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When Parkinson’s Disease meets Dementia: a Palliative Research Priority

26 Jun, 16 | by hnoble

Dr Clare Mc Veigh (Lecturer in Palliative Care) and Gemma Megarry (Research Volunteer), Northern Ireland Hospice.

CMcVResearch Volunteer final

Parkinson’s disease and Dementia are both diseases in which the brain will become more and more damaged over many years. Parkinson disease is a neurodegenerative disease characterised by motor symptoms such as resting tremor, rigidity (stiffness), bradykinesia (slowness of movement) and postural instability (balance problems). However many patients with advanced PD can also experience nonmotor symptoms such as depression, pain, psychosis, cognitive problems, hallucinations and more commonly dementia. Dementia is also caused by neurodegeneration which results in the unavoidable and gradual deterioration of the person’s cognitive function, and their ability to live independently. The occurrence of dementia in people with PD is increasingly being recognised and can cause particular challenges to the patient and their family, inclusive of behavioural and functional problems. When a person has Parkinson’s motor symptoms for at least a year before experiencing dementia, this is known as Parkinson’s Disease Dementia (PDD).

A European study concluded that the incidence rate of PDD was 74 per 1000 patient-years, with the cumulative risk of developing PDD being 25% after 5 years, and 50% after 10 years of follow-up (Perez et al. 2012). Previous research has additionally estimated that the incidence rate of a dementia in patients with PD is at least four times higher than it is in the general population (Williams-Gray et al. 2009). Dementia can also be present not only in the advanced stages of the illness but from the onset of PD having an impact on the person’s quality of life, and implications for public health and the cost of care (Irwin et al.2013). However dementia is often only recognised later in PD due to the prominent nature of the patient’s motor symptoms.

Palliative care has a key role to play in the provision of care to people with PDD due to the complexity of their holistic symptom need, and the life-limiting nature of the illness. Healthcare professionals provide palliative care in order to help improve the physical, psychosocial and spiritual well-being of their patients and their families, and to aid patients and their carers to have the best quality of life possible. The integration of palliative care early within the disease trajectory can help to improve the management of a patient’s symptoms. Originally, the only patients who had access to palliative care services were those with a diagnosis of cancer and nearing the end of their life. More recently however, it has been recognised that palliative care is also applicable to patients with a non-malignant disease and is an integral part of a patient’s disease management from diagnosis. Despite this awareness, access to specialist palliative care can often still be limited for patients with non-malignant conditions such as PD and a dementia. The need for a model of palliative care for patients with PD and a dementia, to help optimise the provision of holistic care, has been recognized.

Parkinson’s UK previously consulted with people with PD, carers and healthcare professionals to identify the 10 priority areas that need researched to help improve the lives of people with PD. Exploring how we can best care for people with PD and a dementia was recognised as one of these key priorities. The Palliative and end of life care Priority Setting Partnership (PeolcPSP) further identified a need to explore the best ways to determine the palliative care needs of patients with a non-cancer diagnosis, such as PD and dementia, whilst also illuminating the importance of discovering how this care can be initiated and provided. There is a lack of empirical evidence regarding the palliative care experienced by people with PDD, and how this care may be provided. A deeper insight into the holistic symptom needs of this specific group of patients is required, with further exploration of how to optimally deliver palliative care.


Irwin, D.J., Lee, V.M.Y. and Trojanowski, J.Q. (2013) ‘Parkinson’s disease dementia: convergence of [alpha]-synuclein, tau and amyloid-[beta] pathologies.’ Nature Reviews Neuroscience. 14 (9), pp.626-636.

Perez, F., Helmer, C., Foubert-Samier, A., Auriacombe, S., Dartigues, J.F. and Tison, F. (2012) ‘Risk of dementia in an elderly population of Parkinson’s disease patients: A 15-year population-based study.’ Alzheimer’s & Dementia. 8 (6), pp.463-469

Williams-Gray, C.H., Evans, J.R., Goris, A., Foltynie, T., Ban, M., Robbins, T.W., Brayne, C., Kolachana, B.S., Weinberger, D.R., Sawcer, S.J. and Barker, R.A. (2009) ‘The distinct cognitive syndromes of Parkinson’s disease: 5 year follow-up of the CamPaIGN cohort.’ Brain. 132 (11), p.p.2958-2969

Nurse Practitioners in Canada: A Few Steps Forward

19 Jun, 16 | by rheale

As of this month Canada joined the small number of countries across the globe that have legalized assisted suicide.  The regulation titled “Medical Assistance in Dying” was hotly debated by the public, media, and all levels of federal government. In this way the legislation wasn’t different from any that are closely tied to personal values and ethical viewpoints.  However, one very significant difference in this law was that it specifically identified not only physicians, but also nurse practitioners (NPs) as the health care providers who may implement assistance in dying.  As an NP and the President of the Canadian Association of Advanced Practice Nurses, representing NPs in Canada, I was very excited that NPs were finally being recognized for the autonomous and comprehensive care.

