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INTRODUCTION Currently, caesarean section is the primary mode of birth for a breech presenting fetus, leading to a deskilling of clinicians and limitation of birth choices for women. The aim of this review is to present a synthesized summary of existing literature related to women’s experiences of breech birth mode decision-making. METHODS A systematic search of the literature was conducted in April 2021, utilizing five databases to identify and obtain peer-reviewed articles meeting the predetermined selection criteria. RESULTS Four major categories were synthesized from the integrated review: 1) Women who desire a vaginal birth may experience a range of negative emotions such as feelings of disempowerment, loss, uncertainty and a sense of isolation; 2) Women who experience a breech presentation at term experience significant pressures to conform to expectations of medical professionals and their families due to perceptions of risk related to breech birth; 3) Breech birth decision-making in a limiting system; and 4) Overall satisfaction with the decision to plan a vaginal breech birth. CONCLUSION Women with a breech presenting fetus at term experience a complex range of emotions and internal and external pressures due to perceptions of risk around breech birth. Midwives were seen as helpful throughout the breech experience. The reduced caesarean section rate for breech, observed in studies exploring specialized care pathways or dedicated services, could reduce the incidence of Severe Acute Maternal Morbidity.

Introduction Although culture is an integral part of health, there is scarcity of evidence on the influence of culture on caregiving experiences of parents of preterm infants. The aim of this study was to explore the influence of sociocultural practices on caring for preterm infants in the Ghanaian community. Method Narrative inquiry was utilized to explore the influence of sociocultural practices on the care of preterm infants from 21 mothers, 9 fathers, and 12 household members. Data were collected through face-to-face semistructured interviews and observations at participants’ homes. Results Analysis of data resulted in three threads/themes—respect for the elderly, use of herbal medicines, and communal living. Discussion Community and extended family members have great influence on the care of preterm infants. Traditional herbal medicines are considered effective in treating traditional illnesses among preterm infants. Understanding the influence of culture on the care of vulnerable preterm infants in the community is essential in developing interventions for infant survival.

Background: New graduate nurses transition with limited experience, and with anxiety and stress. They present an increased risk of contributing to preventable errors or adverse events. Purpose: The purpose was to develop an understanding of new graduate registered nurses' (RNs) patient safety knowledge and actions within the first year of registration. Methods: The longitudinal mixed-methods study was conducted using a questionnaire delivered at 3 time points (n = 68). Qualitative data were collected by semistructured interviews (n = 11). Results: Self-reported knowledge of medical error decreased over the 3 time points. Themes emerging from qualitative data include patient safety and insights, time management, making a mistake, experiential learning, and transition. Conclusions: Medical errors and time management persist during transition to the RN role. New graduates reported moderate knowledge of safety and quality issues; however, questioning their own abilities overshadowed growth in their involvement in patient safety.

Aim To explore new graduate registered nurses' knowledge and attitudes concerning medical error and patient safety, during their first 6 months of professional practice. Background New graduate registered nurses demonstrate basic skills and levels of performance due to limited exposure and experience in actual situations. There is a concern held for their clinical reasoning skills required to recognize patient deterioration, posing a threat to patient safety. Methods An online questionnaire was used to survey new graduate registered nurses at three time points during graduate nurse programmes between August 2016 and February 2018. Results A decrease in self‐reported knowledge and attitudes regarding medical errors was noted over the three time points. These results indicate initial confidence in theoretical knowledge and attitudes upon completion of undergraduate education, and prior to commencing professional practice. Conclusion Results suggest that a theory practice gap persists with respect to medical error for transitioning new nurses. Impact for Nursing Management New nurses lack confidence around compromised patient safety situations and a knowledge gap around actions related to medical error. Nurse managers and educators should be made aware of this gap to implement strategies to decrease risk during novice nurse transition.

Aims and objectives To determine if extended immersive ward-based simulation programmes improve the preparedness of undergraduate bachelor's degree nursing students to be ward ready for professional practice as a registered nurse. Background The practice readiness of new graduate nurses to enter the workforce continues to raise concern among educators and industry. Often the transition period is a vulnerable time when the reality of clinical practice bears little resemblance of their experiences as a student. Simulation of a busy ward offers the opportunity for pre-registered nurses to practise a variety of situations they are likely to encounter once qualified in a safe and supportive learning environment. Methods The review considered studies that investigated the experiences and learning outcomes of nursing students following participation in extended immersive ward-based simulation. Databases searched included CINAHL, EMBASE, Medline and Scopus. Two reviewers independently assessed retrieved studies that matched inclusion criteria using standardised critical appraisal instruments. Reporting of review followed PRISMA checklist. Results Fourteen studies met the inclusion criteria. The majority of studies used a quasi-experimental mixed methods approach (10). Programme evaluations focused on self-reporting in learning satisfaction and student perceptions of performance. Six studies used a pre- and post-test design to compare the after effect on preparedness for professional practice. Two studies investigated student learning between simulated experiences and experiences gained during clinical placements. Conclusion Learning satisfaction was high among students who participated in programmes that incorporated extended immersive ward-based simulation experiences. Students are able to practise what they need to know and on what will be expected of them in professional practice. Evidence on whether these programmes make a difference in workplace performance, and retention of graduate nurses is yet to be established. Relevance to clinical practice Extended immersive ward-based simulation allows educators the opportunity to meet the perceived needs of students in preparation for professional practice.

