This study examined antenatal counseling for congenital anomaly tests provided by midwives in the Netherlands using video recordings. The study aimed to 1) describe the focus on health education, decision-making support, and relationship building during counseling, 2) describe client versus midwife contributions, and 3) explore how client characteristics related to counseling. Counseling focused more on health education than decision-making support. Midwives contributed more than clients across functions. Counseling of multiparous women was shorter and contained less health education and decision-making support than for nulliparous women. The findings suggest midwives should reflect on how they individualize counseling based on client characteristics.
PACS (Picture Archive and Communication Systems) are digital systems used to store, view, and manage diagnostic imaging studies. They allow for faster access to images compared to traditional film, which can improve patient care. While initial implementation of PACS is costly, studies have shown cost savings from reduced lost images, repeated exams, and shorter hospital stays. PACS integrate with other hospital information systems and allow multiple providers to view images simultaneously from different locations. This improves care coordination and patient discussions. Overall, PACS aim to make healthcare delivery more effective and efficient through electronic access and sharing of diagnostic images.
Compassion fatigue and burnout are significant issues for nurses that can lead to negative consequences if left unaddressed. Both result from the stress of caring for patients, though burnout has a gradual onset due to work environment stressors, while compassion fatigue occurs acutely from caring for suffering clients. Clinical manifestations are similar and include desensitization, increased medical errors, and lack of attention to detail. Hospitals can decrease these issues by improving communication, providing education on coping mechanisms, encouraging work-life balance, instituting debriefing sessions, and promoting an accepting work environment as per Jean Watson's Humanbecoming Theory.
Yale-New Haven Hospital Always Events Program: Premature Life TransitionaPicker Institute, Inc.
This document outlines the importance of clear, consistent, compassionate communication when providing end-of-life care for infants and their families. It discusses barriers to effective communication and strategies for both verbal and non-verbal communication, emphasizing the need to respect cultural differences, avoid medical jargon, allow time for questions, and deliver difficult news with empathy and care.
Data Visuallization for Decision Making - Intel White PaperNicholas Tenhue
Clinicians must analyze large amounts of patient data from various sources to assess health and develop treatment plans. This process is becoming more complex with new sources of data. The study explored creating data visualization tools to help clinicians make sense of growing data volumes and varieties. Participants provided feedback on prototype tools, identifying challenges and beneficial design approaches. The tools showed potential to improve the speed and accuracy of healthcare decisions by making implicit thought processes more explicit.
The document summarizes research on patient fall prevention strategies. It finds that while many fall risk assessment tools and interventions have been developed, there is little consensus on the most effective approach. The literature shows that assessment tools have limitations but clinical studies find they can still reduce falls when used correctly. The document concludes the most promising approach combines using a validated tool, properly selected and enforced interventions tailored for each patient, and monitoring the program over time.
Nicholas Tenhue completed his Master's degree in MSc ICT Innovation at University College London, this document is his thesis on Making Sense of Risk by Visualizing Complex Health Data.
Find out more about Nicholas at http://nicholastenhue.com
PACS (Picture Archive and Communication Systems) are digital systems used to store, view, and manage diagnostic imaging studies. They allow for faster access to images compared to traditional film, which can improve patient care. While initial implementation of PACS is costly, studies have shown cost savings from reduced lost images, repeated exams, and shorter hospital stays. PACS integrate with other hospital information systems and allow multiple providers to view images simultaneously from different locations. This improves care coordination and patient discussions. Overall, PACS aim to make healthcare delivery more effective and efficient through electronic access and sharing of diagnostic images.
Compassion fatigue and burnout are significant issues for nurses that can lead to negative consequences if left unaddressed. Both result from the stress of caring for patients, though burnout has a gradual onset due to work environment stressors, while compassion fatigue occurs acutely from caring for suffering clients. Clinical manifestations are similar and include desensitization, increased medical errors, and lack of attention to detail. Hospitals can decrease these issues by improving communication, providing education on coping mechanisms, encouraging work-life balance, instituting debriefing sessions, and promoting an accepting work environment as per Jean Watson's Humanbecoming Theory.
Yale-New Haven Hospital Always Events Program: Premature Life TransitionaPicker Institute, Inc.
This document outlines the importance of clear, consistent, compassionate communication when providing end-of-life care for infants and their families. It discusses barriers to effective communication and strategies for both verbal and non-verbal communication, emphasizing the need to respect cultural differences, avoid medical jargon, allow time for questions, and deliver difficult news with empathy and care.
Data Visuallization for Decision Making - Intel White PaperNicholas Tenhue
Clinicians must analyze large amounts of patient data from various sources to assess health and develop treatment plans. This process is becoming more complex with new sources of data. The study explored creating data visualization tools to help clinicians make sense of growing data volumes and varieties. Participants provided feedback on prototype tools, identifying challenges and beneficial design approaches. The tools showed potential to improve the speed and accuracy of healthcare decisions by making implicit thought processes more explicit.
The document summarizes research on patient fall prevention strategies. It finds that while many fall risk assessment tools and interventions have been developed, there is little consensus on the most effective approach. The literature shows that assessment tools have limitations but clinical studies find they can still reduce falls when used correctly. The document concludes the most promising approach combines using a validated tool, properly selected and enforced interventions tailored for each patient, and monitoring the program over time.
Nicholas Tenhue completed his Master's degree in MSc ICT Innovation at University College London, this document is his thesis on Making Sense of Risk by Visualizing Complex Health Data.
Find out more about Nicholas at http://nicholastenhue.com
Healthcare delivery in the periphery workshop outputDayOne
This document summarizes a tri-national workshop on healthcare delivery in peripheral regions. The workshop brought together participants from Germany, France, and Switzerland to identify challenges in peripheral healthcare, develop collaborative projects to address these challenges, and plan next steps. Three priority projects were selected: 1) A platform for hospitals to share best practices and develop an adherence app, 2) A workshop on technological solutions to attract physicians to peripheral areas, and 3) An exchange program for nurses and nursing students to collaborate with technology companies and work towards harmonizing training across borders. Immediate next steps included reporting outcomes to relevant conferences and planning an expert workshop in early 2020.
The document discusses the need for radical change to improve patient safety and decrease preventable adverse events. It notes that recent studies have found adverse event rates in intensive care units and neonatal units to be much higher than previously estimated, with over half of events found to be preventable. The articles presented in this topic aim to address how nursing can better understand and contribute to a culture of patient safety through examining roles, education, frameworks, and models related to safety practices and hazard recognition.
This document provides an overview of the Med-Peds specialty, which involves training and practice in both internal medicine and pediatrics. It discusses the history and development of Med-Peds programs, the residency and training process, practice options, growth potential, and salaries for Med-Peds physicians. The document also examines reasons for choosing Med-Peds and provides results from an O-Net profiler assessment of the author's investigative and social skills that relate to this specialty.
Method of educating nursing students on proper handfatimazaheer12
The document outlines a study comparing hand washing versus hand sanitizer for nursing students to improve infection control during the COVID pandemic. It finds that hand sanitizers are more effective and efficient at killing viruses and preventing disease transmission compared to hand washing, which risks recontamination and takes more time. A two-day study of 10 nursing students is conducted to test procedures, collect data on sanitizer versus hand washing, and analyze results, finding that hand sanitizers kill germs faster and are more practical for maintaining hygiene.
This document provides an overview of the Med-Peds specialty, which involves training and practice in both internal medicine and pediatrics. It discusses the history and development of Med-Peds programs in the 1960s in response to the primary care movement. The document outlines the 4-year residency training requirements, including rotations in adult/pediatric medicine, intensive care, and various subspecialties. It also explores practice options for Med-Peds physicians and reasons for choosing this specialty, including working with patients across the lifespan and career flexibility. Potential graduate programs in South Carolina are described.
The document proposes implementing color-coordinated fall risk identifiers for patients at risk of falls at the Manhattan VA Hospital to potentially decrease falls. It reviews literature finding single interventions like signs or bracelets are less effective than multiple reminders. The proposal is to randomly assign patients scoring high on the Morse Fall Scale to either bright yellow socks/bracelets or a red dot outside their room. Incidences of falls will be compared over 3 months between the two groups to evaluate if color-coordinated identifiers reduce falls more than the current program.
1) The document discusses implementing an Admission, Discharge, Teaching (ADT) nurse role on a postpartum floor to improve patient satisfaction, nurse satisfaction, and safety. Studies show the ADT role increases time for direct patient care and reduces workload.
2) The ADT nurse would help with admissions, discharges, teaching, and follow-up calls. This would free up floor nurses to spend more time with patients.
3) Based on the evidence, the author recommends considering staffing one ADT nurse daily initially to help with teaching classes and follow-up calls, which should improve satisfaction, and help with other tasks as time allows.
A patient undergoing blood transfusion experienced an allergic reaction after the nurse failed to properly monitor his vital signs as required every 30 minutes. Transfusion reactions can be life-threatening if not properly monitored and treated. Nurses have a duty of care to patients under their care. By neglecting to monitor the patient's vital signs as ordered, the nurse breached their duty of care, which likely contributed to the patient's adverse reaction going unnoticed and untreated. Strengthening nursing home staff training and increasing minimum staffing requirements could help avoid such medical errors and improve patient safety and outcomes.
HRSA Comprehensive Geriatric Education Grant Posternomadicnurse
This grant funds a Clinical Nurse Specialist position to work with current Gerontological CNS in providing education, mentoring / support, developing / measuring outcomes for knowledge, practice change and patient outcomes by:
Expanding NICHE training at Piedmont Hospital in Atlanta beyond Acute Care nurses to include Emergency Department nurses;
2) Introducing NICHE training at Piedmont Fayette, Piedmont Newnan and Piedmont Mountainside for Acute Care and Emergency Department nurses;
3) Introducing NICHE training for nursing staff at two of our Long-Term Care facility partners; and
4) Disseminating program materials and information to other healthcare entities throughout Georgia and the U.S. through local workshops and presentations at national healthcare conferences.
Assessing the Effectiveness of the New Senior ED Program at SummaAhmed Furkan Ozgur
This document describes a study that assesses the effectiveness of a new Senior Emergency Department (ED) program at Summa Akron City Hospital. The study compares outcomes between a historical cohort of geriatric ED patients from 2012 and patients seen in the new Senior ED program from 2013. Key outcomes measured include length of stay, admission rates, observation rates, and discharge disposition. The results showed that the Senior ED program significantly reduced admissions, increased observations, and increased discharges home compared to usual ED care. This suggests the new program effectively managed elderly patients.
Presented at the George Washington University 1st GME Retreat. Includes overview of handoff function and content, pitfalls for handoffs, and strategies for safe and effective communication during handoffs, and how to use process improvement techniques to make handoffs safer. Handout includes handoff menu of educational tools to be used by faculty teaching.
Cynthia's Resume Health Communication SpecialistCynthia Strong
Cynthia Strong is seeking a position as a Health Communication Specialist. She has 25 years of experience as a Physical Therapist Assistant and has a Master's in Healthcare Administration. She has expertise in treating medical conditions, conducting classes, and marketing to target audiences. She is skilled in health communication principles, public speaking, and collaborating on projects. Her experience includes coordinating in-services, assisting physical therapists, and managing business operations for home health agencies.