Nurse practitioners are advanced practice nurses who have completed graduate education and written a licensing exam. So, unlike some APN roles and unlike some countries, in Canada NP’s licence to practice is separate from that of the RN.  NPs have been practicing in Canada for over 40 years, but regulation within each jurisdiction (provinces and territories) commenced in Ontario in 1998 and NPs are now regulated across Canada.

Nurse Practitioners are fully autonomous health care providers which means that we conduct physical assessment, order diagnostic tests, diagnose conditions and prescribe medication and other treatments for our patients independently, without physician supervision.  Our scope of practice in every province and territory is the same. We implement research evidence into our practice and to ensure the care we provide is patient directed- not just the treatment of the disease.  Nurse practitioners practice in all settings and with all types of patients – primary care clinics, hospital settings, home care, palliative care, First Nations Communities.  Nurse practitioners often work with vulnerable patients and in locations where they are the only access to health care, such as nursing stations in rural and remote areas.

Study after study demonstrates nurse practitioner practice results in positive health outcomes such as reduction in blood pressure for a person with a diagnosis of hypertension or improved blood sugar control in a person with diabetes.  Patient satisfaction is high with NP care and studies show that NPs enable better self -care for conditions such as mental health, diabetes, breathing disorders and high blood pressure.

Despite the success of the NP role, it hasn’t been without difficulties.  There have been, and continue to be, ongoing barriers to practice which have the potential to reduce access to all care for our patients. The Canadian Association of Advanced Practice Nurses was invited to present to the Justice Committee and to the Senate with respect to the legislation.  We submitted a brief related to wording and specific issues in the proposed regulation and sent a message to each Member of Parliament and Senator by email.  Despite this, an amendment was put forward by a senator that wasn’t related to the criteria or process of assisted dying, but rather related to NP scope of practice.  The amendment, although rejected, would essentially have restricted NP’s scope of practice by requiring them to be supervised by a physician. Our concern was for patients of NPs and access to care, so there was relief when the amendment was rejected.

The issue is bigger than this legislation. There is a need for ongoing marketing of the NP role, both with legislators and the public so that NP practice is understood and the value of NPs in health care is well known.  NPs will have to continue to advocate for our patients to ensure that they are able to receive comprehensive care.  However, this isn’t a time for pessimism. Although there were hiccups in the process, NPs inclusion in the bill for medical assistance in dying was an important step in the recognition of the role of the NP in Canadian healthcare and we’re excited to see what happens next.


Roberta Heale, President of the Canadian Association of Advanced Practice Nurses, Associate Editor Evidence Based Nursing  @robertaheale  @EBNursingBMJ

To Tweet or not to Tweet

12 Jun, 16 | by josmith

Copyright Image - Mark Pearson Photography

IMG_0206This weeks EBN Twitter Chat on Wednesday 15th June between 8-9 pm (UK time) will be hosted by Kirtsen Huby (@KirstenHuby) and Joanna Smith (@josmith175) Lecturer’s in Children’s Nursing, University of Leeds and will focus on ‘to tweet or not to tweet’ in relation to social media and healthcare.



Participating in the Twitter chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN Twitter chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

Twitter was started by Jack Dorsey in 2006 with the first tweet being sent on March 21 (; Twitter now has 310 million monthly active users ( Over the last 10 years Twitter is being used in many different ways within organisations, by professional bodies and individuals. There are guidelines and policies on how to use social media professionally and an emerging evidence base for the use of Twitter. It is therefore timely to consider whether ‘to tweet or not’.