Aims To explore women's experiences of breech pregnancy and birth to identify areas in practice for improvement. Design A descriptive exploratory study was conducted involving 20 women who had experienced a breech birth between 2013 and 2018. Methods Semi-structured interviews were audio recorded and transcribed. Transcripts were examined using a free-form 'circling and parking' style of analysis. Foucault's concepts of power/knowledge were utilized to describe existing power relations. Results Women experienced varying degrees of disciplinary power throughout their experiences. Knowledge was used as a means of enforcing disciplinary power by some clinicians and by women to 'arm' themselves and 'fight' to regain what they perceived as a loss of power and autonomy. Midwives were seen as navigators of a restrictive, medicalized healthcare system. Conclusion By better understanding the power dynamics which exist as well as the stages women go through when experiencing a breech presentation, there remains the potential to identify areas in practice which need improving, and aid clinicians in better supporting women through what can be a very difficult time.

AIM This scoping literature review aimed to answer the question: What are the shared decision-making experiences of adult children in regard to their parent/s' health care in residential aged care facilities? BACKGROUND Shared decision-making has been an important patient-centred approach to nursing care since the 1990s, yet it is becoming increasingly evident that it is still not the reality in aged care facilities fifty years on. Currently, it is not well understood how adult children participate in shared decision-making and the types of decisions they are required to make. DESIGN A review of original research papers using Kable, Pich and Maslin-Prothero 12-step systematic approach to documenting a search strategy. METHOD The researcher screened 597 articles from four databases, published in the English language, during the period 1985-2019. The researcher used the Mixed Methods Appraisal Tool version 2011 to determine the methodological quality of the included studies. The Joanna Briggs Institute QARI data tool was used to appraise the seven selected articles and thematically analyse findings, respectively. RESULTS Four themes were highlighted: communication; staffing; being involved; and staff-family relationships. Despite these themes being apparent, families have limited opportunities to participate in shared health decision-making in regard to their parents' care. CONCLUSION The findings from this literature show how shared decision-making is affected by the RACF environment. There is a need to find out and understand what is important from a family member's point of view to optimise shared decision-making and nursing care of the family member in residential aged care settings. RELEVANCE TO CLINICAL PRACTICE The limited findings specific to the SDM experiences of adult children of parents in RACFs in this review could help staff and RACFs to develop strategies and staff training to encourage and facilitate the implementation of shared health decision-making with staff and families on older people's care.

Colonization with Group B Streptococcus in pregnancy is a major risk factor for neonatal infection. Universal screening for maternal streptococcal colonization and the use of intrapartum antibiotic prophylaxis has resulted in substantial reductions of neonatal early-onset Group B Streptococcus disease. To achieve the best neonatal outcomes, it is imperative for maternity healthcare providers to adhere to screening and management guidelines. This literature review uses a systematic approach and aims to provide a synthesis of what is known about compliance with Group B Streptococcus screening protocols in a variety of global settings, including maternity homes, private obstetric practice, and hospital clinical environments. The review was carried out using electronic databases as well as hand-searching of reference lists. Included papers reported primarily on compliance with Group B Streptococcus screening guidelines, potential factors which influence compliance rates, and implementations and outcomes of interventions. Six international studies have been retained which all focused on adherence to Group B Streptococcus screening guidelines and demonstrated that different factors might have an influence on adherence to GBS screening protocols such as financial aspects and high caesarean section rates. Findings of relatively low compliance rates led to recognizing the need of developing improved strategies for optimising antenatal GBS screening adherence. Adhering to Group B Streptococcus screening guidelines to prevent neonatal infection is crucial. Various factors influence compliance rates such as financial aspects and high proportions of caesarean sections. The implementation of strategies and different forms of education can result in improved compliance rates.

BACKGROUND The development of an integrated care pathway with multidisciplinary input to standardize and streamline care for pregnant women experiencing breech presentation at 36 or more weeks of gestation poses several challenges because of the divisive and contentious nature of the phenomenon. Although many clinicians are interested in obtaining the skills required to safely support women desiring a vaginal breech birth, the primary trend in most health care facilities is to recommend a cesarean section. OBJECTIVE This paper aims to discuss the mixed methods approach used in a doctoral study conducted to generate new knowledge regarding women’s experiences of breech birth in Western Australia and professional recommendations regarding the care of women experiencing breech presentation close to or at term. This study was designed to inform the development of an integrated care pathway for women experiencing a breech presentation. This mixed methods approach situated within the pragmatic paradigm was determined to be the optimal way for incorporating multidisciplinary recommendations with current clinical practice guidelines and consumer feedback. METHODS A mixed methods study utilizing semistructured interviews, an electronic Delphi (e-Delphi) study, and clinical practice guideline appraisal was conducted to generate new data. The interviews were designed to provide insights and understanding of the experiences of women in Western Australia who are diagnosed with a breech presentation. The e-Delphi study explored childbirth professionals’ knowledge, opinions, and recommendations for the care of women experiencing breech presentation close to or at term. The clinical practice guideline appraisal will examine the current national and professional breech management and care guidelines. This study has the potential to highlight areas in practice that may need improvement and enable clinicians to better support women through what can be a difficult time. RESULTS Data collection for this study began in November 2018 and concluded in March 2020. Data analysis is currently taking place, and the results will be disseminated through publication when the analysis is complete. CONCLUSIONS The results of this study will guide the development of an integrated care pathway for women experiencing a breech presentation close to or at term, with the hope of moving toward standardized breech care for women in Western Australia. This study protocol has the potential to be used as a research framework for future studies of a similar nature. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/23514

In many countries, including the UK, Australia, China, and the USA, more than 80% of breech-presenting fetuses are born by caesarean section. However, it is important for midwives to note the options that are available to women desiring a vaginal birth. This article will investigate cephalic version methods available to women with a breech-presenting baby, including external cephalic version, moxibustion and acupuncture. The literature emphasises the need for further research into alternative methods of cephalic version, for clinicians to up-skill on vaginal breech birth techniques and, if not recommend, then advise women of alternative methods available if mainstream interventions are unacceptable or contraindicated.