A comparison of public perceptions of physicians and veterinarians in the uni...Eduardo J Kwiecien
The document compares public perceptions of physicians and veterinarians in the United States. A survey of 606 participants rated 25 personality characteristics for each profession on a 9-point scale. Statistical analysis found veterinarians were perceived as more approachable, sensitive, sympathetic, patient and understanding, while physicians were seen as more proud and arrogant. Overall, the results indicate the public tends to view veterinarians more favorably than physicians.
This document discusses improving handoffs between physicians in the emergency department. It notes that communication errors during shift changes are a common cause of treatment delays and adverse events. The document then reviews factors that can lead to errors during handoffs, including distractions, lack of standard processes, fatigue and inexperience. It proposes using multidisciplinary handoffs, clear guidelines and identifying high-risk patients to help improve safety during physician shift changes in the emergency department.
InfoRehab is a research program that uses data from the interRAI Home Care assessment tool (RAI-HC) to identify home care clients who could benefit from rehabilitation services and those at risk for poor health outcomes. The research found that machine learning algorithms were better able to predict rehabilitation potential than current clinical methods. Analyzing RAI-HC data from over 24,000 clients identified various risk factors for hip fractures and helped develop a manageable list of important risk factors. Presenting results to stakeholders showed potential for using machine learning in home care planning and decision support.
Submission ide 41d14985 d484-4305-976f-c8858ad6647630 sirock73
This reflective journal discusses knowledge and skills gained during a Professional Capstone and Practicum course. It covers topics like new nursing practice approaches using evidence-based practice, interprofessional collaboration, healthcare delivery systems, ethical considerations, culturally sensitive care, ensuring human dignity, population health concerns, the role of technology in healthcare, health policy, leadership models, health disparities, and conclusion. The course helped students acquire practical skills and knowledge applicable to nursing practice.
2011/2012 Always Event℠ Challenge Grant Recipient Project OverviewsPicker Institute, Inc.
This document describes grant recipients for the 2011/2012 Picker Institute Always Events Challenge. It provides summaries of 6 recipient organizations and their proposed projects:
1) Quality Partners of Rhode Island will use PictureRx software to provide visual medication schedules to patients before discharge from nursing homes.
2) Massachusetts General Hospital aims to ensure patients always know their care team and receive timely responses through strategies like welcome videos and identification boards.
3) Planetree/Griffin Hospital will utilize an online patient assessment tool and care partners to ensure alignment between patients, caregivers and providers across healthcare settings.
4) St. Jude Children's Research Hospital will implement a parent mentor program to support newly diagnosed families through treatment and beyond
This study examined the core predictors of "hassles" experienced by patients with multiple chronic conditions (multimorbidity) in primary care. The researchers surveyed 486 patients with multimorbidity across four general practices in the UK. They found that the most commonly reported hassles related to lack of information about conditions/treatments, poor communication among providers, and poor access to specialists. Having more conditions, symptoms of anxiety/depression, younger age, employment, and no recent discussion with their GP predicted greater hassles. The study highlights key hassles that should be addressed and patient groups most at risk to help design improved models of care for multimorbidity.
This document discusses using high-fidelity simulation in undergraduate nursing education to improve communication and critical thinking skills. It provides background on high-fidelity simulation and reviews literature finding that it increases nursing students' confidence, skills, and narrow the gap between theory and practice. The author aims to determine if high-fidelity simulation improves competence and confidence in new graduate nurses through their research question. The theoretical framework discussed is Benner's novice to expert model, which the author believes fits with helping students progress their skills through various teaching methods like simulation.
El documento ofrece consejos sobre técnicas de estudio efectivas, incluyendo establecer un horario y lugar fijo para estudiar, determinar la cantidad de material y horas diarias de estudio, y decidir si estudiar solo o en grupo. Recomienda centrarse en lo que se lee sin distracciones, subrayar las partes más importantes, tomar notas con las ideas principales mientras se lee atentamente, y realizar apuntes propios.
Here are the key facts about PETA:
- PETA is the largest animal rights organization in the world, with over 3 million members and supporters.
- It was founded in 1980 by Ingrid Newkirk and Alex Pacheco to promote animal protection and welfare through peaceful public education and nonviolent protest.
- PETA focuses its efforts on four main areas where animals suffer the most: factory farming, the clothing trade, laboratories, and the entertainment industry.
- Through investigations, undercover footage, celebrity endorsements, protests, and educational outreach, PETA aims to end animal abuse and encourage a vegan lifestyle.
- Some of PETA's impacts include pressuring fast food chains like
Healthcare delivery in the periphery workshop outputDayOne
This document summarizes a tri-national workshop on healthcare delivery in peripheral regions. The workshop brought together participants from Germany, France, and Switzerland to identify challenges in peripheral healthcare, develop collaborative projects to address these challenges, and plan next steps. Three priority projects were selected: 1) A platform for hospitals to share best practices and develop an adherence app, 2) A workshop on technological solutions to attract physicians to peripheral areas, and 3) An exchange program for nurses and nursing students to collaborate with technology companies and work towards harmonizing training across borders. Immediate next steps included reporting outcomes to relevant conferences and planning an expert workshop in early 2020.
The document discusses the need for radical change to improve patient safety and decrease preventable adverse events. It notes that recent studies have found adverse event rates in intensive care units and neonatal units to be much higher than previously estimated, with over half of events found to be preventable. The articles presented in this topic aim to address how nursing can better understand and contribute to a culture of patient safety through examining roles, education, frameworks, and models related to safety practices and hazard recognition.
This document provides an overview of the Med-Peds specialty, which involves training and practice in both internal medicine and pediatrics. It discusses the history and development of Med-Peds programs, the residency and training process, practice options, growth potential, and salaries for Med-Peds physicians. The document also examines reasons for choosing Med-Peds and provides results from an O-Net profiler assessment of the author's investigative and social skills that relate to this specialty.
Method of educating nursing students on proper handfatimazaheer12
The document outlines a study comparing hand washing versus hand sanitizer for nursing students to improve infection control during the COVID pandemic. It finds that hand sanitizers are more effective and efficient at killing viruses and preventing disease transmission compared to hand washing, which risks recontamination and takes more time. A two-day study of 10 nursing students is conducted to test procedures, collect data on sanitizer versus hand washing, and analyze results, finding that hand sanitizers kill germs faster and are more practical for maintaining hygiene.
This document provides an overview of the Med-Peds specialty, which involves training and practice in both internal medicine and pediatrics. It discusses the history and development of Med-Peds programs in the 1960s in response to the primary care movement. The document outlines the 4-year residency training requirements, including rotations in adult/pediatric medicine, intensive care, and various subspecialties. It also explores practice options for Med-Peds physicians and reasons for choosing this specialty, including working with patients across the lifespan and career flexibility. Potential graduate programs in South Carolina are described.
The document proposes implementing color-coordinated fall risk identifiers for patients at risk of falls at the Manhattan VA Hospital to potentially decrease falls. It reviews literature finding single interventions like signs or bracelets are less effective than multiple reminders. The proposal is to randomly assign patients scoring high on the Morse Fall Scale to either bright yellow socks/bracelets or a red dot outside their room. Incidences of falls will be compared over 3 months between the two groups to evaluate if color-coordinated identifiers reduce falls more than the current program.
1) The document discusses implementing an Admission, Discharge, Teaching (ADT) nurse role on a postpartum floor to improve patient satisfaction, nurse satisfaction, and safety. Studies show the ADT role increases time for direct patient care and reduces workload.
2) The ADT nurse would help with admissions, discharges, teaching, and follow-up calls. This would free up floor nurses to spend more time with patients.
3) Based on the evidence, the author recommends considering staffing one ADT nurse daily initially to help with teaching classes and follow-up calls, which should improve satisfaction, and help with other tasks as time allows.
A patient undergoing blood transfusion experienced an allergic reaction after the nurse failed to properly monitor his vital signs as required every 30 minutes. Transfusion reactions can be life-threatening if not properly monitored and treated. Nurses have a duty of care to patients under their care. By neglecting to monitor the patient's vital signs as ordered, the nurse breached their duty of care, which likely contributed to the patient's adverse reaction going unnoticed and untreated. Strengthening nursing home staff training and increasing minimum staffing requirements could help avoid such medical errors and improve patient safety and outcomes.
HRSA Comprehensive Geriatric Education Grant Posternomadicnurse
This grant funds a Clinical Nurse Specialist position to work with current Gerontological CNS in providing education, mentoring / support, developing / measuring outcomes for knowledge, practice change and patient outcomes by:
Expanding NICHE training at Piedmont Hospital in Atlanta beyond Acute Care nurses to include Emergency Department nurses;
2) Introducing NICHE training at Piedmont Fayette, Piedmont Newnan and Piedmont Mountainside for Acute Care and Emergency Department nurses;
3) Introducing NICHE training for nursing staff at two of our Long-Term Care facility partners; and
4) Disseminating program materials and information to other healthcare entities throughout Georgia and the U.S. through local workshops and presentations at national healthcare conferences.
Assessing the Effectiveness of the New Senior ED Program at SummaAhmed Furkan Ozgur
This document describes a study that assesses the effectiveness of a new Senior Emergency Department (ED) program at Summa Akron City Hospital. The study compares outcomes between a historical cohort of geriatric ED patients from 2012 and patients seen in the new Senior ED program from 2013. Key outcomes measured include length of stay, admission rates, observation rates, and discharge disposition. The results showed that the Senior ED program significantly reduced admissions, increased observations, and increased discharges home compared to usual ED care. This suggests the new program effectively managed elderly patients.
Presented at the George Washington University 1st GME Retreat. Includes overview of handoff function and content, pitfalls for handoffs, and strategies for safe and effective communication during handoffs, and how to use process improvement techniques to make handoffs safer. Handout includes handoff menu of educational tools to be used by faculty teaching.
Cynthia's Resume Health Communication SpecialistCynthia Strong
Cynthia Strong is seeking a position as a Health Communication Specialist. She has 25 years of experience as a Physical Therapist Assistant and has a Master's in Healthcare Administration. She has expertise in treating medical conditions, conducting classes, and marketing to target audiences. She is skilled in health communication principles, public speaking, and collaborating on projects. Her experience includes coordinating in-services, assisting physical therapists, and managing business operations for home health agencies.
A comparison of public perceptions of physicians and veterinarians in the uni...Eduardo J Kwiecien
The document compares public perceptions of physicians and veterinarians in the United States. A survey of 606 participants rated 25 personality characteristics for each profession on a 9-point scale. Statistical analysis found veterinarians were perceived as more approachable, sensitive, sympathetic, patient and understanding, while physicians were seen as more proud and arrogant. Overall, the results indicate the public tends to view veterinarians more favorably than physicians.
This document discusses improving handoffs between physicians in the emergency department. It notes that communication errors during shift changes are a common cause of treatment delays and adverse events. The document then reviews factors that can lead to errors during handoffs, including distractions, lack of standard processes, fatigue and inexperience. It proposes using multidisciplinary handoffs, clear guidelines and identifying high-risk patients to help improve safety during physician shift changes in the emergency department.
InfoRehab is a research program that uses data from the interRAI Home Care assessment tool (RAI-HC) to identify home care clients who could benefit from rehabilitation services and those at risk for poor health outcomes. The research found that machine learning algorithms were better able to predict rehabilitation potential than current clinical methods. Analyzing RAI-HC data from over 24,000 clients identified various risk factors for hip fractures and helped develop a manageable list of important risk factors. Presenting results to stakeholders showed potential for using machine learning in home care planning and decision support.