Benefits of using Twitter in healthcare include increased engagement with students, colleagues and patients (Ferguson, 2013), developing networks and communities (Moorley and Chinn, 2014) often across geographical boundaries (Richardson et al., 2016) and enabling the ‘real-time’ sharing of information and discussion during conferences (Ferguson et al., 2014). By making research data, findings and publications available to the public it is possible to make research more accessible (Lupton, 2014) which may promote evidence based practice and discussion around the research that is conducted. As with all social medial platforms there are concerns. As Twitter enables us to have conversations with no restrictions on who can engage there may be a blurring of personal and professional personas (Eggers and McGonigle, 2012) which some may find uncomfortable. There is also the risk of feeling overloaded by the volume of information available (Eggers and McGonigle, 2012) or feeling pressured to engage, the one reason NHS Employers (2014) gives as not a valid reason to engage.

The use of social media is now a part of life for many of us on a daily basis. We choose how we wish to engage and with whom, the platforms we use and the information that we share. Increasingly social media is utilised in our professional lives. This may be because we see benefits to doing this, the organisation we work for requires us to use it or our patients, students or colleagues wish to engage this way. For some people this may feel as though their choices in regards to the use social media are restricted.

image1Question to think about before the Twitter Chat:

  1. Why do you think nurses should use Twitter as a means of communication?
  2. What are your experiences of using Twitter as a means of sharing information and networking?
  3. How can we make tweeting accessible and relevant so that people choose to engage?



Readiness for Change: No Easy Answers

6 Jun, 16 | by rheale

The concept of patient readiness to make positive lifestyle changes has been on my mind lately. I’ve often used Prochaska and DiClemente’s Stages of Change Model to evaluate the stage of change of a person and to guide my approach to health promotion activities for such things as counseling people to stop smoking or implement exercise into their daily lives. It includes pre-contemplation, contemplation, preparation, action, maintenance, relapse.

It looks straightforward, but it’s anything but.  Of all the steps, the one that seems to be the most difficult for people is from preparation to action, or actually implementing the positive lifestyle change.

A quick search for research about factors related to readiness to change an aspect of lifestyle show that while there are a great number of articles about evaluating the stages of change, there is little about factors that influence readiness of an individual to make this change. The articles that do identify factors related to readiness for change demonstrate the complex nature of readiness as well as the numerous individual factors associated with each situation.

The role of nurses in readiness for change isn’t entirely clear to me.  We educate, coach, or guide people to make positive lifestyle changes, but how many people actually make the changes?  What needs to be in place to move people to a state of readiness for change?  I recently participated in research that offers one interesting insight.  In a survey of patients at a family practice clinic, people who were able to see their primary health care provider on the day that they requested an appointment were significantly more likely to indicate that they had made a lifestyle change. Perhaps then, accessibility to care at a time that a person wants to see their provider, is also a time when they are ‘more ready’ to receive information, education and support for lifestyle changes.  This association needs to be confirmed, but it’s certainly worth further exploration.

Nurses work to help people achieve a healthy lifestyle and optimum health.   It’s important for us not only to develop programs that meet people’s need for information and provide the resources to do so, but also to consider the intangible element of readiness for change.

Roberta Heale, Associate Editor of EBN, @robertaheale @EBNursingBMJ


Creating Nursing Leaders to Translate Evidence into Practice

24 May, 16 | by ashorten

Yesterday was graduation day for a wonderful group of future nursing and midwifery leaders in our school. We launched 92 new “Yale Nurses” from our Master of Science in Nursing, Doctor of Nursing Practice (DNP) and PhD programs. As our students walked proudly across the stage, supported by the cheers of faculty, family and friends, I began to think about their exciting new opportunities and future responsibilities as current and future nursing leaders.

Our profession seems to be constantly evolving and redefining educational essentials to keep up with the ever-changing landscape of healthcare. Expectations of our clinical nursing leaders have moved far beyond proficiency in a specialized area of clinical care. Clinical nursing leaders face increasing demands to provide expertise in project management, informatics, bioethics, navigating the business of healthcare, developing and applying healthcare policy, and implementing evidence-based nursing care to meet the healthcare needs of diverse patient populations.1,2 A new cadre of nurse leaders is currently embracing this professional challenge in the United States (US) by completing their Doctor of Nursing Practice (DNP) qualification. Yale School of Nursing (YSN) just graduated our second cohort of DNPs – 14 new nurse leaders in total.

