Improving intrapartum fetal monitoring in India: is training the answer?

Introduction: Although intrapartum fetal monitoring is a fundamental aspect of intrapartum care worldwide, research on its use in LMIC is lacking. This thesis uses a multi-methods approach to evaluate an intrapartum FM training and quality improvement package in a government hospital in India, informed by staff and patient perspectives. Methods: This research was conducted in two Government hospitals in central India. The qualitative study involved eight clinician/researcher focus groups and 53 semi-structured interviews with high-risk women before and after labour induction; data was analysed using a framework approach to thematic analysis. A FM training programme was implemented and evaluated using a fixed, parallel, convergent design based on Kirkpatrick’s four-stage evaluation model and reflective diary. The prospective cohort data were analysed to evaluate risk factors, outcomes and FM practices. We then outlined an evidence-based theory of change for FM training, that is adaptable to the local context. Results: The qualitative study developed six themes (in bold). 1. Women preferred vaginal birth as it was "trouble for two hours [rather than] trouble for two months”. 2. Women gained knowledge through experience. 3. FM was part of a positive birthing experience [and women] "felt good by hearing the beats”. 4. Interactions with women, relatives and clinicians were important. 5. Clinicians felt FM as per guidelines was "practically not possible", and 6. FM and risk were linked. "Trying for normal" birth without good FM was considered "too risky”. Clinicians felt that more FM training and equipment would help. Clinicians enjoyed the FM training and gained knowledge and confidence. Post-training, they could quantify and describe how cases were managed differently. Of 84 clinicians, 77 (86%) engaged with one session or more. The interactions between the training, co-interventions, relationships, systems and context were paramount. The pre-and post-intervention groups included 2,272 women (2,319 babies) and 1,881 women (1,920 babies), respectively. The mean fetal heart rate (FHR) documentation count during labour increased significantly from 5 to 7.5 (p=<0.001); the mean time between the last FHR and delivery fell significantly from 60 to 50 minutes (p=<0.001). There were non-significant trends toward increased operative birth rates (42.9% vs 45.5%) and reduced perinatal mortality (4.6% vs 3.7%). Neonatal intensive care unit (NICU) admission rates fell significantly (16.7% vs 10.2%), as did NICU admissions for asphyxia (1.2% vs 0.6%). The CS rate was 42.5% in this very high-risk population. Fetal indications were the most common indication for operative birth (15.4% of all births), and 13.7% were admitted to NICU. Only 3.4% of NICU admissions were for birth asphyxia and 1.2% for meconium aspiration syndrome. The total perinatal mortality rate, using the Indian definition, was 68.7/1000 (459/6682), of whom 58 were possible/confirmed in-facility intrapartum fresh stillbirths (8.9/1000 WHO definition) and 25 neonatal deaths due to asphyxia. Conclusion: Women want a healthy baby and “normal” birth, but clinicians feel vaginal birth is unsafe with inadequate FM, and this drives high operative birth rates. "Hearing the beats" and kind communication promotes a positive birth experience for women. FM training is a complex intervention that can improve FM process indicators and some neonatal outcomes. Clinicians enjoyed the training, gained knowledge and confidence, and changed their practice. However, the interaction between training, co-interventions, context, people and systems is essential. For change to occur, training must be embedded within wider interventions so that barriers to implementation are identified and overcome

Assessing patient and caregiver intent to use mobile device videoconferencing for remote mechanically-ventilated patient management

The Michigan Medicine adult Assisted Ventilation Clinic (AVC) supports patients with neuromuscular disorders and spinal cord injuries and their caregivers at home, helping them avoid expensive emergency department visits, hospitalization, and unnecessary or excessive treatments. Mobile device videoconferencing provides an effective capability for remote mechanically-ventilated patient management but must rely upon an unknown infrastructure comprising patient and caregiver mobile device ownership, connectivity, and experience—and intent to use the service if provided. The purpose of this study was to measure the extent of this infrastructure and the perceived ease of use, perceived usefulness, and intent to use this mobile device capability using a questionnaire based on the technology acceptance model (TAM). Of 188 patients and caregivers asked, 153 (n = 153) respondents completed a questionnaire comprised of 14 demographic and 24 Likert-type questions. Inferential results indicated a significant correlation between perceived ease of use (PEU) and perceived usefulness (PU) of mobile devices in remote care and their intent to use them (sig. \u3c .001). Also, mobile device own/access significantly correlated with PEU and PU (p = .003 & .004, respectively), but not intent to use. No single demographic variable (age, distance to AVC, diagnoses, mobile device experience, tracheostomy, etc.) significantly correlated with intent to use. Descriptive results indicated a significant patient/caregiver provided infrastructure: 96% have cellular/WiFi/Internet access, 91% own or have access to mobile devices, 77% have downloaded apps, 68% have used videoconferencing, and 80% own between two and five ICT devices

Gestalt Biometrics and their Applications; Instrumentation, objectivity and poetics