Background Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes. Aims The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes. Methods Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity. Results Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay. Conclusion Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required. Relevance to clinical practice Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

Aims and objectives To explore the connection between +6 nursing leadership and enhanced patient safety. Background Critical reports from the Institute of Medicine in 1999 and Francis QC report of 2013 indicate that healthcare organisations, inclusive of nursing leadership, were remiss or inconsistent in fostering a culture of safety. The factors required to foster organisational safety culture include supportive leadership, effective communication, an orientation programme and ongoing training, appropriate staffing, open communication regarding errors, compliance to policy and procedure, and environmental safety and security. As nurses have the highest patient interaction, and leadership is discernible at all levels of nursing, nurse leaders are the nexus to influencing organisational culture towards safer practices. Design The position of this article was to explore the need to form a nexus between safety culture and leadership for the provision of safe care. Conclusions Safety is crucial in health care for patient safety and patient outcomes. A culture of safety has been exposed as a major influence on patient safety practices, heavily influenced by leadership behaviours. The relationship between leadership and safety plays a pivotal role in creating positive safety outcomes for patient care. A safe culture is one nurtured by effective leadership. Relevance to practice Patient safety is the responsibility of all healthcare workers, from the highest executive to the bedside nurse, thus effective leadership throughout all levels is essential in engaging staff to provide high quality care for the best possible patient outcomes.

Aims and objectives: To critically appraise available literature and summarise evidence pertaining to the patient safety knowledge and practices of new graduate registered nurses. Background: Responsibility for patient safety should not be limited to the practice of the bedside nurses, rather the responsibility of all in the healthcare system. Previous research identified lapses in safety across the health care, more specifically with new practitioners. Understanding these gaps and what may be employed to counteract them is vital to ensuring patient safety. Design: A focused review of research literature. Methods: The review used key terms and Boolean operators across a 5-year time frame in CINAHL, Medline, psycINFO and Google Scholar for research articles pertaining to the area of enquiry. Eighty-four articles met the inclusion criteria, 39 discarded due to irrelevant material and 45 articles were included in the literature review. Results: This review acknowledges that nursing has different stages of knowledge and practice capabilities. A theory-practice gap for new graduate registered nurses exists, and transition to practice is a key learning period setting new nurses on the path to becoming expert practitioners. Within the literature, there was little to no acknowledgement of patient safety knowledge of the newly registered nurse. Conclusions: Issues raised in the 1970s remain a concern for today's new graduate registered nurses. Research has recognised several factors affecting transition from nursing student to new graduate registered nurse. These factors are leaving new practitioners open to potential errors and risking patient safety. Relevance to clinical practice: Understanding the knowledge of a new graduate registered nurse upon entering clinical practice may assist in organisations providing appropriate clinical and theoretical support to these nurses during their transition.

The objective was to identify factors leading to falls and determine the role of nurses and carers play in falls prevention. A retrospective audit of the performance of nurses and carers regarding falls prevention among older adults was used. Residents who had a fall during July 2015 (n=25) were identified using purposeful sampling. Data for this study were collected from the files of these residents. Data analysis was done by using the Fisher exact test which was appropriate for the collected data. Residents aged 85-89 years had the most falls (32%); however, one resident who fell five times in the studied month was aged 90 years. Residents aged 70-74 years had the lowest number of falls (8%). Twenty-two (88%) of the residents who fell were incontinent, 20 (80%) were confused, 19 (76%) were using walking aids and four (16%) were blind. Only five (20%) residents who reported falls in the studied month were independent. Most falls occurred among residents of advanced age, and among those who had incontinence, were confused and failed to use walking aids. Residential home staff should increase vigilance during specific times and monitors closely residents with a high risk of falls.

Objectives To synthesise the current evidence of the implications of postgraduate nursing qualifications on patient and nurse outcomes. Design A systematic review. Data sources Primary research findings. Review methods A systematic search following PRISMA guidelines and the Joanna Briggs Institute's framework was conducted. A structured and comprehensive search of three electronic databases CINAHL, MEDLINE, PsychINFO, search engine Google Scholar, and a manual-search of reference lists was undertaken. The search was limited to articles in English between 2000 and 2019. The combined search yielded 3710 records. Search records were exported to EndNote X8 and duplicates were removed. Inclusion eligibility was assessed by title, abstract and full text. All team members were involved in selecting the studies and assessing methodical quality. Discrepancies were resolved through rigorous discussion between the reviewers. Twenty studies (quantitative and qualitative) were finally selected as suitable for inclusion in the review. A qualitative descriptive synthesis was undertaken to summarise and report the findings. Results This systematic review has shown that the empirical evidence to date does not support nurses' perceptions of the implications of postgraduate education. The findings from this review fell into three major themes: perceived implications of postgraduate study, clinical outcomes and patient satisfaction. Nurses perceived that postgraduate qualifications had improved their knowledge and skills and thus clinical practice, patient outcomes and health services. This perception has not been borne out by measurable outcomes as yet. The literature also suggests that postgraduate education should improve career opportunities and progression for nurses. This is not supported by the nurses' perceptions in the research available to date. It should be noted that these findings predominantly came from qualitative data. A few studies did report descriptive statistical analysis: demographics, knowledge levels, qualifications etc. None conducted any inferential statistical analysis. Conclusion Although the literature suggests that postgraduate nursing qualifications improve outcomes for patients, the level of evidence is weak. Exploration methods are suggested to move beyond examining nurses' perceptions, to empirical measures of the value of postgraduate education on nurse and patient outcomes.

