Context: a key dimension in midwifery decision making and practice for safe labour care

2020 ◽  
Vol 14 (3) ◽  
pp. 1-14
Author(s):  
Elizabeth Chodzaza ◽  
Elaine Haycock-Stuart ◽  
Aisha Holloway ◽  
Ursula Kafulafula
Keyword(s):  
Decision Making ◽  
Maternity Care ◽  
Clinical Decision Making ◽  
Medical Profession ◽  
Contextual Factors ◽  
Real Life ◽  
Clinical Decision ◽  
Structured Interviews ◽  
Theoretical Understanding ◽  
The Real

Background/Aims Research into midwifery decision making to date is limited and, where it exists, theoretical understanding has focused on the cognitive aspects of the process. Understanding the real-life context in which midwives work and how this influences their decision making during labour is important for safer maternity care. This study aimed to explore the contextual factors that influence the decision making of midwives at secondary and tertiary level health facilities during the first stage of labour in the real context of practice. Methods Using a focused ethnographic methodology, data from nine midwives working in two hospital labour ward settings were collected from October 2013 to May 2014. A total of 27 participant observations of midwives supporting women in the first stage of labour, 26 semi-structured interviews with midwives, and a documentary analysis of maternal labour records were conducted. All data were analysed using theme and category formation. Results Four major themes that influenced midwifery decision making for the safe care of women in labour were found: dominance of the medical profession over maternity care, shortage of midwifery staff, limited material resources, and midwifery strategies for maternal and child safety. Conclusions Understanding and improving clinical decision making requires consideration of contextual factors. For safe maternal care during the first stage of labour, midwives need to be supported to manage contextual factors for favourable outcomes for the mother and neonate.

scholarly journals Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Resha Al-Azzawi ◽  
Peder A. Halvorsen ◽  
Torsten Risør
Keyword(s):  
Decision Making ◽  
General Practitioner ◽  
Scoping Review ◽  
English Language ◽  
Clinical Decision Making ◽  
Contextual Factors ◽  
Real Life ◽  
Clinical Decision ◽  
Antibiotic Prescribing ◽  
Consultation Process

Abstract Background How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. Method The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. Results Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. Conclusion Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

scholarly journals The development of the WHO Labour Care Guide: an international survey of maternity care providers

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Veronica Pingray ◽  
Mercedes Bonet ◽  
Mabel Berrueta ◽  
Agustina Mazzoni ◽  
María Belizán ◽  
...  
Keyword(s):  
Decision Making ◽  
Maternity Care ◽  
Health Personnel ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Research Network ◽  
Respectful Maternity Care ◽  
Care Providers ◽  
Skilled Health Personnel ◽  
Skilled Health

Abstract Background The partograph is the most commonly used labour monitoring tool in the world. However, it has been used incorrectly or inconsistently in many settings. In 2018, a WHO expert group reviewed and revised the design of the partograph in light of emerging evidence, and they developed the first version of the Labour Care Guide (LCG). The objective of this study was to explore opinions of skilled health personnel on the first version of the WHO Labour Care Guide. Methods Skilled health personnel (including obstetricians, midwives and general practitioners) of any gender from Africa, Asia, Europe and Latin America were identified through a large global research network. Country coordinators from the network invited 5 to 10 mid-level and senior skilled health personnel who had worked in labour wards anytime in the last 5 years. A self-administered, anonymous, structured, online questionnaire including closed and open-ended questions was designed to assess the clarity, relevance, appropriateness of the frequency of recording, and the completeness of the sections and variables on the LCG. Results A total of 110 participants from 23 countries completed the survey between December 2018 and January 2019. Variables included in the LCG were generally considered clear, relevant and to have been recorded at the appropriate frequency. Most sections of the LCG were considered complete. Participants agreed or strongly agreed with the overall design, structure of the LCG, and the usefulness of reference thresholds to trigger further assessment and actions. They also agreed that LCG could potentially have a positive impact on clinical decision-making and respectful maternity care. Participants disagreed with the value of some variables, including coping, urine, and neonatal status. Conclusions Future end-users of WHO Labour Care Guide considered the variables to be clear, relevant and appropriate, and, with minor improvements, to have the potential to positively impact clinical decision-making and respectful maternity care.

scholarly journals Shared clinical decision-making experiences in nursing: A qualitative study

2021 ◽  
Author(s):  
Fen-Fang Chung ◽  
Shu-Chuan Lin ◽  
Yu-Hsia Lee ◽  
Pao-Yu Wang ◽  
Hon-Yen Wu ◽  
...  
Keyword(s):  
Decision Making ◽  
Nursing Education ◽  
Nursing Staff ◽  
Cultural Sensitivity ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Information Communication ◽  
Structured Interviews ◽  
Clinical Nursing ◽  
Basic Ability

