'The STORK Study' : the Scottish trial of refer or keep : Midwives' Intrapartum Decision Making

The STORK Study Abstract Aim: This thesis describes a study which aimed to explore whether midwives decision making during labour care was affected by the midwives’ own attitude to risk. Specifically, whether midwives who scored highly on risk tendency would delay making a referral for medical assistance compared to those who scored lower. A secondary aim was to explore whether years of clinical experience or location had an effect on midwives’ decision to refer. Project Outline/Methodology: Research Questions 1. Do midwives vary in their general risk propensity, as assessed by scores on a standardised measure of risk propensity? 2. Are midwives risk propensity scores related to their decisions when to seek medical assistance or transfer women to medical care during labour (transfer decisions)? 3. Are ‘transfer’ decisions related to the experience of the midwife or the type of maternity unit in which she practices? Design A correlation study examined the relationship between midwives personal risk tendency and the timing of their decision to make referrals in a series of fictitious case scenarios. Setting and Sample Four Scottish Health Board areas with one or more Consultant Led Units (CLU) and at least one associated Community Midwifery Unit (CMU). Sample - 100 midwives providing labour care. Permission for access and ethics Ethical approval was granted by the Research Ethics Committee, Department of Nursing and Midwifery, University of Stirling and the NHS Research Ethics Committee - Ref No. 05/S1401/44. Research & Development management approval was granted from each area. Permission for access was granted by the head of midwifery of each participating site. Data collection This was an internet based study using vignettes and questionnaires. Five vignettes were developed which represented a range of labour care scenarios. Each contained snap-shot information about five time points describing a worsening case history e.g. high blood pressure or fetal distress. Participants were asked to review each of the vignettes and decide at which time point they would refer the woman for medical care. For each case midwives could decide not to refer at all. Midwives also completed a questionnaire comprising: social and demographic information, two validated measures of risk attitude and a personality assessment. Key Results Despite being presented with the same information midwives made a range of referral decisions. There was no correlation between referral scores and measures of risk, personality or years of experience. No statistically significant difference between the referral scores of midwives working in CLUs or CMUs was found. However, a significant difference did emerge between the health board areas, with midwives from one area making referrals at a significantly earlier stage. It is interesting that maternity services in this area had experienced several high profile adverse events prior to this study; possibly impacting on the midwives’ timing of referrals. Conclusions The range of referral decisions was not due to risk propensity, personality factors, experience or location. Local factors may influence individual decision making choices. What does this study add to the field? This study contributes to the understanding of midwives’ decision making during intrapartum care. The study also involved the development of an innovative internet based study design which will be useful for other research studies. Implications for Practice or Policy The study questions assumptions about midwives’ decision making being influenced by personality, place of work or length of service and highlights the range of decisions made by midwives when presented with the same case factors. Where to next? Further study is required to explore factors which may explain the variability of midwives’ decisions to refer. These factors may include individual differences for example, tolerance of ambiguity, the nature of past experience or individual thresholds for acceptable risk

Progression from gestational diabetes to type 2 diabetes in one region of Scotland: an observational follow-up study

Background: The aim of this study was to investigate long-term risk of type 2 diabetes (T2D) following a diagnosis of gestational diabetes and to identify factors that were associated with increased risk of T2D. Methods: An observational cohort design was used, following up all women diagnosed with gestational diabetes mellitus (GDM) attending a Diabetes Antenatal Clinic in the Dundee and Angus region of Scotland between 1994 and 2004 for a subsequent diagnosis of T2D, as recorded on SCI-DC (a comprehensive diabetes clinical information system). Results: There were 164 women in the study who were followed up until 2012. One quarter developed T2D after a pregnancy with GDM in a mean time period of around eight years. Factors associated with a higher risk of developing T2D after GDM were increased weight during pregnancy, use of insulin during pregnancy, higher glycated haemoglobin (HbA1c) levels at diagnosis of GDM, and fasting blood glucose. Conclusions: These findings suggest there is a viable time window to prevent progression from GDM to T2D and highlights those women who are at the greatest risk and should therefore be prioritised for preventative intervention