Aims To explore the transition experiences of newly graduated registered nurses with particular attention to patient safety. Background New graduate registered nurses’ transition is accompanied by a degree of shock which may be in tune with the described theory–practice gap. The limited exposure to clinical settings and experiences leaves these nurses at risk of making errors and not recognising deterioration, prioritising time management and task completion over patient safety and care. Design Qualitative descriptive approach using semi‐structured interviews. Methods Data were collected during 2017–18 from 11 participants consenting to face‐to‐face or telephone semi‐structured interviews. Interviews were transcribed verbatim, and data were analysed using thematic analysis techniques assisted by Nvivo coding software. The study follows the COREQ guidelines for qualitative studies (see Supplementary File 1). Results Key themes isolated from the interview transcripts were as follows: patient safety and insights; time management; making a mistake; experiential learning; and transition. Medication administration was a significant cause of stress that adds to time management anguish. Although the new graduate registered nurses’ clinical acumen was improving, they still felt they were moving two steps forward, one step back with regards to their understanding of patient care and safety. Conclusion Transition shock leaves new graduate registered nurses’ focused on time management and task completion over patient safety and holistic care. Encouragement and support needed to foster a safety culture that foster safe practices in our new nurses. Relevance to practice Having an understanding of the new graduate registered nurses’ experiences and understanding of practice will assist Graduate Nurse Program coordinators, and senior nurses, to plan and provide the relevant information and education during these initial months of transition to help mitigate the risk of errors occurring during this time.

Background The development of an integrated care pathway with multidisciplinary input to standardize and streamline care for pregnant women experiencing breech presentation at 36 or more weeks of gestation poses several challenges because of the divisive and contentious nature of the phenomenon. Although many clinicians are interested in obtaining the skills required to safely support women desiring a vaginal breech birth, the primary trend in most health care facilities is to recommend a cesarean section. Objective This paper aims to discuss the mixed methods approach used in a doctoral study conducted to generate new knowledge regarding women’s experiences of breech birth in Western Australia and professional recommendations regarding the care of women experiencing breech presentation close to or at term. This study was designed to inform the development of an integrated care pathway for women experiencing a breech presentation. This mixed methods approach situated within the pragmatic paradigm was determined to be the optimal way for incorporating multidisciplinary recommendations with current clinical practice guidelines and consumer feedback. Methods A mixed methods study utilizing semistructured interviews, an electronic Delphi (e-Delphi) study, and clinical practice guideline appraisal was conducted to generate new data. The interviews were designed to provide insights and understanding of the experiences of women in Western Australia who are diagnosed with a breech presentation. The e-Delphi study explored childbirth professionals’ knowledge, opinions, and recommendations for the care of women experiencing breech presentation close to or at term. The clinical practice guideline appraisal will examine the current national and professional breech management and care guidelines. This study has the potential to highlight areas in practice that may need improvement and enable clinicians to better support women through what can be a difficult time. Results Data collection for this study began in November 2018 and concluded in March 2020. Data analysis is currently taking place, and the results will be disseminated through publication when the analysis is complete. Conclusions The results of this study will guide the development of an integrated care pathway for women experiencing a breech presentation close to or at term, with the hope of moving toward standardized breech care for women in Western Australia. This study protocol has the potential to be used as a research framework for future studies of a similar nature. International Registered Report Identifier (IRRID) DERR1-10.2196/23514

Background Simulation is an important teaching strategy in the preparation of nursing students for professional practice. The focus of simulation has shifted from single patient encounters to multiple case studies provoking immersion in all the activities that are regularly performed on the ward. Extended immersive simulation cannot replicate completely the stresses of working on a ‘real’ ward, but it does provide a safe environment for students to practice the role of being a registered nurse. Objective To evaluate satisfaction associated with student experiences of mentorship by industry partners, self-reflection on performance, and responses to clinical situations following an episode of extended immersive ward-based simulation. Design Mixed methods case study. Setting School of Nursing and Midwifery metropolitan Western Australian university. Participants A cohort of 278 final year students enrolled in a three-year Bachelor of Nursing program. Method Eight demonstration rooms were re-configured to resemble a mixed medical/surgical ward. Nursing students and manikins in each room simulated different patient scenarios. Students were organised in three-hour shifts in which to undertake the role of a registered nurse. Industry partners undertook shift coordinator and senior nursing roles. Surveys were distributed to students at the end of the two-day simulation. Student satisfaction was evaluated using the Satisfaction with Simulation Experience scale and content analysis of open-ended questions. Results A total of 243 students (87.4%) responded to the survey. None of the scaled items had a mean score of below 4.5. Content analysis of 458 written responses identified three themes: simulation, role of registered nurse and learning. Conclusion Extended immersive ward-based simulation offers the opportunity for educators to mirror what happens in clinical practice. Students value the opportunity to safely experience simulated demands of working on a busy ward and learn how to meet workplace pressures in the delivery of patient care.

BACKGROUND Those who experience a critical illness or condition requiring admission to an intensive care unit (ICU) frequently experience physical and psychological complications as a direct result of their critical illness or condition and ICU experience. Complications, if left untreated, can affect the quality of life of survivors and impact health care resources. Explorations of potential interventions to reduce the negative impact of an ICU experience have failed to establish an evidence-based intervention. OBJECTIVE The aim of this study is to evaluate the impact of a Web-based intensive care recovery program on the mental well-being of intensive care survivors and to determine if it is a cost-effective approach. METHODS In total, 162 patients that survived an ICU experience will be recruited and randomized into 1 of 2 groups. The intervention group will receive access to the Web-based intensive care recovery program, ICUTogether, 2 weeks after discharge (n=81), and the control group will receive usual care (n=81). Mental well-being will be measured using the Hospital Anxiety and Depression Scale, The Impact of Events Scale-Revised and the 5-level 5-dimension EuroQoL at 3 time points (2 weeks, 6 months, and 12 months post discharge). Family support will be measured using the Multidimensional Scale of Perceived Social Support at 3 time points. Analysis will be conducted on an intention-to-treat basis using regression modeling. Covariates will include baseline outcome measures, study allocation (intervention or control), age, gender, length of ICU stay, APACHE III score, level of family support, and hospital readmissions. Participants’ evaluation of the mobile website will be sought at 12 months postdischarge. A cost utility analysis conducted at 12 months from a societal perspective will consider costs incurred by individuals as well as health care providers. RESULTS Participant recruitment is currently underway. Recruitment is anticipated to be completed by December 2020. CONCLUSIONS This study will evaluate a novel intervention in a group of ICU survivors. The findings from this study will inform a larger study and wider debate about an appropriate intervention in this population.