Submission ide 41d14985 d484-4305-976f-c8858ad6647630 sirock73
This reflective journal discusses knowledge and skills gained during a Professional Capstone and Practicum course. It covers topics like new nursing practice approaches using evidence-based practice, interprofessional collaboration, healthcare delivery systems, ethical considerations, culturally sensitive care, ensuring human dignity, population health concerns, the role of technology in healthcare, health policy, leadership models, health disparities, and conclusion. The course helped students acquire practical skills and knowledge applicable to nursing practice.
2011/2012 Always Event℠ Challenge Grant Recipient Project OverviewsPicker Institute, Inc.
This document describes grant recipients for the 2011/2012 Picker Institute Always Events Challenge. It provides summaries of 6 recipient organizations and their proposed projects:
1) Quality Partners of Rhode Island will use PictureRx software to provide visual medication schedules to patients before discharge from nursing homes.
2) Massachusetts General Hospital aims to ensure patients always know their care team and receive timely responses through strategies like welcome videos and identification boards.
3) Planetree/Griffin Hospital will utilize an online patient assessment tool and care partners to ensure alignment between patients, caregivers and providers across healthcare settings.
4) St. Jude Children's Research Hospital will implement a parent mentor program to support newly diagnosed families through treatment and beyond
This study examined the core predictors of "hassles" experienced by patients with multiple chronic conditions (multimorbidity) in primary care. The researchers surveyed 486 patients with multimorbidity across four general practices in the UK. They found that the most commonly reported hassles related to lack of information about conditions/treatments, poor communication among providers, and poor access to specialists. Having more conditions, symptoms of anxiety/depression, younger age, employment, and no recent discussion with their GP predicted greater hassles. The study highlights key hassles that should be addressed and patient groups most at risk to help design improved models of care for multimorbidity.
This document discusses using high-fidelity simulation in undergraduate nursing education to improve communication and critical thinking skills. It provides background on high-fidelity simulation and reviews literature finding that it increases nursing students' confidence, skills, and narrow the gap between theory and practice. The author aims to determine if high-fidelity simulation improves competence and confidence in new graduate nurses through their research question. The theoretical framework discussed is Benner's novice to expert model, which the author believes fits with helping students progress their skills through various teaching methods like simulation.
El documento ofrece consejos sobre técnicas de estudio efectivas, incluyendo establecer un horario y lugar fijo para estudiar, determinar la cantidad de material y horas diarias de estudio, y decidir si estudiar solo o en grupo. Recomienda centrarse en lo que se lee sin distracciones, subrayar las partes más importantes, tomar notas con las ideas principales mientras se lee atentamente, y realizar apuntes propios.
Here are the key facts about PETA:
- PETA is the largest animal rights organization in the world, with over 3 million members and supporters.
- It was founded in 1980 by Ingrid Newkirk and Alex Pacheco to promote animal protection and welfare through peaceful public education and nonviolent protest.
- PETA focuses its efforts on four main areas where animals suffer the most: factory farming, the clothing trade, laboratories, and the entertainment industry.
- Through investigations, undercover footage, celebrity endorsements, protests, and educational outreach, PETA aims to end animal abuse and encourage a vegan lifestyle.
- Some of PETA's impacts include pressuring fast food chains like
The student likes their campaign idea and feels the use of facts on the posters works well. They also like featuring a well-known character and logo to make the posters more recognizable and link back to the campaign. While the work shows the intended cartoon style, it could be made more professional by changing features on the posters and adding more detail. Over the next two weeks, the student will finish the remaining posters and start producing planned merchandise to support the campaign.
This document provides background context on Latina women in Texas experiencing domestic violence. It discusses that Latinas represent a significant portion of the Texas population, yet have lower median incomes than white or black families. Domestic violence is a serious issue, with over 50% of women in the US experiencing intimate partner violence. Latina women face unique challenges like language barriers, immigration status, and cultural pressures. The document outlines domestic violence laws in Texas and notes that gun violence is a significant threat, with more women killed by intimate partners with guns than other means. It will analyze texts from non-profits the Texas Council on Family Violence and Alianza to understand how policy frames challenges for battered Latinas.
Strings In OOP(Object oriented programming)Danial Virk
The document discusses strings and string handling in Java. It covers the String and StringBuffer classes, basic string methods like length(), substring(), indexOf(), and replace(). It also discusses parsing strings with StringTokenizer and the differences between StringBuffer and String in terms of mutability and capacity. StringBuffer allows growing the string size while String is immutable.
Protecting intellectual property is important but can be challenging due to project time pressures and fears of making bad decisions or being too rigid. An assertive IP strategy focuses on inventing where it matters by thinking broadly about problems, competitors, customers, and opportunities rather than taking a one-size-fits-all approach. This proactive strategy catalyzes growth through early planning and unified technical and commercial functions, providing sustained competitive advantages from well-grounded decisions and mastering diverse protection tactics.
Interfaces allow for separation of concerns and evolution of a system over time without disrupting existing structures. They specify a service that a class or component provides without implementing any structure or behavior. Common modeling techniques for interfaces include identifying seams between components, modeling static and dynamic types, using packages to group logically related elements, and creating architectural views to visualize different aspects of a system.
Control structures in C++ affect how statements are executed and include sequence, selection, and loop structures. Sequence structures execute statements sequentially, selection structures choose between alternatives using if, if/else, and switch statements, and loop structures repeat statements using do-while, while, and for loops. Common control structures are used to make decisions, repeat actions, and transfer control based on conditions.
detailed information about Pointers in c languagegourav kottawar
This document discusses pointers in C programming. It begins with an introduction to pointers and memory organization. It then covers basics of pointers including declaration, initialization, dereferencing, and pointer expressions. The document discusses various pointer applications including pointer arithmetic, pointers to pointers, dynamic memory allocation, pointers and arrays, and character strings. It provides examples to illustrate concepts like pointer expressions and pointer arithmetic with arrays. The document is intended as a reference for understanding pointers in C.
There are three main types of control structures in computer programming: sequential logic, selection logic, and iteration logic. Sequential logic executes code line-by-line. Selection logic (e.g. if/else statements) allows executing code conditionally. Iteration logic (e.g. for loops) repeats code execution in loops. The document provides examples of if/else, nested if, switch statements, and the conditional operator for implementing various control structures in C programming.
The Importance Of Protecting Your RoofJEREMY JOBIN
This short document contains 5 photos credited to "chefranden" with no other text or context provided. The final slide encourages the viewer to create their own presentation on SlideShare.
USB (Universal Serial Bus) is a standard interface that allows devices to be connected using a single standardized port. It replaced multiple previous standards with a single connection type. RS-232 is an older serial communication standard that defines the signals and connectors used between data terminal equipment and data communication equipment for asynchronous transmission of data. Firewire (IEEE 1394) is a serial bus interface standard that allows for high-speed communications and has features like hot pluggability and power delivery through the cable. It has higher maximum speeds than USB but shorter cable lengths.
Applying and Sharing Evidence Discussion.docxwrite22
This document discusses implementing routine distress screening for gynecologic cancer patients using the Distress Thermometer and Problem List. A study found that 66% of patients screened had moderate to high distress levels. The top problems identified were nervousness, worry, fatigue and sleep issues. Healthcare providers saw benefits for patients in validating their concerns and opening discussion. They also felt it enhanced holistic care. However, finding time for screening in busy clinics was challenging.
Detecting Distress in Gynecologic Cancer Patients Worksheet.docxstudywriters
1) A study assessed distress levels in 62 gynecologic cancer patients using the Distress Thermometer and Problem List. 66% of patients scored 4 or higher on the Distress Thermometer, indicating follow up was needed. The top reported problems were nervousness, worry, fears, fatigue, and sleep problems.
2) Staff perceptions of using distress screening tools were also examined through interviews. While screening helped identify patient needs, staff noted high levels of distress required referral to appropriate services.
3) Both quantitative and qualitative data provided insight into the prevalence and types of distress experienced by gynecologic cancer patients, as well as challenges in implementing distress screening in a clinical setting.
Informatics and nursing 2015 2016.odette richardsOdette Richards
This document summarizes a literature review of research papers in clinical informatics and digital health in nursing from 2015-2016. It describes the search strategy and criteria for including papers, which resulted in 73 papers being shortlisted. Of these, 5 top papers were chosen that either identified gaps in the literature or demonstrated improved patient care through digital health innovations. The document discusses each of these 5 papers and their relevance. It concludes with recommendations and limitations of the literature review.
Telehealth and Geriatrics How telehealth improves medicati.docxAASTHA76
Telehealth and Geriatrics:
How telehealth improves medication management
and patient safety in the geriatric patient
Avrakham Rubinov
Adelphi University
College of Nursing and Public Health
December 3rd, 2018
What is Geriatrics?
Geriatrics is a subspecialty of internal medicine and primary care that was named in 1909 by Ignatz Leo Nascher.
Geriatrics is that specialty of medicine that addresses the health needs of the elderly.
Gellis, Z. D., Kenaley, B., McGinty, J., Bardelli, E., Davitt, J., & Ten Have, T. (2012).
2
Telemedicine is a highly effective
and necessary tool in geriatrics.
The global population of elderly people is increasing at a remarkable rate,
This is expected to continue for some time.
Older patients require more care.
The current model of care delivery indicated costs are expected to rise.
Telemedicine is a great opportunity for medical practice to evolve to cost effective and new levels of engagement with patients
Chang, W., Homer, M., & Rossi, M. (2018).
3
Geriatics, HIT and Patient Safety
CONCERNS:
SOLUTIONS:
Patient safety is a concern.
Telehealth: Difficult to monitor conditions in a patient’s home.
Safety risks such as falls and inability to get in and out of the tub or shower.
Fewer In-Person Consultations
Doctors worry about technical problems associated with telemedicine. poor broadband connections could lead to “possible patient mismanagement.”
Many physicians and patients alike still like a “personal touch,” and not all procedures – even simple checkups – can be performed digitally.
Difficult to monitor depression or other emotional issues.
Health information technology (HIT) is the future of improving care and outcomes for older adults.
There is a growing program of research. HIT are solutions to improving the safety, quality and efficiency of care.
Gerontological nurse scientists are at the forefront of advancing this work.
Electronic health records (EHRs)and telehealth will blend care of older adults.
Multimedia/advanced directives from HIT provided to patients recovering from critical illness have increased the intent to sign an advanced directive by 25 times
Liu, L., Stroulia, E., Nikolaidis, I., Miguel-Cruz, A., Rincon, A. R. (2016).
4
The HITECH Act resulted growth in the development and implementation of the EHR.
The impact of an integrated EHR in 29 Kaiser Permanente hospitals was significant on process and outcome indicators for patient falls and hospital acquired pressure ulcers and other measures of patient safety.
The EHR system was associated with improved documentation of falls/pressure ulcers and significant improvements for pressure ulcer risk assessment documentation.
Bowles, K. H., Dykes, P., & Demiris, G. (2015).
5
NICHE
(Nurses Improving Care for Healthsystem Elders)
NICHE builds decision support within the workflow of nurses caring for old.
