gynecological cancer although their role and scope of practice have not been well defined. As patients are a key stakeholder, understanding their experience of care is an important step in better defining the role and scope of practice of specialist nurses in gynecological oncology in Australia and New Zealand. Objectives This review sought to consider gynecological cancer patients’ experiences of specialist nursing care. Exploring the patients experience of care by a specialist nurse is one step in the process of better defining the role and scope of practice of specialist gynecological-oncology nurses in Australia and New Zealand. Inclusion criteria Types of participants This review included studies with a focus on women with gynecological cancer who had been cared for by a specialist nurse. Studies of women with gynecological cancer at any point on the continuum of care from pre-diagnosis to survivorship or end of life, including those with a recurrence of the disease, were included, with no limit to the duration of care received for inclusion in the review. Phenomena of interest Studies that explored how women with gynecological cancer experience the care and interventions of specialist nurses were included. Types of studies Qualitative studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research were considered for review. This review also considered the qualitative components of mixed method studies. Context Research conducted in any country was considered for inclusion in this review providing that the study was reported in English. Studies conducted in any setting including, but not limited to, acute hospitals, outpatient/ambulatory clinics, chemotherapy or radiotherapy units, support groups, palliative care units or the patients home were included. Search strategy A three-step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by a comprehensive search using all identified keywords and index terms across all included databases. The reference lists of all identified reports and articles were hand searched for additional studies. Methodological quality Each paper was independently assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute the Qualitative Assessment and Review Instrument. When disagreement arose between the reviewers, the given paper was independently appraised by a third reviewer. Data extraction Data were extracted from papers included in the review using the standardized data extraction tool from Joanna Briggs Institute the Qualitative Assessment and Review Instrument. Data extraction was completed independently by two reviewers. Data synthesis Extracted findings from seven included papers were grouped according to similarity in meaning from which 11 categories were developed. These categories were then subjected to a meta-synthesis that produced a set of three synthesized findings. Results Key findings were extracted from six included papers and classified as unequivocal (U) or credible (C). A total of 30 findings were extracted and aggregated into 11 categories based on similarity in meaning. From the 11 categories, three synthesized findings were developed: i) Tailored care: specialist nurses play a role in understanding and meeting the individual needs of women with gynecological cancer; ii) Accessible care: specialist nurses guide women with gynecological cancer along the continuum of care and are an easily accessed source of knowledge and support; iii) Dependable expertise: women with gynecological cancer express trust and reassurance in the experience and expertise of the specialist nurse. Conclusions This systematic review synthesized the findings of seven studies that captured the experiences of women with gynecological cancer who received care from a specialist nurse. The specialist nurse offers tailored, accessible and expert care to women with gynecological cancer. From the synthesis it is recommended that women with gynecological cancer have access to the services of a specialist nurse at key points on the continuum of care, that specialist nurses provide information to patients on their disease and treatment in the form preferred by the patient and ensure that this information has been understood, and that specialist nurses are afforded time to spend with patients to enable greater exploration and identification of patient needs and the provision of personalized care. Further study that considers other key stakeholders in the specialist nurse role in gynecological oncology is recommended in order to gain a full understanding of specialist nurses’ contribution to the care of women with gynecological cancer. Additionally, it is recommended that further studies be conducted to seek the perspectives of women with gynecological cancer from culturally and linguistically diverse backgrounds and Indigenous populations on specialist nursing care as they appear to be under-represented in current research.

Managing projected midwifery workforce deficits through collaborative partnerships

To address workforce shortages, the Australian Government funded additional nursing and midwifery places in 2009 pre-registration courses. An existing deficit in midwifery clinical placements, combined with the need to secure additional clinical placements, contributed to a serious shortfall. In response, a unique collaboration between Midwifery Academics of Victoria (MIDAC), rural and metropolitan maternity managers (RMM and MMM) groups and Department of Health (DOH) Victoria was generated, in order to overcome difficulties experienced by maternity services in meeting the increased need. This group identified the large number of different clinical assessment tools required to be being completed by midwives supervising students as problematic. It was agreed that the development of a Common Assessment Tool (CAT) for use in clinical assessment across all pre-registration midwifery courses in Victoria had the potential to reduce workload associated with student assessments and, in doing so, release additional placements within each service. The CAT was developed in 2009 and implemented in 2010. The unique collaboration involved in the development of the CAT is a blueprint for future projects. The collaboration on this project provided a range of benefits and challenges, as well as unique opportunities for further collaborations involving industry, government, regulators and the tertiary sector.

Differences in meconium stained amniotic fluid in an Australian population: A retrospective study

BACKGROUND Meconium stained amniotic fluid commonly occurs postdates ( >40 weeks gestation) indicating fetal maturity. Previous literature indicates that different ethnicities mature at different rates. AIM To compare the rate of meconium stained amniotic fluid of Australian-born and non-Australian born women. METHODS A retrospective correlation study design was implemented, using data collected in the birth outcomes system at one tertiary hospital. Data was collected from all women who gave birth to a term (>/=37 weeks gestation), singleton, liveborn baby between January 1st to December 31st, 2014. Maternal country of birth was used for comparison. Categorical data was analyzed using Chi-Square test for Independence. Continuous variables were assessed for normality, and differences were compared using an Independent t-test or a Mann-Whitney U test. All tests were two-tailed and p<0.05 was considered statistically significant. RESULTS 3,041 women were included; 1131 Australian-born and 1910 non-Australian born. Meconium stained amniotic fluid occurred more frequently in non-Australian born women compared to Australian-born women (23.5% vs. 19.8 p=0.02). Their babies were significantly smaller (Mean=3265g, Standard Deviation 463.8 vs Mean=3442g, Standard Deviation 499.2, p<0.001), with no difference in gestational length (Mean=39.4, Standard Deviation 1.28 vs Mean=39.5, Standard Deviation 1.18, p=0.06). Increasing gestational age had the strongest association with meconium stained amniotic fluid; >/=42 weeks gestation occurring 3.52 (95% Confidence Interval: 2.00, 6.22, p=<0.001) more than <40 weeks gestation. CONCLUSION Maternity health services should record ethnicity and region of birth to provide individualised care as women born overseas often have poorer perinatal outcomes when compared to Australian-born women.

Japanese Men’s Success in Altered Fatherhood Role in a Foreign Country

This study explores the meaning of the lived experience of childbirth and parenting of Japanese men who became fathers in a foreign country. Japanese men have been raised to maintain very strict gender roles, excluding them from sharing with their wives the experience of childbirth and the day-to-day parenting of young children. The study employed a descriptive phenomenological approach with in-depth interviews. Participants included nine Japanese men born and raised in Japan who were living in Honolulu. Three theme categories emerged from the data: “making active efforts in preparation for childbirth in a foreign country”; “challenges in pregnancy, childbirth, child care, and as husbands or partners”; and “challenges in transition to parenthood.” Japanese men successfully altered their transitional and authoritarian gender role to a family orientated social structure, under the influence of Western values, when living in foreign country. By spending more time with their new family, they acknowledged the processes of becoming a father. The ability to adapt their expectations of fatherhood in line with Western values was enhanced by the support of coworkers, their mature age, rich educational background, and the personal financial resources of the male participants in the study.