Background Those who experience a critical illness or condition requiring admission to an intensive care unit (ICU) frequently experience physical and psychological complications as a direct result of their critical illness or condition and ICU experience. Complications, if left untreated, can affect the quality of life of survivors and impact health care resources. Explorations of potential interventions to reduce the negative impact of an ICU experience have failed to establish an evidence-based intervention. Objective The aim of this study is to evaluate the impact of a Web-based intensive care recovery program on the mental well-being of intensive care survivors and to determine if it is a cost-effective approach. Methods In total, 162 patients that survived an ICU experience will be recruited and randomized into 1 of 2 groups. The intervention group will receive access to the Web-based intensive care recovery program, ICUTogether, 2 weeks after discharge (n=81), and the control group will receive usual care (n=81). Mental well-being will be measured using the Hospital Anxiety and Depression Scale, The Impact of Events Scale-Revised and the 5-level 5-dimension EuroQoL at 3 time points (2 weeks, 6 months, and 12 months post discharge). Family support will be measured using the Multidimensional Scale of Perceived Social Support at 3 time points. Analysis will be conducted on an intention-to-treat basis using regression modeling. Covariates will include baseline outcome measures, study allocation (intervention or control), age, gender, length of ICU stay, APACHE III score, level of family support, and hospital readmissions. Participants’ evaluation of the mobile website will be sought at 12 months postdischarge. A cost utility analysis conducted at 12 months from a societal perspective will consider costs incurred by individuals as well as health care providers. Results Participant recruitment is currently underway. Recruitment is anticipated to be completed by December 2020. Conclusions This study will evaluate a novel intervention in a group of ICU survivors. The findings from this study will inform a larger study and wider debate about an appropriate intervention in this population. International Registered Report Identifier (IRRID) PRR1-10.2196/10935

The difficulties of caring for preterm infants and associated psychological stress incurred by parents of preterm infants admitted to Neonatal Intensive Care Unit (NICU) have been well established. However, much less is known about parents' experiences of caring for preterm infant at home after NICU discharge. This study synthesized qualitative studies on this phenomenon. Nine categories were obtained from 12 qualitative studies and grouped into three syntheses – (1) support improves confidence in care; (2) dealing with challenges of caring for preterm infant; (3) overprotective parenting. Parents' experiences of caring for preterm infants post-NICU discharge is constructed as a process that requires support to improve caring confidence, a process that deals with the challenges of caring for preterm infants after discharge and complicated by overprotective parenting. Thus, NICU nurses must endeavour to provide appropriate support for parents in order to increase their caring confidence after discharge.

Aim The aim of this study was to investigate stories of recovery through the lens of intensive care unit (ICU) survivors. Background Survival from ICUs is increasing, as are associated physical and psychological complications. Despite the significant impact on survivors, there is inadequate support provision in Australia and world-wide for this population. Design An interpretive biographical approach of intensive care survivors' experiences of recovery. Methods Data were collected during 2014-2015 from diaries, face to face interviews, memos and field notes. Six participants diarized for 3 months commencing 2 months after hospital discharge. At 5 months, participants were interviewed about the content of their diaries and symbols and signifiers in them to create a shared meaning. Analysis of diaries and interviews were undertaken using two frameworks to identify themes throughout participants' stories and provides a unique portrait of recovery through their individual lens. Findings Participants considered their lives had irreparably changed and yet felt unsupported by a healthcare system that had "saved" them. This view through their lens identified turmoil, which existed between their surface and inner worlds as they struggled to conform to what recovery "should be". Conclusion The novel biographical methods provided a safe and creative way to reveal survivors' inner thoughts and feelings. Participants' considered creating their stories supported their recovery process and in particular enabled them to reflect on their progress. Findings from this study may lead to increased awareness among health care providers about problems survivors face and improved support services more broadly, based on frameworks appropriate for this population.

Aim: To acquire a fuller understanding of the influences on decision-making in an acute care hospital for seriously ill patients. Background: Fromthe moment of a diagnosis of serious, potentially life-limiting illness, patients and their families are faced withmultiple, complex and significant decisions that will influence the entire illness trajectory, including their end-of-life care (EOLC). Compounding personal factors is the complexity of dying today with acute ward areas in tertiary hospitals use of technological interventions to prolong life, at all costs being the norm. If hospice care is initiated, in these areas, it is often at too late a stage to relieve distressing symptoms and to offer the person the best possible path of care for a dignified death. Design and methods: A retrospective cohort research design was used for this study. Results: Thirty nine (39) medical records that met the inclusion criteria were audited. While medical records are limited in terms of the quality of the information contained in them in terms of social, behavioural and other qualitative information, the audit obtained detailed clinical information on patient characteristics, clinical care, and family and clinician involvement in the care of these patients. Communication between health professionals and patient and or family were limited. Poor documentation in the medical record did not support shared decision-making with decisions to amend the care pathway to palliative not undertaken in most instances despite no improvement in response to care or deterioration in the patient’s condition. Conclusion: Communication between health care professions, patients and their family’s needs to be addressed. The management of patients who are seriously ill in acute ward areas should be altered to reflect the patient’s condition. Nurses, using a person-centred approach, have a role in advocating for the patient and the family in times of stress. Discussions concerning end-oflife of seriously ill patients need to be open, transparent and communicated as these discussions are critical to ensuring the patient’s wishes are realised.