This document outlines the doctoral thesis of Dr. Svin Deneckere on improving teamwork and preventing burnout through the use of care pathways. It discusses the growing need for teamwork in healthcare due to factors like increasing specialization and fragmented structures. Care pathways are presented as a tool to improve teamwork by facilitating communication, coordinating roles, and documenting care processes. The thesis involved 4 studies: 1) developing a set of indicators for measuring teamwork; 2) a literature review finding care pathways can improve teamwork; 3) a cluster randomized controlled trial finding care pathways positively impact teamwork; and 4) process evaluations of implementation. The thesis examines how care pathways can enhance teamwork in healthcare organizations.
The document summarizes a study that explored client-centered care experiences in inpatient rehabilitation settings from the perspectives of patients, families, and healthcare providers. The study involved interviews with 8 patients, 4 family members, and 15 healthcare providers from 4 rehabilitation facilities. The main finding was that "Being on common grounds/Working toward client set goals" was important for both clients and healthcare providers. While successful partnerships were formed, most clients assumed a passive role rather than being actively involved in decision making. Clients needed more information about rehabilitation progress and alternative treatment options to better participate in their care.
Brett William Taylor is an academic emergency pediatrician and clinical informatician with over 25 years of experience in pediatric and emergency medicine. He has held positions at several universities and hospitals in Canada, and currently serves as an Associate Professor at Dalhousie University and the IWK Health Centre. His research focuses on using technology and informatics to improve patient-centered care, and he has published widely on topics relating to pediatric emergency medicine and health informatics.
Evidence-based practice is important for nurses to utilize when making decisions about client care. Using the most up-to-date evidence alongside a client's values and preferences can help guide the healthcare process. When evidence-based guidelines are included in a client's plan of care, the clinician has substantial data to make sound decisions and develop the best strategy for delivering care. One study found that pain from venous ulcers was not always properly addressed, negatively impacting healing. This highlighted the need for evidence-based wound care practices that adequately treat pain.
This document describes mHealth tools developed by InSTEDD to help prevent maternal-to-child transmission of HIV, including Remindem for sending reminders via text, Verboice for interactive voice messages, Resource Map for tracking health resources, and Pollit for conducting mobile surveys. The tools are designed to help improve adherence to treatment, identify available prevention and treatment resources, fight stigma, and engage communities.
This document provides an agenda and details for the Annual Health Care Leaders Conference taking place from March 31 to April 1, 2016. The conference will feature keynote speakers David Naylor and Michael Villeneuve and will include multiple concurrent sessions on topics such as role clarity for nursing teams, patient and family centered care, leadership, and more. Poster presentations will also be featured on innovations and initiatives in nursing.
VOLUME 21, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 79CJO.docxjessiehampson
VOLUME 21, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 79CJON.ONS.ORG
A
Detecting Distress
Introducing routine screening in a gynecologic cancer setting
Moira O’Connor, BA(Hons), MSc, PhD, Pauline B. Tanner, RN, RM, CertOnc, SBCN, Lisa Miller, MBBS, DCH, FRACGP, FAChPm, FRANZCP,
Kaaren J. Watts, BA(Hons), PhD, and Toni Musiello, BA(Hons), MA, PhD
ALONGSIDE PHYSICAL SYMPTOMS AND SIDE EFFECTS of treatment, cancer results
in psychological, social, and practical challenges, which can contribute to
patient distress (Carlson, Waller, Groff, Giese-Davis, & Bultz, 2013). The
International Psycho-Oncology Society highlights distress as a critical factor
affecting patients’ well-being and recommends that distress be named the
sixth vital sign in oncology (Holland, Watson, & Dunn, 2011). The report-
ed prevalence rates of psychological distress in patients with cancer range
from 35%–49% (Carlson, Groff, Maciejewski, & Bultz, 2010). However, the
actual rates of distress are thought to be much higher because of underdetec-
tion. Clinician assessments have been shown to be inferior to gold-standard
methods, such as validated screening tools and clinical interviews (Werner,
Stenner, & Schüz, 2012), and distress is often missed by clinicians (Mitchell,
Vahabzadeh, & Magruder, 2011).
Distress encompasses a range of issues, including psychological, spiritual,
and existential distress, as well as juggling roles and having financial concerns
and practical problems, such as needing help with accommodation or travel.
Distress is associated with poorer physical and psychological quality of life
(Carlson et al., 2010). Detecting distress in patients with cancer can result in
early intervention, which helps avoid patients struggling with unmet or com-
plex needs (Faller et al., 2013). Identifying distress early could also reduce the
financial burden on health services (Han et al., 2015). Healthcare profession-
als (HCPs) must recognize distress so it can be adequately managed (Werner
et al., 2012); to do this, HCPs need to screen all patients systematically.
Several organizations and professional bodies state in their standards
for quality cancer care that psychosocial support should include routine
screening for distress, followed by appropriate referrals targeted to the needs
identified by patients (Holland et al., 2011; Werner et al., 2012). Despite this,
uptake of routine distress screening in clinical oncology settings has been
suboptimal (Mitchell, Lord, Slattery, Grainger, & Symonds, 2012). Many
barriers exist to the successful implementation of routine distress screen-
ing in clinical settings, including a lack of training, clinicians’ perception of
limited skills and confidence in identifying distress, and inadequate referral
resources (Absolom et al., 2011). A shortage of private space has also been
identified (Ristevski et al., 2013). Many HCPs believe that addressing distress
will take too much time. However, appropri ...
Literature Evaluation TableStudent Name Vanessa NoaChange.docxmanningchassidy
Literature Evaluation Table
Student Name: Vanessa Noa
Change Topic (2-3 sentences): Patient safety is one of the pertinent issues in nursing home health care. The literature evaluation table summarizes the strength and relevance of eight peer-reviewed articles on the role of nurse education on fall prevention.
Criteria
Article 1
Article 2
Article 3
Article 4
Author, Journal (Peer-Reviewed), and
Permalink or Working Link to Access Article
Author: Howard Katrina
Journal: MEDSURG Nursing
https://www.thefreelibrary.com/Improving+Fall+Rates+Using+Bedside+Debriefings+and+Reflective+Emails%3A...-a0568974192
Authors: Jang and Lee
Journal: Educational Gerontology
Link: https://doi.org/10.1080/03601277.2015.1033219
Authors: Kuhlenschmidt et al.
Journal: Clinical Journal of Oncology Nursing
Link: https://doi.org/10.1188/16.CJON.84-89
Authors: Minnier et al.
Journal: Creative Nursing
Link: https://doi.org/10.1891/1078-4535.25.2.169
Article Title and Year Published
Title: Improving Fall Rates Using Bedside Debriefings and Reflective Emails: One Unit’s Success Story
Year: 2018
Title: The Effects of an Education Program on Home Renovation for Fall Prevention of Korean Older People
Year: 2015
Title: Tailoring Education to Perceived Fall Risk in Hospitalized Patients With Cancer: A Randomized, Controlled Trial
Year: 2016
Title: Four Smart Steps: Fall Prevention for Community-Dwelling Older Adults
Year: 2019
Research Questions (Qualitative)/Hypothesis (Quantitative), and Purposes/Aim of Study
RQs: Why falls remain a challenging and complex problem
What innovative measures can reduce patient falls
Quantitative research
Aim/purpose: To discuss a project that seeks to implement innovative measures that help decrease patient falls
RQs: Does an education program on home renovation reduce falls among older people?
Quantitative study
Hypothesis: Appropriate education is crucial for fall prevention
Aim/Purpose: To verify the impacts of an education program on home renovation for preventing falls among older adults
RQs: Are there evidence-based interventions tailored to the perception of falls risk
Quantitative study
Aim/Purpose: To determine the effects of tailored, nurse-delivered interventions
RQs: Do guides for fall prevention enhance older adults’ knowledge and awareness of fall risks.
Quality improvement project
Aim/Purpose: To implement a simple, author-designed guide for fall prevention among older adults dwelling in the community
Design (Type of Quantitative, or Type of Qualitative)
Survey
Quasi-experimental
Randomized, controlled design
Narrative model
Setting/Sample
A team of clinical staff and leaders
51 participants
91 patient participants
Senior center
Methods: Intervention/Instruments
Open discussions to enable clinical staff to discuss concerns and provide feedback
In-depth interviews and survey
A two-group, controlled design. This design helped to test interventions in the bone marrow plantation unit
The prevention program dubbed Fou.
Discharge Education Plan in a Heart Failure Clinic.docxwrite5
The document discusses developing an evidence-based discharge education plan for patients in a heart failure clinic to reduce readmissions. It provides considerations for developing an orientation course plan, discharge education plan, or care coordination plan including objectives, topics, accountability tools, and aligning plans to professional standards and guidelines to ensure patients understand self-care. The goal is to improve consistency and compliance of education to decrease readmissions by 5% over the next year.
Running Head Course Project ROUGH DRAFT 1Course Project ROUG.docxjoellemurphey
Running Head: Course Project ROUGH DRAFT 1
Course Project ROUGH DRAFT 3
Module 08 Course Project Rough Draft
Course Project Introduction
For more than fifty years, North Memorial has been serving communities across the northwest metro. There are now over five thousand employees working in various hospitals, including, North Memorial Maple Grove. North Memorial Maple Grove Hospital has a 130-bed count and provides emergency, medical, and surgical care to patients in Maple Grove, Minnesota, and surrounding areas. Services at North Memorial Maple Grove include internal medicine, gastroenterology, podiatry, diabetes education, women’s health, men’s health, Ear/Nose/Throat, urgent Care, weight loss and laboratory. Comment by Laura Sheneman: good
In order to give the best service to their patients, North Memorial Maple Grove lives by their mission statement, values, and their guiding principles. North Memorial’s values include respect, accountability, communication, teamwork, and pride. North Memorial believes in listening to, creating relationships with, and involving all patients. By making sure all patients are in the best care, North Memorial promises a safe, secure, and healing environment. They want to make sure all patients are well cared for, comfortable, and most of all, staying well. Our mission at Maple Grove Hospital is to inspire each other to give our patients and their families’ compassionate, remarkable care (Maple Grove Hospital, 2014).
Ensuring safety is Maple Grove’s top priority. Medications are always stored in a safe in each patient’s room. All medications are electronically charted into the system and dispensed using bar coding. All patients’ records are stored in electronic health records so nurses and physicians can have immediate access to patient medical history for accurate and timely treatment. Throughout the hospital there is guaranteed fresh and clean air with their high filtration air exchange systems. To ensure infant safety when they are born, North Memorial Maple Grove has a top-notch infant protection system in the facilities Family Birth Center to help safeguard parents and their offspring. Among the many safeguards the hospital uses to protect patients and their family, they also provide alerts and alarms that directly contact the care team for each patient from anywhere within the hospital through direct communications though the hospitals wireless system.
Each of the 130 private rooms all provide a clean bathroom stocked with a hairdryer, hand towels, and toiletries. Others gadget such as a large screen, HD TV’s that include Direct TV and variety radio stations; bedside remote controls to adjust the heat or air conditioning in each room, and to adjust the shades or lighting within the room; and a pullout sofa for patients guests to feel comfortable while staying overnight. All the rooms incorporated calming, earthy colors to help soothe and relax the patient and their family.
St ...