DNP programs have spread across the US in recent years, with over 240 DNP programs currently available nationally.3 Traditionally, PhD programs have been the pathway to a terminal degree for nurses and midwives. PhDs provide rigorous research training, enabling nurses and midwives to make significant contributions to the body of knowledge within our disciplines. Graduates of PhD programs can provide the answers to important research questions, generating evidence to inform practice. The DNP is also a terminal degree, yet it offers something quite different to that of a traditional research doctorate. While research leaders with PhDs expand our evidence base, DNP leaders focus their skills on implementing the evidence through innovation in clinical practice and evidence-based health policy.

There has been much debate in the US about the relative merits of different types of doctoral level study for advanced practice nurses and nursing leaders, and the discourse continues regarding how each might fit within the healthcare system.  There are currently a wide variety of clinical DNP programs available for advanced practice specialty nursing and also DNPs specifically for leadership and policy. 2 The DNP graduates I applauded as they walked across the stage yesterday were mid-career leadership and policy DNPs. Examples of their evidence-based projects include “Building an Evidence Based Succession Planning Tool for Chief Nursing Executives” – Stephan Davis; “Design of an Evidence-Based Mentorship Program for Inpatient Nurse Practitioners” – Kimberley Ennis; ”Development and Validation of an Electronic Medical Record Information Prioritization Tool for Evidence-Based Diabetes Management” – Caroline Piselli;  and “Implementing the Point of Care Integrated Breast Cancer Screening Model” – Jill Muhrer. Implementing evidence-based models of care through the development of innovative tools, programs and policies was a consistent project theme.

There was much excitement around the contribution each new DNP graduate had made to their clinical community, healthcare organization and patient population – each making a difference and leading the way to strengthen the profession for the future and making improvements in population health. It will be interesting to see how DNP programs are shaped over time and exciting to see how these new nurse leaders are able to use their expanded skillset to increase the pace at which we are able to implement evidence-based healthcare delivery for the future.


American Association of Colleges of Nursing. (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. Washington, DC:

American Association of Colleges of Nursing. (August 2015). The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations.

American Association of Colleges of Nursing (July 2014) Doctor of Nursing Practice (DNP) Talking Points


Allison Shorten PhD RN RM FACM

Associate Professor

Yale School of Nursing


15 May, 16 | by josmith

This week’s EBN Twitter Chat will be held on Wednesday the 18th of May between 8-9 pm (UK time) and will be hosted by Kelly Young who is the Children’s Theme Team Lead for the Yorkshire and Humber Clinical Research Network (@mrskellyyoung) and will focus on the #whywedoresearch campaign.

Participating in the Twitter chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN Twitter chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

At EBN promoting research that underpins nursing is one of our core values: our research made simples series is one way of helping nurses understand research, the series can be accessed via our web site or the link below, with many article free to download:

#whywedoresearch campaign @mrskellyyoung

In 1995 I qualified as a Registered Nurse (Adult) and was one of the first Staff Nurses to emerge from Project 2000 image002programme at Mid Trent College of Nursing and Midwifery in Lincolnshire. Soon after qualifying I embarked on a career in neonatal nursing. Fast forward 20 years and I have, and still am, enjoying a fantastic and fulfilling nursing career in neonatal care. In 2010 I became a research nurse supporting families and clinical teams through research care pathways. In 2015 I became the Bradford based Children’s Theme Team Lead for the Yorkshire and Humber Clinical Research Network (CRN)

My role is to focus on increasing good quality research opportunities for children and their families that will ultimately improve care and outcomes for future generations; which is most definitely my own personal ‘#whywedoresearch’!

I was excited to become one of the first #whywedoresearch ambassadors in 2015. I embraced this opportunity recognised the benefits to being involved, which for me are to engage colleagues, children and families in research. #whywedoresearch has huge potential to engage and unite all stakeholders in research through a simple interaction, simple but powerful. The engagement of clinical colleagues including nursing staff cannot be underestimated as we move towards a culture whereby research opportunities for patients are embedded in clinical care. Kelly Young RGN, @mrskellyyoung

15030213_Neonatal_Childrens_Research_Poster_D2 (2)


Some things to think about before the Twitter Chat:

Why do you think nurse should understand, undertake and implement research?

What are the challenges facing nurse researchers?

What are the challenges in relation to undertaking research with children?