Aims and objectives To critically appraise the available literature and summarise the evidence related to the use, prevalence, purpose and potential therapeutic benefits of intensive care unit diaries following survivors' discharge from hospital and identify areas for future exploration. Background Intensive care unit survivorship is increasing as are associated physical and psychological complications. These complications can impact on the quality of life of survivors and their families. Rehabilitation services for survivors have been sporadically implemented and lack an evidence base. Patient diaries in intensive care have been implemented in Scandinavia and Europe with the intention of filling memory gaps, enable survivors to set realistic recovery goals and cement their experiences in reality. Design A review of original research articles. Methods The review used key terms and Boolean operators across a 34-year time frame in: CIHAHL, Medline, Scopus, Proquest, Informit and Google Scholar for research reports pertaining to the area of enquiry. Twenty-two original research articles met the inclusion criteria for this review. Results The review concluded that diaries are prevalent in Scandinavia and parts of Europe but not elsewhere. The implementation and ongoing use of diaries is disparate and international guidelines to clarify this have been proposed. Evidence which demonstrates the potential of diaries in the reduction of the psychological complications following intensive care has recently emerged. Results from this review will inform future research in this area. Conclusions Further investigation is warranted to explore the potential benefits of diaries for survivors and improve the evidence base which is currently insufficient to inform practice. The exploration of prospective diarising in the recovery period for survivors is also justified. Relevance to clinical practice Intensive care diaries are a cost effective intervention which may yield significant benefits to survivors.

Aim The aim of this study was to explore the potential use of visual diarizing to enable intensive care unit (ICU) survivors to create their story of recovery. Background An ICU experience can have deleterious psychological and physical effects on survivors leading to reductions in quality of life which for some may be of significant duration. Although there has been exploration of many interventions to support recovery in this group, service provision for survivors remains inconsistent and inadequate. Design and participants A qualitative interpretive biographical exploration of the ICU experience and recovery phase of ICU survivors using visual diarizing as method. This paper is a component of a larger study and presents an analyses of one participant's visual diary in detail. Methods Data collection was twofold. The participant was supplied with visual diary materials at 2 months post-hospital discharge and depicted his story in words and pictures for a 3-month period, after which he was interviewed. The interview enabled the participant and researcher to interpret the visual diary and create a biographical account of his ICU stay and recovery journey. Findings The analysis of one participant's visual diary yielded a wealth of information about his recovery trajectory articulated through the images he chose to symbolize his story. The participant confirmed feelings of persecution whilst in ICU and was unprepared for the physical and psychological disability which ensued following his discharge from hospital. However, his story was one of hope for the future and a determination that good would come out of his experience. He considered using the visual diary enhanced his recovery. Conclusions The participant perceived that visual diarizing enhanced his recovery trajectory by enabling him to recreate his story using visual imagery in a prospective diary. Relevance to clinical practice Prospective visual diarizing with ICU survivors may have potential as an aid to recovery.

AIM To present an adaptation of interpretive interactionism that incorporates and honours feminist values and principles. BACKGROUND Interpretive interactionism as described by Denzin can be useful when examining interactive processes. It is especially useful when events affect turning points in people's lives. When issues of power and power imbalances are of interest, a critical post-structural lens may be of use to the researcher. The authors planned to examine the interactions between midwives and women at the 'epiphaneal' points of decision making during second-stage labour. It became clear that it was necessary to honour and thus incorporate feminist principles and values in their methodology. DATA SOURCES This paper draws on a recently completed PhD project to demonstrate the application of post-structural feminist interpretive interactionism. Twenty six midwives representing each state and territory across Australia who were representative of every model of midwifery care offered in Australia were interviewed to gauge their experiences of what they believed represented good and poor case examples of decision making during second-stage labour. REVIEW METHODS The authors critique the philosophical underpinnings of interpretive interactionism, and then modify these to acknowledge and incorporate post-structural and feminist ideologies. DISCUSSION Interpretive interactionism is a useful methodology when the research question is best addressed by examining interactional processes and the meanings people make of them, especially if these occur at turning points in people's lives. Interpretive interactionism methodology can and should be improved by taking account of issues of power, feminism and post-structural values. CONCLUSION Post-structural feminist interpretative interactionism has much to offer healthcare researchers who want to develop methodologically robust findings. IMPLICATIONS FOR PRACTICE/RESEARCH Post-structural feminist interpretive interactionism enables the researcher to be more cognisant of the complex social political and historical context of midwifery. Researchers using feminist and post-structural ideologies will enhance research findings when these tools are applied consciously and reflexively.

Background Intensive care unit survivors face many physical and psychological difficulties during their recovery following discharge from hospital. These difficulties can significantly affect their quality of life. Healthcare providers and survivors' families often do not understand what recovery means in this population, which may affect the support provided. Aim To consider the potential of the biographical method in helping to create stories that illustrate recovery in intensive care survivors and other populations. Discussion This paper identifies how the biographical approach has provided survivors with a way to uncover the hidden parts of their lives through diaries and interviews, and reveal the hidden stories of intensive care survivorship and recovery. Conclusion The application of the biographical method enabled stories to be created that identified the disruption survivors encounter as they struggle to appear recovered. Implications for practice The biographical method can illuminate experiences uncaptured by other methods. This insight into recovery journeys can help healthcare practitioners and family members to understand and recognise the need for support during recovery.