Accelerating Student Success: The Case for Corequisite Instruction

The successes of corequisite remediation courses and supplemental instruction over traditional remediation courses such as the modular Math Essentials have been widely and recently documented (Logue, Watanabe-Rose, & Douglas, 2016). Corequisite reform is an important strategy to improve student completion of higher education goals. A robust corequisite model integrates gateway course content with lifelong tools such as time management and study skills that help students beyond the scope of one course. Corequisite remediation may not completely eliminate developmental courses; however, “a fundamental redesign of the support system for academically underprepared students” will include corequisite remediation (Vandal, 2014). This broader “support system” may integrate corequisite courses with the current (or similar) modular curriculum with non-modular precollege courses such as MTH 5 or MTH 9 in the Virginia Community College System (VCCS). Student placement into the optimal teaching/learning mode may be as key as course level placement (Bickerstaff, 2016). Corequisite remediation provides the VCCS with a powerful tool for student success. Wise integration of corequisite courses as part of a robust remediation program makes the vision of the VCCS strategic plan, Complete 2021, more clearly attainable

The purple line as a measure of labour progress: a longitudinal study

Background: Vaginal examination (VE) and assessment of the cervix is currently considered to be the gold standard for assessment of labour progress. It is however inherently imprecise with studies indicating an overall accuracy for determining the diameter of the cervix at between 48-56%. Furthermore, VEs can be unpleasant, intrusive and embarrassing for women, and are associated with the risk of introducing infection. In light of increasing concern world wide about the use of routine interventions in labour it may be time to consider alternative, less intrusive means of assessing progress in labour. The presence of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. The study described in this paper aimed to assess in what percentage of women in labour a purple line was present, clear and measurable and to determine if any relationship existed between the length of the purple line and cervical dilatation and/or station of the fetal head. Methods: This longitudinal study observed 144 women either in spontaneous labour (n=112) or for induction of labour (n=32) from admission through to final VE. Women were examined in the lateral position and midwives recorded the presence or absence of the line throughout labour immediately before each VE. Where present, the length of the line was measured using a disposable tape measure. Within subjects correlation, chi-squared test for independence, and independent samples t-test were used to analyse the data. Results: The purple line was seen at some point in labour for 109 women (76%). There was a medium positive correlation between length of the purple line and cervical dilatation (r=+0.36, n=66, P=0.0001) and station of the fetal head (r=+0.42, n=56, P<0.0001). Conclusions: The purple line does exist and there is a medium positive correlation between its length and both cervical dilatation and station of the fetal head. Where the line is present, it may provide a useful guide for clinicians of labour progress along side other measures. Further research is required to assess whether measurement of the line is acceptable to women in labour and also clinicians

Is the effectiveness of tobacco image-based warning labels likely to vary by socio-demographic variable? Findings from an online survey of 19,000 members of the UK Public

Objective: Smoking continues to be a major global cause of mortality and morbidity. Countries have increasingly adopted the use of images as warnings on cigarette packs. We aimed to investigate the likely differential impact of varied images and messages on sub-groups of the United Kingdom (UK) smoking population. Methods: Forty two images developed and approved by the European Union (EU) were viewed by participants in an online survey. Respondents indicated which images they felt would most effectively reduce rates of smoking. Socio-demographic data was sought from participating adults including age, sex, occupation, ethnicity and current smoking behaviour. There were 19,810 participants in the survey. Results: Three images, with graphic content, were found to consistently stand out as the most popular across all sub-groups. Smokers (as opposed to ex- and non-smokers) and men were found to vote for significantly fewer images, potentially indicating greater scepticism regarding the efficacy of images. Significant socio-demographic variations across a number of images were found suggesting that particular images and messages may have a differential impact on particular sub-groups. Conclusion: Images may vary significantly in their impact on different social sub-groups. Careful consideration is required when selecting which images to use. Attaching images targeting a sub-group to tobacco brands with that socio-demographic market may enhance the effectiveness of such warnings

The Scottish Trial of Refer or Keep (the STORK study): midwives' intrapartum decision making