Advance care planning with people who have kidney failure

9 May, 16 | by hnoble

Peter O’Halloran, Lecturer, Queens University Belfast


A couple of years ago I was discussing the demise of the Liverpool Care Pathway with colleagues in one of our local hospitals. We had just completed some research [1] exploring some of the reasons for the failure of the pathway – one of which was the difficulty clinicians of all stripes have in discussing death and dying in a timely way. Often the discussion, if it happens at all, takes place when the person is only days away from death, with the risk that communication with the patient and family takes place in the midst of fear and uncertainty. My colleagues thought advance care planning might be part of the solution to this problem.

Advance care planning (ACP) has been defined as a process of discussion between an individual, their care providers, and often those close to them, about future care.[2] It may lead to an advance statement of preferences; an advance decision to refuse treatment (ADRT); or to the appointment of someone with lasting power of attorney. It seemed an area of practice with considerable potential – and ripe for research; but which patient group should I focus on? ‘You should look at people with end-stage renal disease,’ said my colleague, Helen Noble (@helnoble). That didn’t seem obvious to me, but it was difficult to get away from the idea – partly because I share an office with Helen but mostly because, when I looked into the literature, I discovered a group of people who might well benefit from advance care planning. Here are the facts:

The prevalence of moderate to severe chronic kidney disease (defined as stages 3-5 CKD) has been estimated at 6-8.5% amongst adults in the UK [3–5] and at over 30% in those aged 75 and over. [4] It’s associated with rising risks of hospitalisation, cardiovascular events, cognitive impairment and death.[6] The rapidly growing minority of older patients with CKD who progress to end-stage kidney disease (ESKD) are at even greater risk, as they exhibit the mixture of functional decline and co-morbidity typical of frail older people. [7] However, a substantial proportion of patients and their families do not discuss end-of-life care (including withdrawal of dialysis, ICU admission, involvement of specialist palliative care, cardiopulmonary resuscitation, and place of death) with health professionals.[8] To compound the matter, the high incidence of impaired cognitive capacity amongst patients with ESKD limits their ability to make informed choices and places additional decision-making burdens on their families.

Helen introduced me to an array of enthusiastic renal clinicians (doctors and nurses with a deep commitment to enhancing quality of life for their patients) and we formed a research team which included people living with renal disease, and some experienced trialists – and slowly a research proposal took shape.

Fast-forward to the present and we are just about to start a feasibility study for a trial of advance care planning with older patients who have end-stage kidney disease – the ACReDiT study ( Identifier: NCT02631200). Hopefully this deferred entry randomised controlled trial, side-by-side with a mixed methods process evaluation, will pave the way for a full multi-centre trial to see whether (and how) advance care planning really works for patients and their families.

1       McConnell T, O’Halloran P, Donnelly M, et al. Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients: a realist evaluation. BMJ Support Palliat Care 2014;:bmjspcare – 2014–000723 – . doi:10.1136/bmjspcare-2014-000723

2       Royal College of Physicians. Advance care planning. Concise Guidance to Good Practice series. London: : Royal College of Physicians 2009.

3       Stevens PE, O’Donoghue DJ, de Lusignan S, et al. Chronic kidney disease management in the United Kingdom: NEOERICA project results. Kidney Int 2007;72:92–9. doi:10.1038/

4       Roth M, Roderick P, Mindell J. National Statistics Health Survey for England – 2010, Respiratory health. Leeds: : The Health and Social Care Information Centre 2011.

5       Jameson K, Jick S, Hagberg KW, et al. Prevalence and management of chronic kidney disease in primary care patients in the UK. Int J Clin Pract 2014;68:1110–21. doi:10.1111/ijcp.12454

6       National Collaborating Centre for Chronic Conditions. Chronic kidney disease. London: : Royal College of Physicians 2008.

7       Anderson S, Halter JB, Hazzard WR, et al. Prediction, progression, and outcomes of chronic kidney disease in older adults. J Am Soc Nephrol 2009;20:1199–209. doi:10.1681/ASN.2008080860

8       Arulkumaran N, Szawarski P, Philips BJ. End-of-life care in patients with end-stage renal disease. Nephrol Dial Transplant 2012;27:879–81. doi:10.1093/ndt/gfs028

How do nurses use technology to enhance care?

2 May, 16 | by josmith

This week’s EBN Twitter Chat on Wednesday 4th May between 8-9 pm (UK time) will be hosted by Professor Alison Twycross (@alitwy) who is editor of EBN, and will be lead by Dr David Barrett (@barrett1972), associate editor EBN, from the University of Hull.

Participating in the Twitter chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN Twitter chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.