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes.The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes.Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity.Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay.Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required.Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

Background: Human beings live storied lives and it is these stories that define the “self” in a community. Narrative inquiry, a qualitative research methodology seeks to understand social and cultural experiences of people and communities by studying stories from the perspective of individuals who are living the story and relating it to time, place and person. Narrative inquiry has two aspects: (1) the lived experiences (phenomenological aspect), and (2) the interactions of the stories with the story teller’s sociocultural environment (ethnographical aspect). However, only the lived experiences aspect of narrative inquiry is overemphasized in the literature. The aspect that deals with the interactions of stories to the story teller’s sociocultural environment has been overlooked. Aim: To explore the sociocultural feature of narrative inquiry and to demonstrate how this methodology was used to explore both lived experiences and cultural aspects of parents’ experiences of caring for preterm infants after discharge from four neonatal units in Ghana. Conclusions: Given the dynamic nature of narrative inquiry, this article proposes that its use should not be limited to the study of experiences only. For a qualitative study that requires the study of both experiences and the interaction of participants with their sociocultural environment, narrative inquiry serves the purpose.

Not only do nurse academics teach, research, supervise, engage in professional development and professional organisations, they are compelled as academic nurse educators to write for publication, a task that involves expertise, creativity, skill and large amounts of time.. This article describes a qualitative reflective analysis of the themes which surfaced during an offsite writing retreat attended by nurse faculty. The authors of this paper discovered an added invaluable benefit of their time at writing retreat: time to engage in social interactions that benefit their professional and personal development. In addition through experience of the retreat has been the increase in publications through the commitment to output, and academic development through engagement in mentoring, collegial partnerships, informal learning, and reflection.

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwife's legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery.

In a finding that reflects international experiences, nurses in Australia have been identified as the occupation at most risk of patient-related violence in the health-care sector. A search of the literature was undertaken to explore this concept, with a focus on the emergency department and triage nurses. Significant findings included the fact that nurses are subjected to verbal and physical abuse so frequently that, in many instances, it has become an accepted part of the job. This attitude, combined with the chronic under-reporting of violent incidents, perpetuates the normalization of violence, which then becomes embedded in the workplace culture and inhibits the development of preventative strategies and the provision of a safe working environment. Nurses are entitled to a safe workplace that is free from violence under both the occupational health and safety legislation and the zero-tolerance policies that have been adopted in many countries including Australia, the UK, Europe, and the USA. Therefore, policy-makers and administrators should recognize this issue as a priority for preventative action.

This paper by Deborah Sundin and Kathleen Fahy critiques Denzin's interpretive interactionism in light of critical and postmodern ideas that undermine its theoretical foundations. The authors argue that interpretive interactionism can be improved by acknowledging insights from critical social theory. They present modifications and adaptations to arrive at a methodologically robust research design called critical, post-structural, interpretive interactionism.

Subject positions theory – its application to understanding collaboration (and confrontation) in critical care Background. Doctors and nurses do not usually take a collaborative approach to the ethical challenges of the critical care environment. This leads to the stresses that produce moral anguish and burnout – both for nursing and medical staff. A more collegial relationship between nurses and physicians should improve patient care. If we are to promote this collegiality, one way to proceed is to investigate the interactions between health care professionals in order to develop an understanding of the barriers to, and supports for collaboration. Aim. Subject positions theory offers a method of explaining and elucidating the interactions between nurse and physician in terms of power dynamics, mutual expectations and the discourse available to each individual. This paper aims to demonstrate how subject positions theory can facilitate the interpretation of the interactions between health professionals in terms of the power dynamics influencing those interactions. Discussion. This paper will use the example of a case study from my own research to demonstrate the application of this theory and its usefulness in the analysis of the interactions between health care professionals. Conclusions. Application of this theory is used to demonstrate the author’s argument that the current political and cultural structure of the health care system does not support the subject position – nurse advocate.

Background Intensive care units (ICUs) encompass advanced clinical management and technology, mandating continuing education for nurses to maintain competency. This study examined nurses' perceptions of current education on invasive mechanical ventilation in an Australian ICU. Methods Qualitative data were obtained from five optional open-ended questions as part of a larger 30-item cross-sectional survey of 160 ICU nurses. Content analysis was used to code the data, developing concepts and themes. Results Fifty nurses (31%) completed at least one open-ended question. Content analysis identified five major themes: advanced knowledge, in-service education, practical structured education, interactive bedside teaching, and practicing safe care. Respondents' perceived continuing education on invasive mechanical ventilation to be more focused on novice than experienced ICU nurses and recommended practical, structured bedside teaching as the preferred method of education. Conclusion Respondents recognized the need for interactive, practical, bedside education sessions to transfer learning into the everyday work environment.

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwife's legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery.

In a finding that reflects international experiences, nurses in Australia have been identified as the occupation at most risk of patient-related violence in the health-care sector. A search of the literature was undertaken to explore this concept, with a focus on the emergency department and triage nurses. Significant findings included the fact that nurses are subjected to verbal and physical abuse so frequently that, in many instances, it has become an accepted part of the job. This attitude, combined with the chronic under-reporting of violent incidents, perpetuates the normalization of violence, which then becomes embedded in the workplace culture and inhibits the development of preventative strategies and the provision of a safe working environment. Nurses are entitled to a safe workplace that is free from violence under both the occupational health and safety legislation and the zero-tolerance policies that have been adopted in many countries including Australia, the UK, Europe, and the USA. Therefore, policy-makers and administrators should recognize this issue as a priority for preventative action.

Aim: The aim of the study was to describe the experiences of a group of triage nurses with patient-related workplace violence during the previous month. Background: Globally and within the Australian health industry, nurses have been reported to be the occupation at most risk of patient-related violence, with triage nurses identified as a high risk group for both verbal and physical violence. Method: The study took place in the Emergency Department of a tertiary referral and teaching hospital in regional New South Wales, Australia. Data were collected from August to September 2008, and a qualitative descriptive methodology was employed. Findings: The participants all reported experiencing episodes of patient related violence that were perceived as inevitable and increasing in intensity and frequency. Themes included identification of precipitating factors such as long waiting times and alcohol and substance misuse. Organisational issues included lack of aggression minimisation training; lack of formal debriefing following episodes of violence and frustration at lengthy reporting processes. Conclusion: In the context of the Emergency Department where patients present with a range of diagnoses and behaviours, it is unlikely that the issue of patient-related violence can be totally eliminated. However it can be prevented or managed more effectively on many occasions. Strategies to support staff and prevent and manage violence effectively should be a priority to provide a safe working environment and occupational health and safety for staff. © 2009 Elsevier Ltd.