Abstract Background Shared decision making (SDM) is a patient-centred nursing concept that emphasises the autonomy of the patient. It is a co-operative process of exchanging information, communication and response, and treatment decisions made between medical staff and patients. In this study, we explored the experience of clinical nursing staff participating in SDM. Methods We adopted a qualitative research method. Semi-structured interviews were conducted with 21 nurses at a medical centre in northern Taiwan. The data obtained from interview recordings were transferred to verbatim manuscripts. Content analysis was used to analyse and summarise the data. Results Clinical nursing staff should have basic professional skills, communication and response skills, respect and cultural sensitivity, the ability to form a co-operative team, the ability to search for and integrate empirical data, and the basic ability to edit media to participate in SDM. Conclusions The results of this study describe the experiences of clinical nursing staff participating in SDM, which can be used as a reference for nursing education and nursing administrative supervisors to plan and enhance professional nursing SDM in nursing education.

scholarly journals Use of Acute Psychiatric Hospitalisation: A Study of the Factors Influencing Decisions to Arrange Acute Admission to Inpatient Mental Health Facilities

2021 ◽  
Vol 12 ◽  
Author(s):  
Rajan Nathan ◽  
Mark Gabbay ◽  
Sean Boyle ◽  
Phil Elliott ◽  
Clarissa Giebel ◽  
...  
Keyword(s):  
Mental Health ◽  
Decision Making ◽  
Clinical Decision Making ◽  
Contextual Factors ◽  
Clinical Decision ◽  
Personal Factors ◽  
Liaison Psychiatry ◽  
Acute Admission ◽  
Factors Influencing ◽  
Wide Range

Background: Human decision-making involves a complex interplay of intra- and inter-personal factors. The decisions clinicians make in practise are subject to a wide range of influences. Admission to a psychiatric hospital is a major clinical intervention, but the decision-making processes involved in admissions remain unclear.Aims: To delineate the range of factors influencing clinicians' decisions to arrange acute psychiatric admissions.Methods: We undertook six focus groups with teams centrally involved in decisions to admit patients to hospital (crisis resolution home treatment, liaison psychiatry, approved mental health practitioners and consultant psychiatrists). The data were analysed using qualitative thematic analysis.Results: Our analysis of the data show a complex range of factors influencing decision-making that were categorised as those related to: (i) clinical and risk factors; (ii) fear/threat factors; (iii) interpersonal dynamics; (iv) contextual factors.Conclusions: Decisions to arrange acute admission to hospital are not just based on an appraisal of clinical and risk-related information. Emotional, interpersonal and contextual factors are also critical in decision-making. Delineating the breadth of factors that bear on clinical decision-making can inform approaches to (i) clinical decision-making research, (ii) the training and supervision of clinicians, and (iii) service delivery models.

scholarly journals P418 Does capsule endoscopy impact clinical management in established Crohn’s Disease?

2021 ◽  
Vol 15 (Supplement_1) ◽  
pp. S423-S424
Author(s):  
A Elosua Gonzalez ◽  
M Rullan Iriarte ◽  
S Rubio Iturria ◽  
S Oquiñena Legaz ◽  
C Rodríguez Gutiérrez ◽  
...  
Keyword(s):  
Decision Making ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Capsule Endoscopy ◽  
Clinical Management ◽  
Clinical Decision Making ◽  
Real Life ◽  
Clinical Decision ◽  
Mucosal Inflammation ◽  
Therapeutic Impact

Abstract Background Capsule endoscopy (SBCE) has developed a relevant role in different indications in patients with established Crohn’s Disease (CD). However, evaluation of its impact in clinical management in CD specific modification strategies has been scarce. The purpose of our study was to question therapeutic impact of SBCE in an 11-year real-life cohort of established CD patients. Methods Retrospective single center study including all consecutive patients with CD submitted to SBCE from January 2008 to December 2019. Small bowel patency was evaluated with patency capsule in selected patients. A conclusive procedure was defined as the one that allowed clinical decision-making. Mucosal inflammation was graded as mild (few aphtoid ulcers), moderate (multiple aphtoid ulcers/isolated deep ulcers) or severe (multiple deep ulcers/stenosis). Therapeutic impact was defined as a change in CD related treatment including escalation, de-escalation, dose adjustment or referral to surgery recommended based on SBCE results within the next 3 months after the SBCE. Patients were assigned to four groups regarding CE indication: staging, flare, post-op and remission (fig 1). Results From the 432 CE performed, 378 (87.5%) were conclusive and allowed clinical decision-making. SBCE results guided changes in 51.3% of patients: 199 (46.1%) with escalation and 23 (5.3%) with de-escalation of treatment. Active disease was present in 310 (71.8%) patients; 131 (30.3%) presented mild, 126 (29.2%) moderate and 53 (12.3%) severe activity. Disease activity demonstrated by SBCE correlated with therapeutic changes. With mild activity 24.1% increased therapy, whereas 77.8% and 84.9% increased therapy with moderate or severe disease, respectively (p<0.001). De-escalation was conducted in 12.8% patients with mucosal healing and 6.1% with mild disease but not in moderate or severe activity (p<0.001). Treatment before and after SBCE is shown in the table. Conclusion SBCE is a safe and useful tool when approaching established CD patients guiding therapeutic management in a real-life setting. Its positive impact does not limit to treatment escalation but also helps to de-escalate in patients who can benefit from it.