Technology has a vital role to play in the delivery of healthcare. In the UK, documents such as the ‘Five year forward view’ (NHS England, 2014) and the Scottish eHealth strategy (NHS Scotland, 2015) outline the importance of harnessing the potential of technology to make healthcare more effective and efficient. Internationally, the World Health Organisation (WHO) is working to promote the use of information and communication technologies in healthcare (WHO, 2016).

The evidence base for using technology is growing. For example, the use of telemonitoring (remote monitoring of vital signs and symptoms) appears to reduce mortality and hospital admissions in some patients (Kitsiou et al, 2015). Teleconsultation (the use of real-time video communication to support healthcare) has been shown to provide benefits in a range of clinical contexts, including acute management of patients with symptoms of stroke (Demaerschalk et al., 2012). Other technology-enabled services include phone-based motivational interviewing, electronic care planning and health-focused mobile applications.

Despite the exciting opportunities presented by technology, problems can arise with its implementation and adoption. The use of technology can be limited by issues such as the top-down imposition of change, discomfort with a move away from face-to-face care, and technical limitations/failure.

This Twitter chat provides a chance for nurses to discuss their experiences – good and bad – of using technology in healthcare. By doing so, we can celebrate best practice, identify common challenges and explore the means by which the use of technology can be expanded.

Some things to think about before the Twitter Chat

  1. How have you used technology to enhance the care you provide?
  2. What evidence underpinned the choice of technology?
  3. What challenges did you (or do you) face in the implementation and use of technology within nursing care?
  4. How have you and your colleagues addressed these challenges?
  5. What are your key messages to other nurses wishing to use similar technology within their place of work?
  6. Are there any areas of practice where you think the introduction of technology could enhance care?


Demaerschalk, B., Raman, R., Meyer, B. (2012) Efficacy of telemedicine for stroke: Pooled analysis of the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) and STRokE DOC Arizona telestroke trials. Telemedicine and eHealth, 18(3), 230-237.

Kitsiou S, Paré G, Jaana M (2015) Effects of home telemonitoring interventions on patients with chronic heart failure: An overview of systematic reviews. Journal of Medical Internet Research 17(3): e63

NHS England (2014) Five year forward view. Available from:

NHS Scotland (2015) eHealth strategy, 2014-2017. Available from:

World Health Organisation (2016) eHealth at WHO. Available from:

Introducing Inter-professional Simulation Education

25 Apr, 16 | by hnoble


Photo Gail

Gail Anderson, Lead Midwife for Education, Queens University Belfast

An inter-professional educational initiative was developed within the Schools of Nursing and Midwifery and Medicine. The collaborative aim was to provide interactive workshops focusing on the concepts of normal labour and birth to fourth year medical students and were led by final year midwifery students. Significant emphasis is placed upon the importance of relationship building with women in labour and the concept of being ‘with woman’ is a core focus. Introducing inter-professional simulation education has been suggested to reduce stereotypical views and promote better understanding of the respective roles of the professional in addition to enhancing future collaborative practice. However, the logistics of incorporating inter-professional education (IPE) within the University setting is challenging not least due to the competing demands of separate educational curricula but also due to the respective differing sizes of student cohorts and ensuring equity of experience for all students. A small team of midwifery lecturers and medical colleagues met to explore ways of promoting inter-professional learning and overcoming some of these barriers within the University setting.

It was felt that providing an opportunity for medical students and midwifery students to interact and communicate prior to the undertaking of an obstetric placement within labour ward would help to improve the overall student experience and potentially enhance inter-professional relationships. Midwifery students would benefit from the opportunity to teach and facilitate learning in relation to normal labour and birth, whilst medical students would benefit by learning about the process of birth and familiarisation with the birth environment. This opportunity could provide midwifery students with a positive, confidence building forum where the utilised teaching and learning strategies would be transferable to their professional role as registered midwives and additionally in their health promoting role in providing parent education to women and their partners. Equally, medical students would be supported to understand their role and feel comfortable with assessing and supporting women in normal physiological labour.