This thesis is about the relationship between human bodies and instrumental technologies that can be use to measure them. It adopts the position that instruments are technological structures that evoke and manifest particular phenomena of embodied life. However, through their history of association and use in the sciences and scientific medicine, instruments tend to be attached to a particular ontology, that of mechanical objectivity. Embarking from research into the artistic uses of physiological sensor technology in creative practices such as performance and installation art, this thesis asks whether it is possible to use instruments in a way that departs from their association with scientific objectivity. Drawing on philosophers who have developed an understanding of the relationship of instrumental technologies and human bodies as co-constructive, it explores how this model of con-construction might be understood to offer an alternative ontology for understanding the use of instruments in practices outside of science and scientific medicine. The project is therefore suggestive of degrees of freedom and flexibility that are open to exploitation by creative practices in the realm of instrumentation as an alternative to orthodox rationalisations of the value of scientific equipment as authentic, revealing and objective. The major contribution of the thesis is that transfers and synthesises arguments and evidence from the history and philosophy of sciences that serve to demonstrate how the instrumental measurement of human bodies can be considered to be a form of creative practice. It assembles a position based on the work of thinkers from a number of disciplines, particularly philosophy of science, technology, and the medical humanities. These offer examples of ontological frameworks within which the difference between the realm of the instrumental, material, biological, and the objective, and the phenomenal, meaningful and subjective, might be collapsed. Doing this, the thesis sheds light on how physical devices might enter into the interplay of making, mattering and objectifying the immaterial, a realm that it might be considered the role of artists to manifest. Drawing on contemporary, and secondary, accounts of the development of empirical testing in the medical sciences, the thesis agues for the recovery of a romantic account of human physiology, in which the imagination and meaning are active and embodied. It therefore offers to link the bodily and the instrumental through an extended-materialist account in which the physiological, rather than the psychological, is central. Developing a response to constructionist models of the body and instrumentation, the thesis concludes that a model of the poetic may be adopted as a method for understanding the opportunities and imperatives inherent in the avoidance of deterministic approaches to biosignalling technologies. In doing this, the thesis contributes particularly to the creative arts and technology research practices concerned with the use of body sensor technologies in humanistic applications. It complements the existing works by artists in this area that make use of instruments by assembling a number of theoretical readings and interpretations of how instruments work – among them the thermometer, lie detector, and automatograph – which illustrate the argument that that is possible to operate from a theoretical position within which instruments are both material, performative and symbolic.Engineering and Physical Sciences Research Counci

Using IS/IT to support the delivery of Chinese Medicine

This study investigated aspects of utilising IS/IT in Chinese Medicine practice in Australia. The research proposed that a more suitable synthesis should be adopted for the developments in this domain. Hence, the Chinese Medicine Inquiring System is a combination of the key concepts of Knowledge Management, Inquiring Systems and IS/IT

The application of innovative virtual world technologies to enhance healthcare education

The World Wide Web has evolved leading to the development of three- dimensional virtual worlds. These are online, accessible environments through which a user may engage, communicate and interact via their digital self, known as their avatar. These virtual worlds offer the opportunity for further content to be generated in order to provide new environments and simulations. This research work explores the potential of virtual worlds in providing an educational platform for healthcare professionals. In order to establish this, the effectiveness of a virtual world environment was determined through the use of a custom-built virtual world operating theatre, which was utilised to train operating theatre novices in preparation for the real-life environment. Following the application of a virtual world environment, this research explored the development of a virtual patient scenario for training healthcare professionals. The virtual patient scenario focused on the management of adverse events associated with medical infusion devices with a nurse user group assessing the simulation face validity. The next step was to devise a methodology to develop a series of immersive virtual patients. This involved the use of allied web technologies to produce a robust, reproducible method of 3D virtual patient generation. Three virtual patients were constructed, with distinct surgical pathologies at three levels of increasing complexity. Subsequently the face, content and construct validity of the virtual patients was established to differentiate surgeons of different training grades. Finally the virtual patients were utilised to emulate real clinical situations, in which handoff of patient information occurred. The virtual patients were used to establish if the quality of handoff impacted on the subsequent patient management in a simulated setting. Overall this research has demonstrated the efficacy of virtual world environments and simulations in providing an alternative educational platform for healthcare professionals.Open Acces

The affordances of mobile learning for an undergraduate nursing programme: A design-based study

Philosophiae Doctor - PhDThe global use of mobile devices, and their connectivity capacity, integrated with the affordances of social media networks, provides a resource-rich platform for innovative student-directed learning experiences. Technology has become embedded in the daily lives of students, who become more approachable when technology is used within the higher education context. In 2014 the Educause Centre for Analysis and Research partnered with 213 higher education institutions across the United States of America. It was established that 86 percent of undergraduate information technology students owned a smartphone and half of that percentage owned a tablet. A systematic review on mobile learning in higher education focusing on the African Perspective in 2017 concluded that there was an increase in the use of mobile learning in higher education. Higher education institutions continue to move away from traditional, lecture-based lessons towards new, innovative teaching and learning methodologies to facilitate emerging pedagogies and strategies, thereby enhancing student learning. The adoption of technological innovation could promote the unfolding of a social process that over time could enhance social connectedness among young students and their older adult educators. Mobile learning is fundamentally defined as “learning with mobile devices” and it has the potential to extend the philosophies of learning through innovation It was identified that research in the field of m-learning can be divided into four areas, namely: pedagogy; administrative issues and technological challenges; ensuring sustainable development in education using m-learning; and the impact of new applications. With the increased need for nursing professionals, promoting the quality and effectiveness of nursing education has become crucial. It is thus important to establish learning environments in which personalised guidance and feedback to students regarding their practical skills and the application of their theoretical knowledge within clinical learning environments is provided

Designing and implementing online assessment in the clinical workplace

Peer reviewe