Objectives: To explore midwives’ intrapartum referral decisions in relation to their dispositional attitude towards risk. Design: A web-based correlation study examined the association between midwives personality (personal risk tendency); place of work (location); years experience and the timing of their decisions to make referrals (referral score) in a series of fictitious case scenarios (vignettes). Participants: Sample - 102 midwives providing labour care in both Consultant Led Units (CLU) and Community Maternity Units (CMU) from four Scottish Health Board areas. Analysis: A correlational analysis was carried out to test the association between total risk scores and midwives’ referral scores. Between-group comparisons were also conducted for experienced versus inexperienced midwives, midwives practising in consultant versus CMU settings and between the four Health Board Areas. Findings: Despite being presented with identical information in the vignettes, midwives made a wide range of referral decisions. There was no association between referral scores and measures of risk, personality or years of experience. No statistically significant difference between the referral scores of midwives working in CLUs or CMUs was observed. However, a statistically significant difference did emerge between the four Health Board areas, with midwives from one area making referrals at a significantly earlier stage. The maternity services in this area had experienced several high profile adverse events prior to this study; which may have influenced their referral behaviour (the availability heuristic), so as to make more cautious decisions. Key conclusions: There was no evidence that variability in the range of referral decisions was due to personality factors, risk propensity, experience or whether the midwife worked in a CLU or CMU. Local factors such as recent adverse events may significantly influence subsequent referral behaviour. Further research is required to identify why the midwives showed so much unexplained variability in their responses to the vignettes

The development of research tools used in the STORK Study (the Scottish Trial of Refer or Keep) to explore midwives' intrapartum decision making

Objectives: to develop appropriate tools to assess midwives' attitudes and behaviour in relation to decision making involving risk. Design: a questionnaire and series of vignettes were developed and testes to explore midwives' intrapartum decision making in relation to their attitudes towards risk. An innovative online computer package was developed specifically for use in the STORK Study which enabled the programme to be very tightly controlled with limited functions accessible to participants. Testing: a pilot study was conducted with over 50 midwives and nurses to ensure face and content validity of the vignettes and questionnaire. Initially designed to be a paper-based study, rigorous piloting highlighted the many difficulties in presenting it in that particular format. The solution to this problem was to develop the study as a secure online package. Findings: online data collection provided the researchers with a greater degree of control of the data collection process, not achievable using traditional paper survey methods. Another example of this control is the immediate entry of data from participants' responses to a background database which automatically stores and backs up data this means that no additional time is required for data entry. The cost of employing an information technology professional was easily offset by the financial savings made through the limited use of stationery and postage. Key conclusions: although the development and testing of the research tools for the STORK Study was labour and time intensive, ultimately a questionnaire and vignette package was produced that had been rigorously tested by over 50 midwives and nurses. The researchers are confident in the reliability of the questionnaire and vignettes, as well as the validity of the data collected. The use of an online survey is clearly indicated when the population has readily available internet access, and where controlling the process of data collection is required, as such control cannot be achieved in traditional survey and questionnaire implementation

The development and testing of an algorithm for diagnosis of active labour in primiparous women

Objectives: to describe the development and testing of an algorithm for diagnosis of active labour in primiparous women. Design: qualitative and quantitative methods were used. A literature review was first conducted to identify the key cues for inclusion in the algorithm. Focus groups of midwives were then conducted to assess content validity, finally a vignette study assessed the inter-rater reliability of the algorithm. Setting: midwives from two study sites were invited to participate. Data were collected during 2002 and 2003. Participants: midwives from the first site took part in the focus groups (n=13), completed vignettes (n=19), or both. Midwives from the second site then completed vignettes (n=17). Findings: an algorithm, developed from the key informational cues reported in the literature, was validated in relation to content validity by the findings from the focus groups. Inter-rater reliability was tested using vignettes of admission case histories and was found to be moderate in the first test (K=0.45). However, after modifying the algorithm the kappa score was 0.86, indicating a high level of agreement. Key conclusions: diagnosis of labour may be straightforward on paper but is frequently problematic in practice. This may be because the diagnosis of labour is made in a high pressured environment where conflicting pressures of workload, limited resources and emotional pressures add to the complexity of the judgement. Implications for practice: we offer a valid and reliable decision-support tool as an aid for diagnosis of labour. The evaluation of the implementation of this tool is under way and will determine whether it is effective in reducing unnecessary admissions and improving clinical outcomes for women