The document discusses the roles and responsibilities of a DNP-prepared nurse educator. It explores how a DNP nurse educator can teach both in academic and clinical settings while also bridging the gap between nursing education and practice. It then presents a PICOT question regarding the implementation of a diabetes self-management education program and examines strategies to address barriers to effective diabetes management.
The document discusses the roles and responsibilities of a DNP-prepared nurse educator. It compares the activities of an academic DNP nurse educator, who teaches graduate nursing students, to a clinical DNP nurse educator, who provides education in a healthcare setting. The document also proposes a case study involving implementing a Diabetes Self-Management Education and Support program to impact patients' fasting blood sugar and self-management skills over 8-10 weeks. Barriers to diabetes self-management are discussed, as well as strategies to address those barriers through various forms of patient education.
The document discusses clinical decision support systems (CDSS) which are electronic tools that assist clinicians in making clinical decisions for patients. CDSS helps clinicians focus more on interacting with patients by providing clinical guidelines, recommendations, and diagnostic and prescribing support. While these systems can help with continuity of care, implementing them can also lead to confusion and lack of communication if not done properly. The aim is to compare the design and implementation of CDSS to assess diagnostic accuracy before and after its use in patient care.
1. Antenatal counselling for congenital anomaly tests: An exploratory
video-observational study about client–midwife communication
Linda Martin, MSc (Researcher)a,n
, Eileen K. Hutton, PhD (Professor)a,e
,
Janneke T. Gitsels-van der Wal, MA (Researcher)a,f
, Evelien R. Spelten, PhD (Researcher)a
,
Fleur Kuiper, MSc (Research Assistant)a,b,c,d,e,f
, Monique T.R. Pereboom, MSc (Researcher)a
,
Sandra van Dulmen, PhD (Professor)b,c,d
a
Department of Midwifery Science, AVAG and the EMGOþ
Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
b
NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
c
Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
d
Department of Health Sciences, Buskerud University College, Drammen, Norway
e
Obstetrics & Gynecology, Midwifery Education Program, McMaster University, Hamilton, Ontario, Canada
f
Faculty of Theology, VU University, Amsterdam, The Netherlands
a r t i c l e i n f o
Article history:
Received 25 November 2013
Received in revised form
10 April 2014
Accepted 4 May 2014
Keywords:
Antenatal genetic counselling
Doctor–patient relation
Video recording
Congenital abnormalities
a b s t r a c t
Objective: antenatal counselling for congenital anomaly tests is conceptualised as having both Health
Education (HE) and Decision-Making Support (DMS) functions. Building and maintaining a client–
midwife relation (CMR) is seen as a necessary condition for enabling these two counselling functions.
However, little is known about how these functions are fulfilled in daily practice. This study aims to
describe the relative expression of the antenatal counselling functions; to describe the ratio of client
versus midwife conversational contribution and to get insight into clients' characteristics, which are
associated with midwives' expressions of the functions of antenatal counselling.
Design: exploratory video-observational study.
Participants and setting: 269 videotaped antenatal counselling sessions for congenital anomaly tests
provided by 20 midwives within six Dutch practices.
Measurements: we used an adapted version of the Roter Interaction Analysis System to code the client–
midwife communication. Multilevel linear regression analyses were used to analyse associations
between clients' characteristics and midwifes' expressions of antenatal counselling in practice.
Findings: most utterances made during counselling were coded as HE (41%); a quarter as DMS (23%) and
36% as CMR. Midwives contributed the most to the HE compared to clients or their partners (91% versus
9%) and less to the DMS function of counselling (61% versus 39%). Multilevel analyses showed an
independent association between parity and shorter duration of antenatal counselling; (β¼ À3.01;
po0.001). The amount of utterances concerning HE and DMS during counselling of multipara was less
compared to nulliparous.
Key conclusions: antenatal counselling for congenital anomaly tests by midwives is focused on giving HE
compared to DMS. The relatively low contribution of clients during DMS might indicate poor DMS given
by midwives. Counselling of multipara was significantly shorter than counselling of nulliparous;
multiparae received less HE as well as DMS compared to nulliparous women.
Implications for practice: our findings should encourage midwives to reflect on the process of antenatal
counselling they offer with regards to the way they address the three antenatal counselling functions
during counselling of nulliparous women compared to multiparae.
& 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
Introduction
Antenatal screening for Down syndrome, other chromosomal
and structural congenital anomalies has become common obste-
trical practice in many countries (Nicolaides et al., 2002; Leporrier
et al., 2003). Antenatal screening aims to provide timely informa-
tion to women and their partners about the health of their fetus in
Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/midw
Midwifery
http://dx.doi.org/10.1016/j.midw.2014.05.004
0266-6138/& 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
n
Correspondence to: Louwesweg 6, 1066EC Amsterdam, The Netherlands.
E-mail addresses: linda.martin@INHOLLAND.nl (L. Martin),
huttone@mcmaster.ca (E.K. Hutton),
evelienspelten@yahoo.com (J.T. Gitsels-van der Wal),
Jt.vanderwal@vumc.nl (E.R. Spelten), Kuiper.fleur@gmail.nl (F. Kuiper),
m.pereboom@vumc.nl (M.T.R. Pereboom), S.vanDulmen@nivel.nl (S. van Dulmen).
Please cite this article as: Martin, L., et al., Antenatal counselling for congenital anomaly tests: An exploratory video-observational study
about client–midwife communication. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.05.004i
Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
2. order to enhance their reproductive choice (Economides, 1999). If
the fetus is diagnosed with a chromosomal disorder or structural
congenital anomaly, prospective parents have the opportunity to
either prepare for the birth of a child with a congenital anomaly, or
to opt for termination of the pregnancy (Health Council, 2007;
Fransen et al., 2009). Screening tests and these options are
typically discussed during antenatal counselling. In the Nether-
lands, since 2007, midwives have provided routine antenatal
counselling for congenital anomaly tests to nearly 80% of pregnant
population (Wiegers, 2009). The purpose of this counselling has
been to facilitate autonomous, informed decision-making by pro-
spective parents regarding the uptake of antenatal congenital
anomaly tests using an opting in approach (Health Council,
2007; van Agt et al., 2007; Oepkes and Wieringa, 2008; Waelput
and Hoekstra, 2012).
High quality counselling consists of health education, decision-
making support and relationship-building (Roter et al., 2006; Meiser
et al., 2008; Martin et al., 2013a). The latter function is seen as a
necessary condition for enabling the first two counselling functions
and could be accomplished by showing empathy and understanding
and using partnership statements and social conversation (Weil et al.,
2006; Smets et al., 2007; Martin et al., 2013a; www.riasworks.com).
Health education topics include providing information about the
antenatal tests that are available and the anomalies that can and
cannot be detected (van Agt et al., 2007; KNOV, 2010; Martin et al.,
2013a, 2013b). Key elements of decision-making support include
empowering clients to find personal meaning in the information
given and making psychological sense of the implications for the
future. This support is intended to minimise psychological distress
and increase personal feelings of control as well as to facilitate
autonomous decision-making (Roter et al., 2006; McCarthy Veach et
al., 2007; Smets et al., 2007; Meiser et al., 2008; van Zwieten, 2009;
van Zwieten, 2010).
The extent to which this three-function antenatal counselling
model is reflected in daily practice is, so far, unknown. However,
because of the extensive amount of information counsellors are
obliged to give it has been established by Dutch educational and
research programs that the health education function requires a lot of
time and attention to a variety of information (van Agt et al., 2007;
KNOV, 2010; Schoonen et al., 2012a, 2012b, 2011a, 2011b). Further-
more, the role of health educator is more familiar to most counsellors
in the medical setting compared to the role of providing decision-
making support and therefore more counselling activity seems to
focus on providing health education (Roter et al., 2006). Moreover,
clients' characteristics seem to influence counselling in practice.
Counselling with better educated clients seems to contain both more
health education and decision-making support, as better educated
clients ask probably more questions. The presence of a partner seems
also related to both more health education and decision-making
support, as it will take more effort to inform two persons and to
engage them both into the discussion about the decisions at hand
(Roter et al., 2006; Ahmed et al., 2012; Elwyn et al., 2012; Barr and
Skirton, 2013; Martin et al., 2013a).
The current study was designed to provide a detailed descrip-
tion of routine antenatal counselling for congenital anomaly tests
by midwives in the Netherlands, during videotaped, every day
practice (see Appendix A for more information about the Dutch
antenatal screening context). This study aims to (1) describe the
relative expression of the three functions of the antenatal counsel-
ling model (HE, DMS and CMR) during counselling by midwives;
(2) describe the ratio client versus midwife conversational con-
tribution within the three antenatal counselling functions;
(3) explore characteristics which are associated with midwives'
expressions of the three function antenatal counselling model.
It was expected that the health education function would be
expressed most by midwives compared to decision-making support
and that midwives would contribute more to the conversation
during counselling compared to clients. With regards to clients'
characteristics it was expected that parity was negatively asso-
ciated with the amount of health education given during counsel-
ling, because midwives might expect multipara to have former
knowledge. Furthermore, it was expected that consultations with
better educated clients and/or with partners present would con-
tain both more health education and decision-making support.
Methods
We used a video observational design to study antenatal counsel-
ling. The present study is part of DELIVER, a multicentre national
research programme investigating the quality and provision of
primary midwifery care in the Netherlands (Mannien et al., 2012).
Our study was approved by the Institutional Review Board and
the Medical Ethical Committee of the VU University Medical Centre,
Amsterdam, the Netherlands, supplemented by local agreements to
participate from all participating midwifery practices.
Participating midwives
From the 20 primary care midwifery practices participating in the
DELIVER study (Mannien et al., 2012), six practices were purposively
sampled based on their practice size and location in the Netherlands
(urban versus semi-rural and percentages of clients from non-Dutch
origin), and participated between August 2010 and April 2011. Every
participating midwife was asked to video-tape 10–20twenty con-
sultations in order to assure the reliability of the test sample (Fletcher
and Fletcher, 2005) and to complete a pre- and post-counselling
questionnaire. As an incentive for participation, each participating
midwife was offered a one time amount 80 euro credit note after
they finished the video-recordings for this study.
Participating clients
Clients were recruited from all consecutive new clients (pregnant
women and their partners) of the six midwifery practices. We used a
video observational design to study antenatal counselling between
June 2010 and May 2011. Clients (nulliparous or multipara) were
eligible if they were: (1) new to antenatal counselling for the current
pregnancy; (2) aged 18 years or older; (3) able to read Dutch or
English.
Procedure
Clients were invited to participate in the study by the practice
assistant and if they agreed received additional, written information
about the study. Participating clients and partners were asked to sign
an informed consent form as well as to complete a pre-visit
questionnaire.
Measurements
Midwifery and client questionnaires
Midwives' characteristics such as age, gender and religion were
derived from a questionnaire completed as part of our study
regarding midwives' views on appropriate antenatal counselling
(Martin et al., 2013b). Clients' background characteristics such as
age, parity and ethnicity, were derived from the pre-visit ques-
tionnaire (Martin et al., 2013a).