Summary Background Clinical decision-making was initially studied in medicine where hypothetico-deductive reasoning is the model for decision-making. The nursing perspective on clinical decision-making has largely been shaped by Patricia Benner's ground breaking work. Benner claimed expert nurses use humanistic-intuitive ways of making clinical decisions rather than the ‘rational reasoning’ as claimed by medicine. Clinical decision-making in midwifery is not the same as either nursing or medical decision-making because of the woman–midwife partnership where the woman is the ultimate decision-maker. Method CINHAL, Medline and Cochrane databases were systematically searched using key words derived from the guiding question. A review of the decision-making research literature in midwifery was undertaken where studies were published in English. The selection criteria for papers were: only research papers of direct relevance to the guiding research question were included in the review. Findings Decision-making is under-researched in midwifery and more specifically birth, as only 4 research articles met the inclusion criteria in this review. Three of the studies involved qualified midwives, and one involved student midwives. Two studies were undertaken in England, one in Scotland and one in Sweden. The major findings synthesised from this review, are that; (1) midwifery decision-making during birth is socially negotiated involving hierarchies of surveillance and control; (2) the role of the woman in shared decision-making during birth has not been explored by midwifery research; (3) clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision. Conclusion We argue that existing research does not inform the discipline of the complexity of midwifery clinical decision-making during birth. A well-designed study would involve investigating the clinical reasoning skills of the midwife, her relationship with the woman, the context of the particular birthing unit and the employment status of the midwife. The role of the woman as decision-maker in her own care during birth also needs careful research attention.

No good evidence exists to support the practice of routinely checking for the nuchal cord, yet it is a common medical intervention in birth. Some evidence shows damage to the baby because the practice more frequently leads to premature cord-cutting and the vaginal examination, required by such routine checking, may be physically and/or emotionally damaging to the women. Our objective was to learn what training midwives have received and what their current practice is in relation to a possible nuchal cord at birth?Questions about nuchal cord at birth were posted to two online midwifery discussion forums and responses were invited. Twenty-six midwives from 10 countries responded to questions on nuchal cord practices.The teaching and practice of routinely checking for the nuchal cord at birth is widespread, according to at least some participants from all 10 countries. Other midwives from the same countries argued that, although they were aware that the procedure is the dominant midwifery practice, many midwives neither teach it nor perform it routinely.In the absence ofclear evidence, firmly entrenched positions are being argued for and against routine checking. The debate is infused with high emotion. Those arguing for routine checking cite safety for the baby as their main concern. Those arguing against checking cite the need to keep birth normal and the well-being of the baby as their primary concerns. There is a need to reconsider how the possibility of nuchal cord at birth should be conceptualised from a midwifery perspective to ensure woman-centred decision-making.

This paper by Deborah Sundin and Kathleen Fahy critiques Denzin's interpretive interactionism in light of critical and postmodern ideas that undermine its theoretical foundations. The authors argue that interpretive interactionism can be improved by acknowledging insights from critical social theory. They present modifications and adaptations to arrive at a methodologically robust research design called critical, post-structural, interpretive interactionism.

This paper reports the findings relating to discharge planning from a larger study (Hegney et al 2001) that aimed to investigate options to improve care co-ordination between the aged, community, acute and primary care sectors for the elderly residents of a large provincial town. The data, which were collected from a wide variety of aged care stakeholders in the region, are consistent with previous Australian studies. First, it appears that inappropriate discharge from acute hospitals occurs in Toowoomba because there is a perceived lack of information regarding the available community care options and a lack of suitable models to support people's care needs within their own homes. Second, inappropriate discharge practices from acute hospitals occur due to a lack of knowledge and communication on the part of health professionals employed in these settings with regard to the on-going health care needs of elderly people. Third, there is little discharge planning occurring that includes the general practitioner in post-discharge care. Finally, inappropriate discharge can also be attributed to the lack of sub-acute/step-down/rehabilitation options and long waiting lists for community home care services in the region.

Summary • The diagnosis of brain death as ‘death’ and organ transplantation have been closely historically linked since the mid twentieth century • It will be argued in this article that the development of a neurological definition of death was introduced to justify the removal of fresh viable organs for transplantation • Brain death cannot be diagnosed reliably using ‘established practices’ • Improved understanding of the pathophysiology of raised intracranial pressure has challenged our understanding of brain death • We need to move forward in our conceptualization of phenomenon of profound coma associated with massive brain damage • If examination for ‘brain death’ is to be carried out at all, there needs to be an examination and re-evaluation of practices and protocols

Many midwives routinely perform a vaginal examination during birth to check for the nuchal cord. Such an invasive procedure would only be consistent with midwifery philosophy if it was common to find a nuchal cord so tight that the only alternative is to cut in order to allow the birth of the baby. A tight nuchal cord, however, seems to be rare. So how did it happen that the invasive procedure of checking for the nuchal cord vaginally became a ritualized practice in contemporary midwifery? The historical literature on the significance of finding a nuchal cord is reviewed in this article. Checking for the nuchal cord has been advocated by medical textbooks. The call to make this procedure routine for all women was not made in medical texts until the late 17th century onwards. Though an exploration of the historical origins of the procedure it is demonstrated that the arguments used act as a model for the way in which all aspects of birth have been medicalized through fear. It is hypothesized that when the midwife avoids routine invasive checking for the cord and instead makes individual clinical decisions for each particular woman and baby this may be a marker of her willingness to practice as an autonomous decision maker and not just of follower of ritual.