The teaching strategy which was developed involves final year midwifery students providing an interactive labour and birth scenario whereby various roles, including mother, partner, midwife and narrator are adopted. A member of the midwifery teaching team facilitates the sessions and ensures a high quality learning experience for both sets of students. The midwifery students use a variety of birth mannequins and support aids to promote learning and the sessions also encourage ‘hands on’ participation and interaction by medical students to enhance the learning experience. Artistic licence is encouraged with the midwifery students to allow them to deliver a unique workshop that demonstrates their own personalities and identities. Low fidelity simulation is the chosen approach for the simulated workshops. Whilst low fidelity simulation does not imitate the realism of the mother in labour it does provide the medical students with an appropriate learning opportunity prior to undertaking their first maternity placement. A low fidelity simulated approach is considered more beneficial for novice learners in addition to which midwifery students may also feel more comfortable and confident with their own teaching abilities using this approach.

Following the interactive workshops the students complete an evaluation questionnaire. To date the results of the evaluation questionnaires strongly suggest a distinct benefit of this education initiative for both sets of students. The findings support much of the current evidence regarding the benefits of inter-professional learning particularly in relation to promoting increased levels of confidence and the understanding of professional roles within the multidisciplinary team. Furthermore the inter-professional learning workshop serves to highlight the importance of all health professionals aiming to promote normal birth for low risk women. This education initiative provides an opportunity for medical students to recognise how to care for healthy low risk women in labour whilst also gaining an insight into their own role within this setting and the role of the midwife as the expert in normal birth. The midwifery students perceive themselves to have achieved a greater level of confidence which will be of benefit to them in their future educative role as health promoting midwives in teaching women and their families as well as other health professionals. This perceived increase in confidence will also enhance their ability for future inter-professional collaboration.

Low fidelity simulation offers ideal opportunities for improved interaction and provides a safe non-threatening learning environment. The benefits of this innovative education initiative have been recognised. Such is the considered success of this education initiative that a commitment has been made by both Schools to embed this education strategy within each of their respective curriculums with a vision for further growth and development of undergraduate inter-professional education involving student midwives and medical students. This innovative education strategy holds promise for the future of inter professional collaboration and goes some way to eradicating a ‘them and us’ culture in clinical practice. However, this concept requires further research to identify the long term benefit of undergraduate inter professional education within the university setting.








Creating tools to improve opportunities for shared decision making during pregnancy

21 Apr, 16 | by ashorten

My research in nursing and midwifery has been shaped by a firm belief that all people should have the opportunity to make informed and supported choices about their healthcare, using the best available evidence. I began my research career in the 1990s when I conducted an economic evaluation of a new midwifery early discharge program at my local hospital, where I was practicing as a midwife.1 As a young midwife studying for my Masters degree I became interested in identifying which models of healthcare provided the best outcomes for pregnant women.

At the time I was curious about large and unexplained variations in Australian obstetric interventions and birth outcomes for women. I found that birth experience and mode of birth depends greatly on health insurance, where women give birth and what type of healthcare professional they choose to provide their care. My colleagues and I examined data that had been collected routinely by midwives for every birth in New South Wales over a 10 year period. From these records we were able to discover that hospital funding models (public or private), provider type (midwife or obstetrician), and models of care were the strongest predictors of interventions and outcomes for birth, even when medical risk factors were considered.2-5 I was hooked on data and the power of gathering evidence to tell the story of healthcare.

The systematic search for the best quality evidence to inform pregnancy care quickly became a way of life. As an educator, the next logical step for my work was to find better ways to translate and share new evidence about birth options with women and families, so they could make birth decisions that were best for them.

Birth Choices after Cesarean Decision Aid: The evidence I had gathered about obstetric and midwifery practices in the Australian healthcare system, combined with my midwifery philosophy of promoting physiological birth, motivated me to explore how to support women as they gather knowledge about the risks and benefits of their options and participate in decision making during pregnancy. Childbirth trends in Australia around that time mirrored the United States, with rising caesarean section rates and declining opportunities for women to attempt vaginal birth after previous caesarean (VBAC). This was despite evidence from research that VBAC was safe for most women, with advantages over repeated caesarean surgery. I had completed a cost-effectiveness analysis of trial of labour versus elective repeat caesarean and found important financial advantages in supportive VBAC policies as well.6 Promoting VBAC as a viable option for women became an important motivator for me to help address gaps between evidence and practice in pregnancy care. A multi-faceted approach was clearly necessary to change routine practice. For my PhD I focused on the question of whether improvements in women’s knowledge about birth options could influence their choices and outcomes. Utilizing the Ottawa Decision Support Framework (DSF), I developed the first decision aid booklet for pregnant women who had experienced previous cesarean birth and called it Birth Choices.7 My goal was to inform women about their birth options, and support them in identifying their values and preferences in the decision making process. I designed and conducted a multi-site randomized controlled trial (RCT), funded by a Medical Benefits Fund grant.