L. Martin et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎2
Please cite this article as: Martin, L., et al., Antenatal counselling for congenital anomaly tests: An exploratory video-observational study
about client–midwife communication. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.05.004i
3. Measurement to code HE, DMS and CMR on videotapes: RIASprenatal
The most well-known and frequently used coding scheme for
provider–patient communication with good reliability and con-
current validity is the Roter Interaction Analyses System (RIAS)
(Roter et al., 2006; Ellington et al., 2011; Roter et al., 2011)
(Appendix B). RIAS is also the most exhaustive coding scheme
available (Ellington et al., 2011; Roter et al., 2011). During the
coding procedure meaningful utterances (e.g. a sentence or a
thought) of midwives and clients were counted, e.g. the client
asking the midwife which anomalies can be found using antenatal
screening; or the midwife informing the client of her risk of having
a child suffering from a congenital abnormality. The occurrence of
utterances with similar themes are categorised and the frequen-
cies are then counted. Three trained observers used an adjusted
version of the RIAS, the RIASprenatal
, to code the video recordings.
Health Education was coded using the content areas ‘medical
condition’ and ‘medical testing’ concerning topics such as informa-
tion exchange about the medical conditions which can be detected
by antenatal congenital anomaly tests, and ‘societal information
exchange’ concerning topics like costs and eligibility of these tests.
All codes within these main categories were computed into the
categories HE Information, HE Questions and Total HE (Table 4).
Decision-making support was coded using the content area ‘counsel-
ling behaviour’ (midwives only category) or ‘psychosocial topics’
containing topics that address exploration of clients' moral dilemmas
concerning the decision about whether to take antenatal congenital
anomaly tests. The main coding area DMS was also divided into two
sub-areas DMS Information and DMS Questions. Finally, the client–
midwife relation was coded using the ‘affective behaviour’ categories
of the RIAS; affective behaviour facilitates this relation through the
development of affinity and responsiveness to the client's emotions.
Examples of this category are giving verbal attention, agree and
backchannel (e.g. ‘hm, hm’ or ‘ok’) and social behaviour.
Coding categories per main coding area (HE, DMS and CMR)
were derived from the original RIAS and expanded with 32 items
of the 58 item QUOTEprenatal
questionnaire, a client-centred
instrument to assess clients preferences regarding antenatal
counselling for congenital anomaly tests (Martin et al., 2013a).
The 32 items were selected from the possible 58 based on the
criterion that they had to be observable as verbal communication
during the coding of the video-taped consultations. The 32 items
we used of the QUOTEprenatal
questionnaire were assigned to the
most suitable coding area based on the Principal Component
Analysis used in the study of Martin et al. (2013a) (Table 1).
Coding reliability
Inter-rater reliability was calculated on a random sample of 26
(9.3%) of the 269 study video tapes. Intraclass correlation (ICC) was
used to measure the inter-rater reliability for midwife, client and
partner categories with a mean occurrence greater than 2% of the
total, which proved to be adequate (Pieterse et al., 2005a, 2005b;
Pieterse et al., 2006). At the start and half way through the coding
process levels of agreement were measured; some videos were
coded again in order to enhance the coding reliability, which it did.
Midwife categories had a substantial mean ICC (ICC single mea-
sures) of 0.67 (Range: 0.53–0.70). The average ICC of client
categories (ICC single measures) was moderate with 0.53 (Range:
0.45–0.58) and the mean ICC of partner categories (ICC single
measures) was good with 0.82 (Range: 0.72–0.91) (Landis and
Koch, 1977). Moderate and substantial ICCs such as 0.53 and 0.67
are seen in other video-recording studies using similar approaches
(Bensing et al., 1995; Roter and Larson, 2002; Pieterse et al., 2005a,
2005b; Steinwachs et al., 2011; van Weert et al., 2013).
Data analysis
Descriptive statistics were used to describe the socio-demographic
characteristics of participating midwives, clients and partners. We
compared characteristics of midwifery respondents with characteris-
tics of the National midwifery population to examine the representa-
tiveness of our research sample with respect to the available
information (i.e. age, gender and place of vocational education).
Non-response analyses of clients, who declined to participate in this
study, were conducted using independent t-tests and χ2
tests to
compare both groups with regards to background characteristics such
as age and parity. Furthermore, descriptive statistics and multilevel
regression analyses were used to describe the potentially independent
association between clients' background characteristics and the dura-
tion of counselling.
Relative expression of the three antenatal counselling functions
Descriptive statistics (frequencies, percentages) of the coded
utterances were used to describe the relative expression of the
three counselling functions by clients, partners and midwives
together. Throughout the analysis utterances are defined as the
smallest unit of expression or statement to which a meaningful
code can be assigned, generally a complete thought, expressed by
each speaker (client, partner, midwife) throughout the counselling
session.
Ratio client versus midwife conversational contribution
The ratio of midwives' versus clients' (women and partners
separately) contributions to the conversation relative to the
total count of utterances were calculated per counselling function
using descriptive statistics. For instance HE: midwives' total
HE utterances/total HE utterances; clients' total HE utterances/
total HE utterances and partners' total HE utterances/total HE
utterances.
Characteristics associated with midwives' expressions of the three
antenatal counselling functions
The data in our dataset came from 20 midwives of six practices.
Therefore, we assumed dependency of our observations. To control
for this clustering, a multivariate multilevel linear regression
analysis was used to examine client characteristics that are
possibly, independently associated with differences in the expres-
sion of the three functions of antenatal counselling by midwives.
During multivariate multilevel linear regression analysis the fol-
lowing procedure was used. First, we ran a ‘naïve’ analysis (linear
regression analysis) of the relationship between each character-
istic (clients' age, parity, religion, ethnicity, education and presence
of the partner during counselling) and each of the three indepen-
dent variables (HE, DMS and client–midwife relation utterances of
midwives). Second, we used the likelihood ratio test to determine
if a random intercept of ‘midwife’ alone, ‘practice’ alone or ‘mid-
wife and practice’ together would provide the best approach for
running the third step. Third we used the likelihood ratio test to
evaluate the necessity of a random slope for each dependent
variable to the model. We built the final association model for each
independent variable separately using a backward selection pro-
cedure. For these final analyses we used pr0.05 to indicate
significance, keeping in mind the arbitrary nature of this limit
(Twisk, 2006). SPSS 21.0 was used for the analysis.
L. Martin et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3
Please cite this article as: Martin, L., et al., Antenatal counselling for congenital anomaly tests: An exploratory video-observational study
about client–midwife communication. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.05.004i
4. Findings
Participating midwives and recorded visits
269 video-recordings of 20 midwives working in six practices
were included in the analyses. Per practice the number of
participating midwives ranged from one to five midwives. Record-
ings per midwife ranged from seven to 23. The mean age of the
participating midwives was 32.8 years of age (range 23–54 years
of age), and mean years of work experience was 8.3 years (range:
just started to 33 years of work experience) (Table 2).
One of the midwives offered counselling for antenatal con-
genital anomaly tests during separate counselling sessions, the
other 19 midwives offered this counselling during the routine
intake. Within the latter group 191 complete intakes were
recorded and in 71 cases the video-recordings were switched on
and off to only record the counselling parts of the intake. In cases
where the video-recordings contained the whole intake, only the
antenatal counselling part was or antenatal counselling parts were
analysed. The coding book for coders provided information about
how to decide the counselling was started and ended.
Table 3 illustrates that the counselling lasted on average 9.13
(SD¼4.16) minutes. Only parity was independently and signifi-
cantly associated with the duration of counselling. Antenatal
counselling of multipara lasted statistical significantly less long
compared to nulliparous (β¼ À3.01; 95% CI: À3.96 to À2.05;
po0.001). The amount of utterances during the counselling is
Table 1
Items of the QUOTEprenatal
added to the main content areas of the RIASprenatal
.
Client–midwife relation
Q17 Give the client (additional) written information
Q18 Tell the client that she can always contact me with any questions she may have (including when the practice is closed)
Health education
Q31 Explain the usefulness of prenatal screening (what the client can decide to do eventually)
Q32 Tell the client about all the different types of prenatal tests
Q26 Explain which anomalies can be identified using prenatal screening
Q43 Explain which prenatal tests will be done first and which will be done later, if required and/or necessary
Q45 Explain how long the client may take to decide whether or not to have the prenatal tests
Q48 Discuss all clients options with regard to prenatal screening and the implications
Q29 Discuss possible negative implications of prenatal screening for the unborn child
Q36 Ask about clients family´s history of birth defects
Q33 Tell the client how prenatal screening can affect her emotions and mental wellbeing
Q41 Tell the client why she is or is not eligible for certain prenatal tests
Q42 Explain what will happen DURING the prenatal tests
Q27 Explain which anomalies cannot be identified using prenatal tests
Q39 Tell the client about HER chances of having a child with a congenital abnormality during this pregnancy
Q40 Talk to the client about how HER risk of having a child with a birth defect will affect her
Q44 Explain who will give the client the results of the prenatal tests and how (verbally, in writing or by telephone)
Q37 Explain how often congenital anomalies occur in pregnant women of clients age
Q46 Explain how long the client may take to decide whether or not to terminate the pregnancy, should the test results show an abnormality
Q34 Tell the client how much prenatal tests cost
Q38 Explain how the chances of a birth defect are calculated for our unborn child
Q28 Provide medical information about the anomalies that are being tested for
Q35 Tell the client about the incidence of birth defects in the Netherlands
Decision making support
Q22 Responded to what the client already knew about prenatal screening
Q55 Ask how the client thinks she will react to the results of the prenatal tests
Q14 Enquire clients' standards, values and views on prenatal screening and diagnostic
Q49 Talk to the client about how her family and she would react to a child with a birth defect
Q50 Ask the client to explain her decision to take/not to take the prenatal tests
Q3 Tell which websites the client can use to find information about prenatal screening and diagnostic
Q53 Ask whether test results indicating that clients unborn child has a birth defect would cause problems with her conscience
Q30 Tell the client what the Dutch government aims to achieve by providing prenatal tests
Q52 Ask the client what for her constitutes a healthy child
Q9 Advise the client about whether or not to take the prenatal tests
Q54 Ask whether clients family, friends or other people close to her would support her decision to terminate the pregnancy if the child were to have a congenital
abnormality
Q51 Asks whether clients family, friends or other people close to her would support her decision about prenatal screening
Table 2
Demographic and professional characteristics of midwives.
Characteristics Midwives
n¼20 (%)
Dutch midwifery population
n¼2264n
(%)
r40 years 16 (80) 1644 (73)
Z41 years 4 (20) 620 (27)
Gender
Male – 43 (2)
Female 20 (100) 2569 (98)
Ethnicity†
Native 14 (70) No information available
Non-Native – Non-
Western Ethnicity
2 (10)
Non-Native – Western
Ethnicity
4 (20)
Work experience (years)
r2 years 4 (20) No information available
3–11 years 12 (60)
Z12 years 4 (20)
Religious background
Non-religious 11 (55) No information available
Religious 9 (45)
n
Hingstman and Kenens (2011).
†
In the Netherlands, ethnic origin is defined by country of birth of a person's
parents. If one of the parents (of both of them) of a person is born outside the
Netherlands, this person is non-Native (Dutch National Office of Statistics; Statistics
Netherlands).
L. Martin et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎4
Please cite this article as: Martin, L., et al., Antenatal counselling for congenital anomaly tests: An exploratory video-observational study
about client–midwife communication. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.05.004i
5. positively related to the duration of counselling and counselling of
nulliparous lasted significantly longer compared to multipara.
Therefore, it was decided to measure the ratio client versus
midwife conversational contribution overall and for nulliparous
(n¼98) and multipara (n¼141) separately.