scholarly journals Medical professionalism: Navigating modern challenges

2021 ◽  
pp. 175573802110526
Author(s):  
Nicola Cooper-Moss ◽  
Helen Hooper ◽  
Kartina A. Choong ◽  
Umesh Chauhan
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
General Practice ◽  
Professional Practice ◽  
Clinical Decision Making ◽  
Medical Profession ◽  
Clinical Decision ◽  
Medical Professionalism ◽  
The Public ◽  
General Practice Training

Medical professionalism is an evolving entity, requiring continual development according to shifting societal priorities. The public trust that underpins the medical profession is imperative for maintaining effective partnerships with patients, their families and the wider community. This article provides an overview of what constitutes medical professionalism, including the current protocols and assessments for general practice training. The aim is to improve understanding of the current issues surrounding professionalism in primary care. Fictional case scenarios are used to illustrate modern professional dilemmas and to promote reflection on the complex interacting factors that influence professional practice and clinical decision-making.

scholarly journals 35. Acceptability of Proposed Stewardship Interventions to Reduce Preoperative Screening and Treatment of Asymptomatic Bacteriuria

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S140-S140
Author(s):  
Kimberly Dukes ◽  
Julia Walhof ◽  
Madisen Brown ◽  
Kalpana Gupta ◽  
Judith Strymish ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Asymptomatic Bacteriuria ◽  
Clinical Decision ◽  
Audit And Feedback ◽  
Structured Interviews ◽  
Research Support ◽  
Independent Contractor ◽  
Urine Screening ◽  
Urine Testing

Abstract Background In 2019, the IDSA Clinical Practice guidelines on asymptomatic bacteriuria (ASB) recommended that clinicians no longer screen or treat patients for ASB before non-urological surgeries. However, it remains to be seen whether these guideline recommendations alone will produce changes in practice. Understanding clinical decision-making about preoperative urine screening and treatment can help design effective interventions to facilitate guideline concordance and support antibiotic stewardship. Our project objective was to qualitatively assess barriers and facilitators to reducing preoperative urine testing and treatment. Methods We conducted semi-structured interviews with 24 participants (surgeons, advance practice providers, pharmacists, infectious disease physicians, epidemiologists) at 4 Veterans Administration hospitals. We solicited feedback on 4 proposed interventions (substitution, lab restrictions, audit and feedback, interactive workshop), and invited suggestions on other interventions. Three researchers separately coded 20% of interview notes to sort responses to each intervention into acceptable, possibly acceptable, and not acceptable. The team then compared coding, resolved differences by consensus, and refined the code dictionary to ensure intercoder agreement; then each member coded one third of remaining notes. Results Participants expressed concerns about de-implementing routine urine testing and treatment for specific procedures and specialties (e.g., cardiothoracic). Some actively sought to identify and treat ASB. Participants found audit and feedback and substitution of different infection-control practices most acceptable. Participants suggested changes to make interventions more acceptable or feasible (e.g., tailoring to procedure, educational tailoring). Participants also identified new potential interventions (e.g. order set changes, collaborative decision making, education on potential harms, identification of testing costs). Table 1. Acceptability of Proposed Interventions by Percentage of Participants. Percentages Do Not Add up to 100% Because Some Interviewees Did Not Answer Every Question. Conclusion Interventions to optimize urine screening and treatment for patients undergoing surgeries may require tailoring for surgical specialties, and should address clinical concerns about intervention feasibility. Disclosures Kalpana Gupta, MD, MPH, Abbott (Shareholder)DBC Pri-Med (Consultant)Glaxo Smith Kline (Consultant)Moderna (Shareholder)Nabriva Therapeutics (Consultant)Pfizer (Other Financial or Material Support, Grant to the institution)Qiagen (Consultant)Rebiotix (Consultant)Spero Therapeutics (Consultant)Utility Therapeutics (Consultant) Daniel Suh, MS MPH, General Electric (Shareholder)Merck (Shareholder)Moderna (Shareholder)Smile Direct Club (Shareholder) Bruce Alexander, PharmD, Bruce Alexander Consulting (Independent Contractor) Marin Schweizer, PhD, 3M (Grant/Research Support)PDI (Grant/Research Support)

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