Through this work I discovered that my decision aid booklet improved women’s knowledge about their options, which also resulted in less decision conflict.8 The decision aid is listed in the International Inventory of Patient Decision Aids, has been internationally validated in studies to standardize decision aids, and is featured in international systematic reviews of patient decision aids. The Birth Choices decision aid has been updated and is still used in clinical practice, which is the most exciting part of research for me. So far it has been translated into French, Japanese, and Spanish, and adapted for a study in New Zealand. A Chinese translation is currently underway.

Shared Decision Making and Health Information Technology: While my previous research found that decision aids were effective in preparing women for making decisions during pregnancy, one of the critical discoveries was that despite decision aid effectiveness, method of birth was highly influenced by organisational factors within pregnancy care services.13 I was back to the powerful effect of where women chose to give birth (which hospital or health service) and who provided their care. The next phase of my research has focused on exploring new ways to overcome organisational and cultural barriers to shared decision making (SDM), in diverse pregnancy care settings. Over the last three years I have been leading a multi-disciplinary team of US researchers with expertise in midwifery, obstetrics, psychology, decision science and health information technology (IT) to identify innovative approaches to combine decision aids for women with shared decision making in busy, urban ethnically diverse clinical settings.

Our research team received funding from the Agency for Healthcare Research and Quality (AHRQ) in 2013 for a feasibility study “Using Interactive Health IT to Support Women’s Choices for Birth after Cesarean” 1R21HS022114-01. Phase one engaged targeted users (women and providers) in an instructional design process, to translate my original paper-based tool into an interactive web-based format for ethnically diverse groups of women.10 Phase two (in progress) involves a feasibility study of the process of integrating the Birth Choices decision aid into busy urban outpatient clinics within the Yale New Haven Hospital (YNHH) system. We are working to fill a gap in knowledge about integrating web-based decision aids into busy clinical practice environments. Our next steps will be towards identifying the best ways to implement decision aids in practice using a SDM framework, with the goal of maintaining the practice change.

Research has become a way of life. After more than 20 years in academic life it is still exciting to plan new projects and uncover new evidence to inform our practice, with the enduring commitment to improving patient experiences and outcomes.

Allison Shorten PhD RN RM FACM

Associate Professor

Yale University School of Nursing



1.     Shorten, A. (1995). Obstetric early discharge versus traditional hospital stay: Analysing the cost of postnatal care. Australian Health Review, 18(2), 19-39.

2.     Shorten, A., Shorten, B. (1999) Episiotomy in NSW hospitals 1993-1996:  Towards understanding variations between public and private hospitals. Australian Health Review, 21(1), 18-32.

3.     Shorten, A., Shorten, B. (2000) Women’s choice? The impact of private health insurance on episiotomy rates in Australian hospitals. Midwifery, 16, 204-212.

4.     Shorten, B., Shorten, A. (2004) Impact of private health insurance incentives on obstetric outcomes in NSW hospitals. Australian Health Review, 27(1), 27-38.

5.     Shorten, A., Shorten, B. (2007) What happens when a private hospital comes to town? The impact of the ‘public’ to ‘private’ hospital shift on regional birthing outcomes. Women and Birth, 20(2), 49-55.

6.     Shorten, A, Lewis, D.E., Shorten, B. (1998) Trial of labour versus elective repeat caesarean section: A cost-effectiveness analysis. Australian Health Review, 21(1), 8-28.

7.     Shorten, A. (2000) Birth Choices: What is best for you…vaginal or caesarean birth. A decision-aid for women making choices about birth after caesarean section. UOW Printery. Wollongong.

8.     Shorten, A., Shorten, B., Keogh, J., West, S., Morris, J. (2005) Making choices for childbirth: A randomized controlled trial of a decision-aid for informed birth after cesarean. Birth , 32(4), 253-262 .

9.     Shorten, A., Fagerlin, A., Illuzzi, J., Kennedy H.P., Lakehomer, H., Pettker, C., Saran, A., Witteman, H.,   Whittemore R., (2015) Developing an Internet-based decision aid for women choosing between vaginal birth after cesarean and repeat cesarean birth, Journal of Midwifery and Women’s Health. (Early View 8 JUN 2015 | DOI: 10.1111/jmwh.12298


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