Participating clients
Of the 460 eligible clients (pregnant women) invited to take
part in the study, 324 (70.4%) agreed to participate, but due to
recording and other problems a number 55 video-tapes were lost,
leaving 269 clients (269/460¼58.5%) to be included in the
analysis. Of those included, 194 consultations (194/269¼72.1%)
clients and their partner visited their midwife together. Data on
background characteristics were available for 241 clients (241/
269¼89.6%) and 171 partners (171/194¼88.1%). Table 4 shows the
background characteristics of clients and partners. The mean age
of clients was 29.2 years of age, (range 20–40 years) and the mean
age of partners was 31.8 years of age (range 18–47 years).
We analysed the characteristics of the 136 clients who declined
participation. The percentage of multiparas in the non-participant
group (75.6%) were higher compared to participants (59.9%) (X2
(1, n¼324)¼8.58, p¼0.003, φ¼0.159).
Relative expression of the three antenatal counselling functions
Table 5a and b presents the total amount of utterances regarding
the three functions of counselling for antenatal congenital anomaly
tests made by midwives, clients and partners. 41% (20635/50154) of
the utterances were coded as HE, 23% (11528/50154) as DMS and 36%
(17991/50154) as building a client–midwife relationship.
Ratio client versus midwife conversational contribution
Table 5a and b shows that the overall conversational contribu-
tion of midwives during antenatal counselling exceeded the
contribution of clients and partners (60% versus 32% and 8%,
respectively) with no difference for the nulliparous compared to
multipara Z5%. More specifically, results show that midwives
contributed the most to the conversation during HE; they made
91% of the HE utterances, 7% were made by clients and 2% by
partners. The majority of the utterances made by midwives were
characterised as giving HE Information (90% out of 91%). Also, most
utterances of clients and partners were characterised as giving HE
Information.
With regards to decision-making support Table 5a and b shows
that midwives' relative contribution to the conversation was 61%,
clients 29% and partners made 10% of the utterances regarding the
decision-making support function of antenatal counselling. How-
ever, these ratios were different for nulliparous compared to
Table 3
Characteristics of the video-taped consults.
Duration of consultations and antenatal counselling n % M in minutes (SD in minutes)
Duration of counselling 269 100.0 9.13 (4.16)
Duration of counselling in integrated consultations 191 71.0 9.29 (4.22)
Duration of counselling in integrated consultations if video recordings were switched on and off 71 26.4 8.32 (3.56)
Duration of separated counselling 7 2.6 n
Duration of counselling nulliparous 98 41.2 11.03 (4.09)
Duration of counselling multipara 140 58.8 7.91 (3.99)
Duration of counselling Dutch participants 184 77.0 9.46 (4.09)
Duration of counselling non-Dutch participants 55 23.0 9.01 (4.82)
Duration of counselling religious participants 127 47.2 9.08 (4.25)
Duration of counselling non-religious participants 112 41.6 9.59 (4.22)
Duration of counselling lower educated women 115 47.9 9.28 (4.27)
Duration of counselling higher educated women 125 52.1 9.40 (4.27)
Duration of counselling if partner was present 197 73.2 9.85 (4.31)
Duration of counselling if partner was absent 72 28.8 7.45 (3.59)
Bold figures indicate independent significantly association between groups (po0.001).
n
Number of cases too small for relevant, further analyses.
Table 4
Characteristics of pregnant women and (if present) their partners.
Characteristics Pregnant women
n¼241n
(%)
Partner n¼171n
(%)
Gender
Male – 168 (99.4)
Female 241 (100.0) 1 (0.6)
Age (years)
r25 years 44 (18.5) 21 (12.6)
26–30 years 108 (45.4) 45 (26.9)
31–35 years 73 (30.7) 69 (41.3)
Z36 years 13 (5.5) 32 (19.2)
Highest level of education†
Up to high school 115 (47.9) 88 (52.1)
Higher vocational education/
university
125 (52.1) 81 (47.9)
Ethnicity‡
Native 184 (77.0) 135 (80.8)
Non-Native 55 (23.0) 32 (19.2)
Religious background
None 112 (47.1) 80 (47.9)
Christian 102 (42.9) 78 (46.7)
Muslim 22 (9.2) 7 (4.2)
Other 2 (0.8) 2 (1.2)
Pregnancy duration
r11 weeks 204 (92.3) 147 (94.2)
Z12 weeks 17 (7.7) 9 (5.8)
Parity
Nulliparous 98 (41.2) 92 (55.1)
Multipara 141 (58.8) 75 (44.9)
n
Due to missing and inapplicable answers the n can vary from variable to
variable. Valid percentages are shown.
†
Up to high school includes the Dutch MBO.
‡
In the Netherlands, ethnic origin is defined by country of birth of a person's
parents. If one of the parents (of both of them) of a person is born outside the
Netherlands, this person is non-Native (Dutch National Office of Statistics; Statistics
Netherlands, 2012).
L. Martin et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 5
Please cite this article as: Martin, L., et al., Antenatal counselling for congenital anomaly tests: An exploratory video-observational study
about client–midwife communication. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.05.004i
6. Table 5
(a) Counsellors' MF (n¼20), clients' (n¼269) and partners' (n¼194) number and percentages of total counselling utterances across the three functions of antenatal counselling.
MF Client Partner Total
n % n % n % n (%)
Health Education (HE)
Health education questions 241 1 453 2 192 0.9 886 (4)
Health education information 18520 90 936 5 293 1.1 19749 (96)
Total Health Education utterances 18761 91 1389 7 485 2 20635 (100)
20635/50154¼41%
Decision-making support
Decision-making support questions 1151 11 35 0 34 0
Decision-making support information 1878 16 3359 29 1123 10
Decision-making support counselling 3948 34 – – – –
Total Decision-making support utterances 6977 61 3394 29 1157 10 11528 (100)
11528/50154¼23%
Client–midwife relation
Affective communication: verbal attention, social behaviour, agree and backchannels, approval, concern, reassurance, disagree 3497 19 11094 62 2689 15
Giving written information 557 3 2 0 2 0
Offer the possibility to talk about antenatal tests again 150 1 – – – –
Total client–midwife relation utterances 4204 23 11096 62 2691 15 17991 (100)
17991/50154¼36%
Total amount of antenatal counselling utterances 29942 60 15879 32 4333 8 50154 (100)
(b) Counsellors' MF (n¼20), clients' (n¼269) and partners' (n¼194) number and percentages of total counselling utterances across the three functions of antenatal counselling for and nulliparous (n¼98) and multipara
(n¼141) separately and all clients together (n¼269).
MF Client Partner Total
n % n % n % n %
Health Education (HE)
Nulliparous 8849 92 553 6 236 2 9638 100
Multipara 8129 90 724 8 197 2 9050 100
Nulliparous and multipara together (n¼269) 18761 91 1389 7 485 2 20635 100
Decision-making support
Nulliparous 3240 65 1252 25 494 10 4986 100
Multipara 3037 56 1854 34 514 10 5405 100
Nulliparous and multipara together 6977 61 3394 29 1157 10 11528 100
Client–midwife relation
Nulliparous 1637 21 4708 60 1480 19 7825 100
Multipara 2163 25 5493 64 916 11 8572 100
Nulliparous and multipara together 4204 23 11096 62 2691 15 17991 100
Total amount of antenatal counselling utterances
Nulliparous 13726 61 6513 29 2210 10 22449 100
Multipara 13329 58 8071 35 1627 7 23027 100
Nulliparous and multipara together 29942 60 15879 32 4333 8 50154 100
Bold figures show differences Z9% between the relative contribution to the conversation between counselling of nulliparous versus multipara.
L.Martinetal./Midwifery∎(∎∎∎∎)∎∎∎–∎∎∎6
Pleasecitethisarticleas:Martin,L.,etal.,Antenatalcounsellingforcongenitalanomalytests:Anexploratoryvideo-observationalstudy
aboutclient–midwifecommunication.Midwifery(2014),http://dx.doi.org/10.1016/j.midw.2014.05.004i
7. multipara. Multipara contributed relatively more to the conversa-
tion during decision-making support (34%) compared to nulliparous
(25%). Overall, of the midwifery utterances coded as DMS, the
majority (34%) were intended to direct behaviour. For example
‘you really have to talk about your decision at home together with
your partner’ or utterances stating the ‘opting in’ system used in
the Netherlands such as ‘it is important to think about the
implications of antenatal testing before you take or refuse them’.
The least frequent utterances of midwives were DMS Questions
(11%), such as ‘what reasons do you have to take or refuse prenatal
tests?’ Both clients and partners made the most utterances
regarding giving DMS Information (29% and 10%, respectively),
such as ‘The combined test is just a risk assessment. I think the
results will only upset me’.
Regarding the client–midwife relation most utterances of mid-
wives, clients and partners were coded as agree or backchannel.
Characteristics associated with midwives' expressions of the three
antenatal counselling functions
Results of the multivariable multilevel analyses of the whole
dataset show that data were clustered within midwives, but not
within practices. Regarding the HE function of counselling, the
multivariable multilevel analyses shows that of the five potential
client characteristics that were included in the model (age, religion,
level of education, parity and partner being present or not), only
parity was independently and significantly associated with the
amount of HE utterances as well as DMS utterances (β¼ À27,41;
CI: À35,20 to À19,63; po0.001 and β¼ À10,62; CI: À14.30 to
À6.95 respectively); midwives used less health educational and
decision-making support utterances during counselling of multipara
compared to counselling of nulliparous. The expression of building a
client–midwife relation was independently and significantly asso-
ciated with the religious background of clients and the age of the
pregnant women. With non-religious clients midwives used less
client–midwife relation utterances compared to religious women
(β¼ À2.42; CI: À4.88–0.04; p¼0.05) and a higher age of pregnant
women was associated with more midwives' utterances regarding
the client–midwife relation (β¼0.41; CI: 0.11–0.70; p¼0.01).
Discussion
This study shows that almost half of the utterances made
during antenatal counselling for congenital anomaly tests by
midwives were coded as related to the health education function
of antenatal counselling. About a quarter of the utterances was
related to the decision-making support function. Building a client–
midwife relation was accomplished by both midwives and clients
primarily through active listening techniques such as giving back-
channels and agreements.
As expected, midwives contributed the most to the conversa-
tion coded as health education. Regarding the decision-making
support function of counselling, the relative contribution of mid-
wives was less extensive compared to their contribution during
health education, whereas clients and their partners contributed
more to the decision-making support conversation compared to
their relative contribution during health education. This ‘pattern’
was different for nulliparous compared to multipara; during
decision-making support of multipara midwives' relative contribu-
tion to the discussion was less compared to their contribution
during decision-making support of nulliparous. Such differences
were not found within the other two functions of counselling.
Counselling of nulliparous women lasted significantly longer than
counselling of multiparous women.
Other research on client–counsellor communication, also con-
cluded that counselling sessions are largely didactic in nature with
relatively little emphasis on the psychological and emotional
aspects of the decision-making process of clients and decision-
making support (Pieterse et al., 2005a, 2005b; Roter et al., 2006).
Most of the counselling took place during the initial intake,
although a separate counselling consultation is recommended by
national guidelines and the literature (de Boer and Zeeman, 2008;
van Zwieten, 2008; Ahmed et al., 2012; Elwyn et al., 2012;
Barr and Skirton, 2013). Perceived time pressure may be a reason
why most practices choose to counsel within the initial intake,
despite recommendations from the national guidelines. Most
clients enter midwifery care between around 8.6 weeks of preg-
nancy (Martin et al., 2013a). Scheduling two appointments
(e.g. one intake and one antenatal counselling session) is challen-
ging as the blood test of the CT has ideally to be done around 10
weeks of the pregnancy. One way to improve this suboptimal
situation is to provide clients with more information about choices
at hand, prior to the initial consultation. For example by asking
clients and partners to complete a decision aid at home and read
information. During counselling the counsellor can then check
knowledge, focus on pros and cons of the options, discuss the
outcome of the decision aid and provide client-centred decision-
making support (Elwyn et al., 2012). As far as we know, this
approach is not commonly used by midwives. Limited time in
combination with a client with little or no prior knowledge could
have affected the way midwives asked decision-making support
questions, i.e. more as rhetorical questions.
With regards to the decision-making support function of coun-
selling the results of our study are promising. Midwives seem to
understand that during this part of the conversation it is impor-
tant to step back and listen to the clients' way of making sense of
the information they just received. However, our study shows also
that midwives use relatively fewer exploring questions compared
to directing behaviour. This approach could potentially cause less
informed decision-making, because clients are not invited to really
answer reflective questions during counselling. As a result, they
might not consider them at all and therefore base their decision on
uninformed instead of informed preferences. Achieving informed
preferences is the optimal goal as decisions will be better under-
stood, based on more accurate expectations about the negative
and positive consequences and more consistent with personal
preferences (Frosch and Kaplan, 1999; Elwyn et al., 2012).
Results of the multilevel analyses showed a strong association
between parity and the amount of health education and decision-
making support provided. Furthermore, as expected, counselling
of nulliparous women lasted significantly longer than counselling
of multiparae. One explanation could be that multiparae know
already more about the available tests and might have experience
in making decisions about the test uptake and therefore need less
health education and decision-making support talk and shorter
counselling. However, from an earlier study of our research group
it is known that significantly fewer multiparae compared to nullipar-
ous women perceive that the HE they received during counselling
met their pre-visit preferences and that a majority of multiparae with
strong preferences for decision-making support perceived that these
preferences were not fully addressed during counselling (Martin et
al., 2013a). As we found no random slope for parity and we did find
clustering of data within midwives, midwives seem to be the initiator
of contributing more to the decision-making support of nulliparous
compared to multiparous women. With the current data it remains
unclear if this approach together with differences in the duration of
counselling is accurate especially within the Dutch context in which
the fee midwives receive for counselling of nulliparous and multipara
is the same. The funded pre-test counselling time is 30 minutes
(Scholman, 2009).
L. Martin et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 7
Please cite this article as: Martin, L., et al., Antenatal counselling for congenital anomaly tests: An exploratory video-observational study
about client–midwife communication. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.05.004i
8. This study indicated that the full funded 30 minutes for
counselling was not used, on average. There may be several
reasons why midwives do not use the allocated counselling time
pre-test counselling during this first antenatal visit. Perhaps mid-
wives plan to spend additional time later in the pregnancy for
example additional counselling for the FAS. Alternatively, they
may want to reserve some extra funded time for post-test
counselling. Furthermore, maybe there is a difference in percep-
tion of time needed between midwives and policy makers. Recent
studies demonstrate that a substantial part of the Dutch midwives'
perceptions regarding the content of health education do not
entirely match clients' preferences and that not all midwives fully
endorse the counselling function decision-making support,
whereas clients prefer tailored health education as well as
decision-making support (Martin et al., 2013a, 2013b). Using the
funded 30 minutes time could improve counselling that meets
clients' individual preferences as well as professional guidelines.
The expression of building a client–midwife relation was
statistically, independently and significantly associated with the
religious background of clients indicating that midwives used
more client–midwife relation utterances during counselling of
religious women. It is difficult to provide examples of the differ-
ences between counselling of religious versus non-religious
women, as the client–midwife relation is built during the whole
counselling using utterances such as ‘yes, I can imagine it is a
difficult decision to make’ or ‘hm, indeed’. However, an explana-
tion for the expression of more client–midwife relation utterances
used within counselling of religious women, could be that in
general believers indicate obedience to an authority (e.g. God, the
bible, doctrines and preacher) as more important than non-
believers do (Becker and de Hart, 2006). So, from the perspective
of a believer, a midwife could be seen as an authoritative person
with whom it is important to build a relationship of trust.
Furthermore, in general, non-believers are more individualised
than believers and one of the characteristics of individualisation is
the emphasis on interest of the person herself (Beck and Beck-
Gernsheim, 2002; Becker and de Hart, 2006).
Study limitations
First, our study included only 20 midwives of the 2264 midwives
in the Netherlands (Hingstman and Kenens, 2011; ). Therefore, the
generalisability of the findings of this explorative study is limited.
Some of the midwives video-taped a relatively small amount of their
consultations, which might not be representative for their way of
counselling. Depending on the medical history of the client and the
policy of the midwifery practice, additional counselling sessions could
be held. These were not included in the study, because especially
during the first consultation, focusing on pre-test counselling, the
foundation for a relationship between the midwife and the client (and
partner) is laid. However, participating midwives stated that they
counselled for both the combined test and the fetal anomaly scan
during the recorded counselling sessions and therefore it is likely that
most of it was video-taped. Second, although the ratio multiparae
versus nulliparae in the current study was the same as the Dutch
pregnant population (The Netherlands Perinatal Registry, 2011) fewer
multiparae participated. Furthermore, our study sample was more
highly educated and more of Dutch origin than the Dutch pregnant
population, although practices participating in this study were also
located in the so called ‘Randstad’ area of the Netherlands, where
significantly more people from non-Dutch origin live (The
Netherlands Perinatal Registry, 2011). This also limits generalisability
of our results. Last, using the RIAS prenatal for analyses as we did, all
utterances get the same count irrespective of whether they refer to
words or backchannels such as ‘hm, hm’ or to a whole expression,
such as ‘you have to know that the combined test is a risk assessment
only’. In general, health education utterances are more likely to be
whole expressions and not backchannels. During decision-making
support backchannels will more often used reflecting active listening
after asking exploring questions. These backchannels are counted as
client–midwife relation utterances. As a result, the relative amount of
health education utterances compared to decision-making support
utterances may have been underestimated.
Key conclusions
À We found that midwives focused primarily on the health
education function of counselling for antenatal congenital
anomaly tests. As expected, during health education midwives
did most of the talking while clients were listening.
À During decision-making support clients, especially multiparae,
contributed more to the conversation compared to their con-
tribution during health education. However, midwives contrib-
uted still more to the discussion compared to clients and used
relatively few exploring questions.
À Parity appears to be independently associated with the way
midwives counsel their clients. Nulliparous women receive
more health education as well as decision-making support and
contributed less to the conversation during decision-making
support compared to multiparae.
Practice implications
Our findings should encourage midwives to reflect on the way
they address the three antenatal counselling functions during
counselling of nulliparous women compared to multiparae. Reflec-
tions should include the connection to knowledge of clients: ‘what
do you know about prenatal screening?’ followed by: ‘can you tell
me what additional information you might need from me?’
Regarding decision-making support, in our study a midwife stated
‘The most important thing to do is to think about what you would
do if your test informs you that your child has Down syndrome
[…] I think it is important to talk this through with your
boyfriend’. Rather than telling a client what to do, we would
encourage midwives to ask open questions such as ‘what would
you do in case prenatal tests informs you that your child has Down
syndrome?’ and wait for the answer, also when it takes the client
some time to formulate it. Another approach to the starting of the
counselling could also be considered; for example, providing
clients with a decision aid to complete prior to starting the
counselling session with the midwife. The counselling could start
with: ‘What do you want to know about the health of your child
during pregnancy?’ or ‘Why would you opt for prenatal screening
or why would you not opt for prenatal screening?’ This directs the
counselling more towards DMS compared to HE.
The Shared Decision Making model could be used as a practical
guideline to optimise both the health education and decision-
making support functions of antenatal counselling. The model
divides the conversation into three parts: ‘choice talk’: the pros
and cons of each choice (e.g. the choices about antenatal screen-
ing, the choices about antenatal diagnosis, the eventual choices
about termination of pregnancy), ‘option talk’: exploration of
preferences and moral values as well as providing further decision
support by using decision tools and ‘decision talk’: reflection on
the time needed to make the decision.
Conflict of interest
None declared.
L. Martin et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎8
Please cite this article as: Martin, L., et al., Antenatal counselling for congenital anomaly tests: An exploratory video-observational study
about client–midwife communication. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.05.004i
9. Acknowledgements
We gratefully acknowledge the contribution of the clients and
midwives in the Netherlands, who provided the data for this
study. We also thank Lydia Gitsels and Veerle Steenhuis for their
work on the video-coding project. In addition, we thankfully
acknowledge AVAG for funding this study.
Appendix A. Dutch antenatal screening context
Since 2007 antenatal screening is offered to all Dutch pregnant
women using an opting in approach (Health Council, 2007; van
Agt et al., 2007; Oepkes and Wieringa, 2008). The screening
programme includes two non-invasive tests: the combined test
(CT), a blood test and an ultrasound to measure the nuchal
translucency, for determining the possibility of Down (around
12th week gestational age), and the Fetal Anomaly Scan (FAS) for
detecting physical anomalies (around 20th week gestational age).
In the case of confirmatory diagnostic testing, two options are
available: pregnancy termination before 24 weeks of gestation, or
health-oriented antenatal care for the fetus combined with
antenatal and postnatal support (NVOG, 2007). Although both
tests are part of a population-screening programme, they are not
offered on the same basis. The FAS is free for all women, whereas
the CT has to be paid for (ca. 150 euro) by women younger than 36
years of age (Health Council, 2007; Oepkes and Wieringa, 2008).
The mean uptake of antenatal congenital anomaly screening
tests in the Netherlands has been around 27% for the CT, but varies
between different regions (range 12–52%) (Fracheboud et al.,
2009; Bosch et al., 2010; Bakker et al., 2012; Schielen, 2012); the
mean uptake of the FAS has been around 91% (range 80–99%)
(Fracheboud et al., 2009; Schielen, 2012). In the Netherlands, an
obstetrician, clinic genetic or paediatrician will provide counsel-
ling following confirmation of a fetal anomaly and discuss the
option of pregnancy termination or health-oriented antenatal care
for the fetus (www.prenatalescreening.nl). In 2011, 970 of the
parents choose to terminate a pregnancy with a confirmed
diagnosis of a congenital anomaly (e.g. about 0.5% of the pregnan-
cies) (IGZ, 2013).
Appendix B. RIAS
The RIAS distinguishes utterances that are primarily informa-
tive (information giving), persuasive (counselling), interrogative
(closed and open-ended questions), affective (social, positive,
negative and emotional) and process oriented (facilitation, orien-
tation and transitions). Information and question utterances were
further specified in: (1) medical condition, symptoms and history;
(2) testing and therapeutic intervention; (3) lifestyle, finances,
self-care, and preventive behaviours; (4) psychosocial topics
related to emotional reactions, coping, family issues, and social
relationships; and (5) counselling or directs behaviour (Roter,
2006; Roter et al., 2006).
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